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2 GRANT RD - BUILDING INSPECTION (2) �5-7o c_�,zk qo The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM Qf Massachusetts State Building Code, 780 CMR ReviseJS�oll 6>0 Building Permit Application To Construct, Repair, Renovate Or Demolish a itOne-or Two-Farnily Dlvelling ernt This Section For Officml Use Only s 7e�,_ Building PerroitNumber:, Date plied. rrwl / rNv►C �. Budding Otltcial(Print Name). Signature Da e " Pl L SECTION I.:SITE INFORMATION If � Pr�erty Ad resr R/� � 1.2 Assessors binp Jt Parcel Numbers �rcrv.� ' 1.1 a Is this an accepted street9yes—If no hlap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sy R) Frontage(11) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required -- Provided. Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage DDisposal System: Public 0' Private 0. Zone: _ Outside Flood Zone? Municipal III.On site disposal system C3 Check if es0 SECTION2: PROPERTYO)VNERSHIP" 2.1 v err of Rec rd:jar �v N7 me(Print) City,State,ZIP 2 r, k- l'i 3�-ZR21 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction O Existing Building O Owner-Occupied 13 1 Repairs(s) ❑ Alteration(s) ❑ Addition O Demolition O Accessory BIdg.13 Number ofUnin Other ❑ Specify: Brief Description ot'Proposed Work-: �� r'h !ih 2Gu Gt S A SECTION 4:ESTIMATED CONSTRUCTION COSTS Item - Estimated Costs: - Offlcial Use Only Labor and Materials - I. Building $ �Qo-dOd I• Building Permit Fee:$ Indicate how fee is determined: O Standard Cilyfrown Application Fee I. Electrical S ❑Total Project Cost!(Item 6)s multiplier s - 3. Plumbing 3 2`? Qther Fees: S 4. Mcch:mical (HVAC) 3 List: 5. Mechanical (Fire 5 'fatal All Fees:S Suppression) Check No. Check Amount: Cash Amount: 6.'rutai Project Cost: S ❑Paid in Full D Outstanding Balance Due: G� Ll_ CO►J TRf-�G-'rp � '�- P-fa tt,I aD 31 l MPk ►LUD 31 6 SECTION 5: CONSTRUCTION SERVICES 5.I Coo tructiar Supervisor Licc lse(CSL) �s •:= "'Y, � License Number Expiration Date N mie.of old CSL H List CSL'fYpe(see below) a (/hd/�5 Type, . Description , "c M. uid Street - )� t/ J �' U UnrestricteJ BuilJin it)to 35.000 cu. It. vn J�*A yz7 R - Restricted 1&2 F:unil Dwellin a, Cdyrrown,State,ZIP M Masonry . . RC Rooting Covering W S Window and Sidin SF Solid Fuel Burning Appliances 7�/ �3�1 � �J/• � dr1 1I Insulation Tcle hmra Email aJJress D I Demolition 5.2 Registered donate Improvement Contractor(HI ) !I 131�� ")�V Z en � 7Ci zov'h L1' 14 �'eo - HIC Registration Number Expiration Date HIC Cann :m Name or 1 Regas oral N ne N 0 U, t s• a�l�� 7�/ �L/g�iQ Email address (fit /Town State ZIP Ii Tel e hone �/ SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.O.[.e.152.§ 2SC(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 Isivance of the building permit Signed Affidavit Attached? Yes ..........Er' No...........(3 SECTION 7a:OWNEI AUTHORIZATION:TO BE.COMPLETED WHEN! OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING..PERMIT 1,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Nance(Electronic Signature) Date 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 contained in this application is true accun the best of any knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. 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 nu have access to the arbitration program or guaranty fund under M.G.L.c. 14 2A.Otlie7(mportaal iaTormatioai on the NIC Program can be toles at NvwW mass cov'oca information on the Construction Supervisor License can be-round at wwW.m� 2. When substantial work is planned,provide the information below: 'total floor area(sq. ft.) �+ (including garage, finished basement/attics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of hal0baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage'may be substituted fur"Total Project Cost" k . - .ClCJOJJaS.lnFup 9KZ0 VW-'N301yW . ££yS NIV114k r • _ P3eMOH laeVI N ,j8lu8w0nnu3.91em03V V20 9LOZ{4Zl9 uogealdx r� ad6y 4901Cy u0gel4s!5 LL 2I-013"yNOD yN3W3A0' 'WI 3W ec�orsng�.y s�lsyjy�apu�msua3lu:ag;". t,AnJyvDGv�/' _�� nwuvuuopJ�� W Massachusetts Department of Public Safety �r Board of Building Regulations and Standards License: CS-076061 W Construction Supervisor MICHAEL J HOWARD ..,��\ �•i� 176 NORTH SHIRE HAMPTON NH 0)84 f 1Y p'IH i� /zcK CA— Expiration: �� Commissioner 10/03I2017 AC o® CERTIFICATE OF LIABILITY INSURANCE DAM(MMMOrYTY) �� 02/23/2016 