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5 GREENLAWN - BUILDING INSPECTION Or1 �� l3© 6- o � - - -- - - -- The Commonwealth of M• ssachusetts Board of Building Regulations and Standards CITY m SALEM Massachusetts State Building Code, 780 CMR Heri.ced.tlur 2011 w .,W Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Funmily Dvelling This Section For 'tcial Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signa at SECTION 1: SITE INFORMATION I.J Pro erty AddrSss: 1.2 Assessors Map& Parcel Numbers f"C.'tr1 I.l a Is this an accepted street9 yes no. Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning-District Proposed Use Lot Area(sq If) Fronlage(It) 1.5 Building Setbacks(D) Front Yard Side Yards Rear Yard Reyuired Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal ❑ On site disposals)s stem ❑ Public❑ Private❑ al Check ifyes❑ P P y SECTION2: PROPERTY OWNERSHIP' 2,1_Qwt)ert of - rd: N`:mic(Print) City.State,ZIP 6•v,( /`�� r�,� � i-N �9 rY w� A✓V W Nu.and Street Street 'telephone 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 ❑ 1 Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Britt'Description of Proposed Work': ��C�� � — SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item (Labor and �Jaterials I. Building $ j I. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee '_. Electrical $ ❑ Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical 01VAC) S List: 5, ,Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount. _ Cash Amount: G. Total Project Cost: S3 i�\�YJV 0 Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) C�_--ut \ `�� ��\ License Nunther F. a on Dale Namcof C'S Ito er ------- List CSL f)'pe(see helow) - No. ;aid Street 1)pe Description . I l Inrestricted(Buildn..s u' to 35,1100 cu. 11.1 Crt}dfuwn.S rtc ZIP - R Restricted 1&2 F;unil Darellin M Masonry RC R, lit Cmerin ` W'S Window anJ Sidon e,0 -ao� k I Insulation tion Burning Appliances �'C I Insulation "fcle hone linnil aJJress D Demolition 5,f,,,RegisteredHomeImprovement Contractor(HIC) �/ 1 6N�1`i`mpd Nal too III Regisame —' I IIC'Registration Number F. piir tion Date �0 5 No. raid Street Email address Cit /Tow ate,ZIP Telephone 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 .......... No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT -- CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owners Name(Electronic Signature) Date SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contain ' in this applicat' is true an cc ate to the best of my knowledge and understan ing. 9 � Print Owner's or Authorize Age Vs Name(Electronic.Sign, tire) Date OTES: 1. An Owner who obtains a uilding permit to do hisiher own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program), will riot have access to the arbitration program or guaranty fund under M.G.L.c. 1 42A.Other important information on the HIC Program can be found at t}W%% nia.��.g;ovoc) Information on the Construction Supervisor License can be found at wxNtr.n '_ When substantial work is planned, provide the information below: Total floor area Isq. R.) (including garage, finished basement'attics,decks or porch) Gross living area(sq. it.) __ Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms ---------------. Number of half'haths 1)pe of heating system--- ` ------__--_.-- Number of decks, porthes. Type of cooling system ----------------" --- -------- IncloscJ --Open 3. "focal Project Square footage-may be substituted for"Total Project Cost" CITY OF SALEM PUBLIC PROPRERTY s° DEPARTMENT Nil.of l Y'IA 14 r11 11C \�A1/11.\la u.\)Ie Ckl' • ),\l l•.N. Me U.u.i tl ,1 11\JPII'. ; 'IS r 1:,.r v7M.7(C•'rYM W'urkurs' Compensation Insurance Ufiduvit: ltulldervointractors/Electrldans/P1umbers 17licant In unnutlo Pleme Print Le •hl �l:IIn011luuiw,y i)rarnrrninrvinJiv�duull: � l cily,Starczip• J�Q .