6 GEDNEY CT - BUILDING INSPECTION t
The Commonwealth of Massachusetts - - CITY OF
Board of Building Regulations and Standards
SALI M
jyra d.9 Massachusetts State Building Code. 780 CMR Revised thu 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tuu-Fancily Duelling
This Section For Olfici Use Onl
Building Permit Number: Dat Applied:
Building Official(Print Name) Signatu'e Date
SECTION I: SITE IN FOR ATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
C�f ne
L I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: ,
Zoning District Proposed Use Lot Area(sy Ill Frontage(Il)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood-Zone?
Public❑ Private❑ Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner' (p�f Record: // n 6
(✓,t 1 olQ �D
Name(Print) City,State,ZIP
tx�� cf 9 �T-7Kr-s-S-ir6
No.and Street 'relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Spccify: =
Brief Description of Proposed Work': z- 7(t e /2.n 3 A �- SopYf l�-zo
w -cc' t2-
f�ri
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials)
I. Building S O �d I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Cost (Item 6)x multiplier x
i, Plumbing S ?. Other Fees: S
4. ,Vshanical (11VAC) S List:
5. ,Mechanical (Fire S '-total All Fees:$
Su �rcs'ion)
Check No. _Check Amount: _ _Cash Auwurn
6. Total Project Cost: S 9' Oc�-UCH 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
2-
Ilse Number I(spirauon Date
Name of CSI. I IuWer
List CS I,)PC(see below)
No. and Street Description
U Mrestricted(Iluildin gs u' to 35,000 Co. 11.)
--F- F& R Restricted by Famil nwellin Cit}'i fawn.Sui e.71P M Nlason
RC Roolin C'overin
W:S Window and SiJin
SF Solid Fuel Burning Appliances
A"61) 2£s.0 0<r'rE COk- I Insulation
Tcic hone Fnutil address D Demolition
5.2 Registered/)tome Improvement Contractor(HIC)
I IIC C nmpan)'Name or 1 hC Registrant Name
I IIC Registration Number Expiration Date
28 }St{�� h e1 F-s/-,c�b2 No.mtJrect 4
Email address
Ci /Town,3tate,ZIP Tole hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........9W No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize S��y /�re✓,.
to act on my behalf,in all matters relative to work authorized by this building permit application.
n I ot Owners Name(Electronic Signature) 2 Z
to
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
i o1rta'n ndrn thi;aication rs1tr Zcfeu`a't tlStbtebesff my knowledge and understanding
Z
Dale
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under %I.G.L. c. 142A.Other important information on the HIC Program can be found at
41-1>s g;1F oca Information on the Construction Supervisor License can be found at
When substantial work is planned, provide the information below:
Tidal flour area(sy. . 11
Grass living area I .l _(including garage, finished basement'attics, decks or porch)
—_ Habitable room count
\'umberuf�ireplaces-----_-- Numberofbedrounrs ----------
N Will her of bath ruonts _--------- ---- Numberufhalfbaths ----------
pe of heating system
___----- Number of decks. porches
1)peul'coolingsystem ..- ---._----
_._ -------_--- En Oclosed-- pen