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(S), AUTHORIZED r REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to 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(s). PRODUCER CONTACT NAME: Richard Moretti LOPRIORE INSURANCE AGENCY INC. IMCO."14 781)438-1376 E4MAIL ADDRESS: rich@lopriore.COm 426 MAIN STREET SUITE TWO INSURERS AFFORDING COVERAGE NAIC# STONEHAM MA 02180 INSURERA: AIM MUTUAL INS CO 33758 INSURED INSURERS: MICHAEL HOWARD INSURERC: ACCURATE ENVIRONMENTAL OF MALDEN INSURERD: 38 MAIN STREET SUITE 33 INSURER E: MALDEN MA 02148 INSURERF: COVERAGES CERTIFICATE NUMBER: 32563 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED 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 THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDLSUBR POLICY EFF POLICY E%P LTR TYPE OF INSURANCE POLICYNUMBER MMR1D/Yl'ri MMIDD/YYYY LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ CI-AIMS-MADE OCCUR PREMISES Ea oauRanca $ MED EXP(Any one person) $ N/A PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY PRO- JECT PRODUCTS-COMP/OP AGG $ ECT LOC OTHER I$ AUTOMOBILE LIABILITY L(Eaawident) ED SINGLE LIMIT $ ANY AUTO INJURY(Par person) $ ALLOWNED SCHEDULEDAUTOS AUTOS N/A INJURY(Peraccidmt)HIRED AUTOS NON-0WNED TY DAMAGEAUTOS tlent UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LIAR ClAIMB-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION X1 STATUTE ERH AND EMPLOYERS'LIABILITY YIN A ANYPROPRIETORIPARTNEWEXOF CER/MEMB RE CLU ED?ECUTIVE N/A NIA N/A VWC10060205802015A 12/30/2015 12/30/2016 E.L.EACH ACCIDENT $ 100,000 (Mandamry In NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 Use,describe under SCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,Additional Remarks Schedule,maybe drenched ifmoreapace is required) Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in slates other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts. This certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification Search tool at www.mass.gov/lwd/workem-compensationlinvestigations/. Sale proprietor has not elected coverage. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Department of Planning & Community Development ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington St 3rd Fir AUTHORIZED REPRESENTATIVE alem MA 01970 Daniel M.Cr"Jey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street,Suite 100 Boston, MA 02114-2017 x www mass.gov/dia ',Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Lefibly Name (Businesss//OOrrganization/Mdividual): 14 Address: —�D �bJ 64 �( l� 3 �� `�� City/State/Zip: �Il�eY/ p7,,/,7 Phone#: Are you an employer Check the appropriate box: Type of project(required): 1.❑1 a employer with employees(full and/or part-time)." 7. ❑New construction 2. I am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3. I am a homeowner doing a]I work myself 9. ❑Demolition ❑ g y [No workers'comp.insurance required.]t ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole I L❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insumnrz.t 6.❑we are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] -Any applicant that checks box#I must also fill out the section below showingtheir workers'com pensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. iContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site information. p Insurance Company Name: 19/ a// (i' 'er ! Policy#or Self-ins.Lic.#7: -LiJL �— 316 ' � Qgg6'1�lA Expiration Date: �Z' Job Site Address: 2 e 9 ,Gq q -(— f2c), City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certib,under the alit and penalties ofperjury that the information provided ab vee ii true and correct. Si ature: Date: 3' 51 1e Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the pemtit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston, MA 02 1 1 4-20 1 7 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia CITY OF SALEA AWSAa7REE M BmDnvGDErAFjAr P 120 WASIMC71MS7REET,3IDFLOOR AL(978)745-9395. RiM1t PAX(978)740-9846 MAYOR 7)KWAS ST.PIERRE DMECTUt OF PURUCPRCMM/BUMMOCMaWCgT= Construction Debris Disposa/Affidavit (required for all demolition and,renovation work) in accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL c40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a property licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by.- (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signatyre of applicant 3 /ll Date