\ry y uu in euq/byar:' Chae the approprlate box: 1 am J empluyvr with 0. ll)M ofprn)toet(regalred): I ❑ I .un a general cuulrxtor and 1 .enlplUyees(IUII Jlld/ef pJ(l•111I1f).• huve hired the.fuh•clm racturs /t• ❑New construction ' ❑ I.un J tale pmprictor or purifier• lined on the inachcd..heat r 7. ❑RemodelinS .chip and have no vmpluyces These subcontractors haw ,.orkind thr into in any capacity workers'comp• insurance. k' Mmolition I Ke workers'comp. insurance I. ❑ We are a cor Q• ❑ouildind uddilian nyuind.Icers porstion and its 1.O ' :Jill J hwrteuwner doing ill work fight of e�I`lion ut their ID•O Etectrieal repair or additions Inyself.I�'o %arkvn'cum . P par hfti6 I I.❑PlumbinS repairs or aJJilinrm p c. 152. ¢10),anj,ve have no 1 insurance rcyuired.I r anployees. ho workers' Ruul'repuia comp. insurance rcyuired.I 1 ❑Uthat ��r)••,gtlwue ihW cheb O,u,fl mull.Jw fill vW the Wow L%6% •twww i 'l lum,n,wnrn,.Mr...Li it this allteavir imlkitin i e hrir uwkwf nwllrrnuelun ryliar infiurrrruiur► e trot Ale Joins All.,•urk Alto 11a'a him wnide ernnrnalps mull.Ulanit a nw,atnJavit irtoltaein •f.•nmwn•n 1hu,hcak iAs t10a mtrt iaahto..n aJJ,Iiu,yl,hurl.huwine ihr ninr/ o/tne,u►•ermratA)1a and Ihfa wYArm'camp.(Wilily a wk'ma un uruplayrr that/r prvv/Jlny morArrs'rurnprntation Grrgnnra�/ar trig strip/uyrat, Br/utv/y rh /!ay on%I a Insurance C'unlpauy .valor 999__ 'G=`A_ +C � I'ulicy 4 ur Sulf•ins. LiC.M; W Zv t;����(�U �. .._^--- �� y Espirafwn Oeb: 1 lob bite �1Jtlress: � C_I Q-�`GV� ^ (� \rtavA a vilify of the workers' eumpunwtiva pulley daelrratlun page(showl M the policynwnb grid Volutea ), ( PAtlure 1u l'500 cuseruge u required prim. Section 251% ul'.%IGL c. 152 cJY lead to rile imposition or'erIfninal penalties ofa Irti ufi m SLSno.Iln Jill Iduil mie•year in,prisrmmcnr, 4 1 well Js civil penJitlu in the l'unn ofa STOP WORK ORDER Jnd a fine ai up rn i?1Q r7o a Jay iYuor i the nolitor Ile 3tivi wd thus i copy urlhlh..fulvinum may he IurwirJvJ W the t.71DE ill lur,..h�,innu uY;lw Uh\ .or imuaoxe a"scri;je ,cnticinun. /du/gvrAy r.rri/'Y nnJ¢r riot mr,/prnn/i•t u prr/r r r t/�r iulur,nrt/oe prvviJrA/ubuvtr is rrw and rorrvrC l r1//l�iu/rnr only, flat rrirr in Ihi.r are lu Ar ru,ny/a•Iny ir/D a' i yur tarnn/J/,iul ( ( fly or 11nrn: _ I,suiny .\ulhuril Pennif/L(ecnta tl i y (tittle anal; I. IL ,uJ o(IlcilUl !. Ihuldm� IIgl.vrmcul I. Citl.'1'ono Clerk J. l•'Icctric.l) lu, rvc Nr G. 171hv♦ j I Plumbink In,ptcror Information and Instructions ar ". every person in the service of anuther under any contra of hire. �I,rs;achu:etis General Laws shaper I i2 Ieywres all enyrluyers to prov ide worker carper+aeon tar their employee+. I•„r,uatll to ous.utute, an rmpfurd is desired sprees ur unphed. oral or wntten." of an two or more �n ernpluyer +desired as"an Individual. partnership.assueiatwa,corporauua tit other legal cnnry, Y lu m .mployces However the t the I;,regumg engaged In alum, cntcrpnsa, and atclalled the legal al gn nativeslOy decried employer.ur the ,ace e l of trustee e g .m indiv,Ju�l, p+amenhrp, ,ssoc,auuo or other legal entity,cap Y g r,+ons to do Inainten, of�ueh'tremploy,nent be Je mcd t:Iion Of repair work on o employer. owner of a dwelling house having not more than Ili apartmenu and who resides therein-or the occupant dwelling the usd .Iwellln1,house of anothet who employs appurtenant thereto shall Ito$bee or on r It,rounds or building CSC 6 also sates that•'even'flats or local"censlag ageas 1 fhhU withhold the issuance oraor %IGL chapter 152. t)_ O required." renervsi of a license ur permit lu operate•husi°en or to eo■U"n c wltlb th slnsuronea overage bdivis say C 71 ewes"Neither the commonwealth nut any of iu pali$ical with t e i ns+hall applicant rho boa not prndue+d acc+pfable+vldsace