3. "Total Project Square Footage-may be substituted for-rot:d Project Cost'
CITY OF SALEM
' PUBLIC PROPRERTY
DEPARTMENT
ibn:M:I Y'ntlN.�l1
\IUtet
1 j^. \VArtnAtl It 518 t1•T • 5.11[.N, M.11v.11.111 q I hJl7):
Ihl: )71l•It5•vi't5 s f tx vle•ItC.lypy
Workers' Cumpensation Insurance Alnduvit: Hui lders/Contractors/Electrlcfans/Plumbers
1 tlicrnt Information
q/ / / PI •4s Prinf Le 'hl
Nil ITI0111ua ccyr)rganvaria vinJivuluull: 9A QY7llC��n Sol�lS
cily,Starc,7.ip•
1 hone its �/- y7�20 S�'
Are ),in an vusployer:t Check the appraprhrle box:
I I 1 ant a cm lu cr with -3 4. 1>M of project(nqulred):
P ) ❑ i :un a general caatraelor and 1
cnlpluyacs(full andlur part-time).• have hired the.uh•cunrracturs h• ❑ New construction
2.0 1 am a sole prnpricnw or partner- listed on the artached sheer. r y ❑Remodeling
ship and have no mnpluyces These sub•coniracton have
Lmysnalt
rile me in any capacity, workers'comp, insurance. d' Demolition
Nocrs'cutup. insurance 5. ❑ We are a corporation and its 9• ❑ Du wing addition
ut)lecrs have cxcmiscd their 10.E Electrical repairs or additions
vuwncr Juing all work right of exemption per hICL 11.0 Plumbing repairs or additions o workers'cutup, e. 152,41(4),and we have no
equired.) t cmPloyccs. IKo workers' 12 ❑ Ruul'npuirs
unmp insuranct rvyuind.J IJ•QUlher
•4nr.,pphrad tliW cnuchs eo1 Or mug:Jay rill tMtl rho v:cnun Iwluw dwwiny iAyi[wwhui cum'I luttwnrwtwn why,latmit this affidavit inrneatin t aatiltlbkvhimaususiss prewliun sim ss"i r hista a"use
r,mtnaawv Thal clash this bat must anaehad ran adalliiu,sl Jet Jtuwiiatq the 113"m o(the sub-comrot rs amt thew uut4yn'saerulmy infurmarim
fame on t'tmployer 1/1r(h prur/dinX ruorken' urnpartnNon hrraronerjur/it employees. Be/ulit/s the pu/Ity rtnd/eb site
iuj✓rnrurbtn,
Insurance C'ompauy Vmne:
I'olicy i(or Sulf•ins. Cic.Is: 6111le o 6S' O�y�
Expiration Dale: /S' l�
Job SiteAJdress:
\'tauh
City, sue- wr Lei �,D
n cuyy Of Ill*workers'wmpunxatlon pulley duclararlun page(showing rho policy aun'ber and expiration date).
pallurc to scours coverage as required under Sccriun 25A ul'JIGL c. 152 can lead ro Ills imposition of criminal penalties of a
fine op at.SLS110.00 intyurune-year imprismuncnt, as tvull us civil rMiallics in the Lunn afa STOP WORK ORDER and a fine
of up rn i'SQ,M)a Jay.rguinar the v6tla(" 11e advi.*W'hut a copy of this murcmenr may be l'urwardcd to the oil lee al'
lot,ali�atbms a' :lie UTA "of mruGmee cnvcNPc Wrillcaom.
/da herrhy t crrijy under the inc r d pear riot a/perjury that the iejurrnyllon provided above is true and com cp
I)an Q ZL /
O liriu(lire an/y. no nnl write its ddr art u. to he ry nptered by city of
/alum u//A'ie2
Cite ur Per'niryt.icvote he . 1
Ivvuinq .\W hurry (circle nnc):
I I. IhrarJ of Ifr.tl'Jt 2. 1lnddio; Mromrnnvrtl I. Cil)r'1'uttu Clerk 4. Electrical Inspcctur i• plumbing Inrpeclor i
her
l'm Ltcl 1't nun:
Information and, Instructions
r.o in the service ut another under any cuntmct of hire.
�Lu;.re huseus General Luws chapter 132 rryuuex all anployers m provide workers compenxauon fitr heir cmp ogees.
11ursu.utt to Mia astute, an rrnvlut're is defined as"...every P'•
,.prey or implied. oral or written,"
to employer n Joined u"an individual, partnership.assoeranoa,coryoration of other legal east] or any two r t more
,n �m ,,,.,Cs. However the
�r the fucegomg engaged m a lumt enterpnsa, and including the legal«p«seutatives of a deceased empluye4 ur t e
ecerver or trustee ul'.ut individual, patmershrp,as 11.1parors or other legal entity, s there g ' P
uwner of a dwelling house having not more that,three apartments and who resides therein,r the occupant of the
Dwelling house of another who cmPIOY9 Persons to
enan thereto shill do uotnbecause of such employment be deemed ttion of repair work an ube m employer.'
or o❑'he grounds or building app
"sing Agency
ad
et
.\IGL chapter 132, §25C(6)it to operate a bues thig siness or to onst 00$of local trues buildings lahhe otmmf orage ris e for any thhold the islusacv r
renewal of a llecnse or per
applicant "lea has not prrtdu1ad 3C(7)strates-'Neither he comcs of monwealth not any ol'its poll ealgSubJivistions+hall
>Jditiunully, NIGL clwpter l S_, 3- l
enter into any contract for the pertommnce ul'public work until acceptable evidence ul'cwupliarree with the insurance
«yuirements of his chapter have been presented to the contracting authority."
Applicants g p to our situation and.if
address(es)and phone numbers)along with their canilicrte(s)of
Ple:txe fill out the workers' compensation afidavit completely,by checking the boxes that apply Y Y
necessary,supply sub-contracturs)n ies IL , with no employees
insurance. Limited Liability Companies(LLCw at orkadtcomperuatioe ituurrnce,(If an)LLC or LLP does have
er than the
rnernbers or partners, are not required to carry
CM a policy is required. Be advised that this affidavit may be submitted to the Department it industrial
i
he rc.liccit n ed to the city ti town shu insurance applicationco coverage'
for the perm t orAlso be sure alicense is being requed date the sted,not he Department of d
Industrial Accidenu, Should you have any questions regarding the law or if you ate required to obtain a worker.
Indust ial Acompensation policy,please call the a any tnent at the number listed below. Self-insured companies should enter their
,elf-insurance license number on the aPPMP1jQtG line-
city or Town Officials
the a licanL
Please he sure that the affidavit is complete and printed legibly. The Department has provided a specs at the .UuT
of the affidavit for you to rill out in the event the Office of investigations has to contact you regarding pP
I'I vxe be sure to till in the pertnitllicmtse number which will be used;a a reference number. In addition,un applicant
cn year.need only
Illat pulicylcal
�fsubmit
ion multiple
jif necessary)land tinder P,JobtSi a Address"he applica ntt.hould write it"all locations no a in vit .caring``tY or
town)."A cmationtit*affidavit that has been officially stamped or marked by the city or town may be provided to the
file for
tuta
ts or licenses. A now
yout each
eir'v�yhere a horns uwnerlid or citizcnti ts on
obminin`a license or petnnit not elated to any business sdavil tor comiust mercial al venture
a Jug license or permit to burn leaves cteJ NOT required to complete this said persotr is at'rl vit. ueauons,
1 he )trice ui luvestigations would Ire*to hunk you in advance fur your cooperation and should you has c:utY y
lease Ju not hesitate to give us a call.
p
fhe Ucpanment's address. telephun*❑nd rjA number:
The C mmonwealth of Massachusetts
Deparanent of Industrial Accidents
OtAce of Iaveadgadons
600 Washington Street
Boston, MA 02111
'fei. # 617-727-4900 ext 406 or 1-977-MASSAFE
Fax M 617-727-7749
www.mass,gov/dia
r
r
CITY OF S.U.&M NWSAC HLSETTS
BLWLYG DEP.IRTIENT
110 WASHLYGTON STREET, 3"a FZOOR
T IM (978) 743.9595
P.1u(978) 7�9846
K1J®ERLSY DRL4COLL
MAYOR THo.�us ST.Pmttttt;
DIRECTOR OF PLBLIC PROPERTY/HLILDLYG CONDIISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
111, S 150A.
The debris will be transported by:
%. tc
(name of hauler)
The debris will be disposed of in
(name of facility),/—
(address of facility)
5isn ure orpermit ap scant
//
date
07/26/2011 TUE 9: 26 PAX 6174231789 0002/005
R CERTIFICATE OF LIABILITY INSURANCE 7/26/11'
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(B), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADD17IONAL INSURED, the po icypes)most be endorsed. If OGATiON IS WAIVED,so actin
the terms and conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(a).
PRODUCER
E:
Paul T. Murphy Insurance Agenc P FaxN
628 Broadway (Rt 99)
Malden, MA 02148 PRODUCER 7064
INSUFE 9 AFFORDING COVERAGE NAIC4
INSURED - INSURERA:Scottsdale Ins
Advanced Energy Solutions LLC INSURER B•Peerless Ins
28 Hamilton Rd. raStlaHtc:AI
Peabody, MA 01960 INSURER D:
R INSIIEt E:
I R
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAM®ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY TEE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS
L TYPE OFINSURANCE AWAR MRJD MLISLISM
POLICY NUMBER MINA YYrY LIMITS
GENERAL LIABILrrY FACHUCCURRENCE f 1 000,000
DAMAGETO RENTED
A cOMAEROIALDENEPALLIABIUTV CP$1014919 5/7/11 5/7/12f 00.000
CLAIMSMADE FxIOCCUR MED W(AIV o,w aem) f_ 5,000
PERSOMLS ADVINIURY f 2,000,000
GENERALAGGREGATE S 2,000,000
GEN'LAGGREGATELMITAPPUESPER PRODUCTS-COMPIOP AGG S 2,000 000
POLICY PRO- LOC S
AUTOMOBILE UASIUTY COMBNEDSINGLELMII If 1,000,000
B ALLOWNEOAUTOS 8633314 3/191/11 3/19/12 BODILY INJURY(PW Pelson) $
BODILY INJURY(PW ardeU S
X SCHEDULEDAUrOS
PROPERTY DMNGE f
X HIRED AUTOS (PWaootlen0
X ANYAUTO 4 8=1dM)
NON-OWNEDAUTOS $
S
UMBRELLA LIA15 OCCUR EACH OCCURRENCE S
EXCESS LIAR CLAIM AGGREGATE f
DEDUCTIBLE
RETENTION S
WORKERS COMPENSATION WCOO5690446 5/14/21 5/14/12 WC 9TATU•AND EMPLOYERS'LIABILITY
C ANYPROPRIETORIPARTNER/E)E%)TNE YIN E.L.EACH MODEM S 1,000,000
OFRCERMEMBER EKCLIDED9 MIA
eAan loryln NH) EL,DISEASE-EA EMPLOYEE S 1,000,000
If Ad1N UMW '
DES RPTIONOFOPERATIONSMIow EL.DISEASE-POLICYLMR $ 1,000,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VFACLPS(AttKh ACORD IM.AdBBoml RWmrks Sdn*A.,him m spm Ie mgdmdl
Insulation-Coverage subject to policy terms conditions and exclusions.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City OF Peaakv6dy� ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED RRREEFRESENTATIVE
V
1 -2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD
Of"Co of Consumer AlTnin;&Business a �
HOME IMPROVEMENT CON7ptah� n•
Registretion, ;164893 RACTOR;.y '-
�.;, Expiration 11/30/2011..
�± .-x . Tr& 2921F. ,
� TYPe i t1
� �rRoratronF2
' 7. .ADVANCEDENERGYSO� 'r
RICHA ' LOTIONS.LLC. ,. r,•
RD BCRGES � a !
"t k 28 HAMILTON;RDti� ���ryF 1, t
(, PEASODY, MA-Q1960°
Nlassachusetts- Department of Public Safct.v `
Board of Building Re ulationsand Standards
Construction Supervisor Licerisfr
License: CS 90902 .;�.�,.. ..w..„:
RICHARD B BORGES;
28 HAMILTON ROAD
PEABODY, MA 01960 "$
-•� -�J'��� Expiration: 11/1/2012
('anmissioncr Tr#: 5481 -