of comp \dditlunulty, JIGL ehupter I S_, a-S l ante! into any contract for the perfomtan a entedblu the canvaalI i aluthorityvidenee ui compliance with the insuranca re uirdmen$s of this chapter have been p' y Applicants g l to uuc situation and,if ensation affidavit completely. yscaw kber(t)ci�g with'he' cartiAeuts(s)of Please lilt out the workers' wmP r address(erl and P LLP)with no employees usher than the recess uy, supply sub-eontructor(s)memo(. ), have workers' compemati submitted w the Dapurtma t ofLLP ��Industrial nsurancc: Limited Liability Cornpanics(LLC)of Limited Liability partnerships if an LLC or I ne,nb its or partners, its not required to carry employees,a policy is required 9n advised that this affidavit may aftmcat of aecidenu for conflfmatiun of insuranca coverage. .alw be sun to alga uad date the utndavlb n,e atYltavit fhaa he rcn,meJ to die city or town that the application for th permit Of license is being requested, not the L7ep You have any 4ueation&regarding the low ur if you ors required 1Oanies should enter their Industrial,\ceidents. Should y arunent at Ile number listed below. Self-insured comp compensation policy, please call the Dep .oar-insurance license number on ilia a Dropriste line. fyry or'fowa OMclab The Department has provided u spaua at the bottom g the app Please he sure that the affidavit Is complete and printed legibly. Pa of die affidavit fur you to IIII out in the evenl the Ot1Sce of lnvefti osiers has to nce AUt you regarding need only suborn on atlldavit indicating current I'I:as,: be sure to fill in the purmit/lieanss number which will be used:Ia a reference nwnbor, In addition,an applicant sit drat ,nust submit multiple Penniulicalse applications in any given year, ythe Lipp antillould be provided w the policy intormation UQ u cel,kviilhat has been officially rod under-Job Site mped or ma4 can by es.I•city or townmay iun in (• Y town►."A copy permits of 11,relat t raw atltdnes ore he filled out each upplicunt as proof that a valid atflduvit is on file tat flnun P entii not related to any business d commercial venture year. 'Where a hums owner at citizen is obtaining license ur p t 1 e, a dug IicmL+a or permit w burn leave cte.) said person is NOT requited ro complete this afftda a haw.urY 4u+suonf, I hat)Mice ut Invcrtigatiuns would I," w thank you in advance tut your cooperation and should y plea., Ju nut hesinre to give us a call. f he U .p:uunant's addre,+, mlephune and fax number tusaelfutetts The Commonwealth of M DepwUltent of Industrial Accidents Of"Ce of favad>isdens 600 Washington Street Gaston, MA 02111 ra )l 617-727-4900 ext 406 of 1.877-MASSAFE Fax is 617.727.7749 www.m=.&ov/di4 A� CERTIFICATE OF LIABILITY INSURANCE 1 DATD/YYYY) O6/21 1211/20,1 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 REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the pollcy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to the terns 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 NONE: Michael Sokolowski Genesis Insurance Group PHONE 781-350-4410 FAX 599 North Ave.Door 6 AIC No Wakefield,MA 01880 ADDRESS: mike@geninsure.com PRODUCER MC1004201223305 INSURERS AFFORDING COVERAGE NAICS INSURED Thomas McGilley dba INSURER A: Arbella Protection McGilley Roofing and Construction INSURERS: Atlantic Charter 6 Eastside Avenue Saugus,MA 01906 INSURERC: INSURER D INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 ADDL SUER POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR MD POLICY NUMBER MMIDDIY MWM LIMITS GENERAL LIABILITY EACH OCCURRENCE $ DAMAGE-TO RENTED COMMERCIAL GENERAL LIABILITY PREM SES Me osourronse) $ CIAIMS-MADE D OCCUR MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENERALAGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER'. PRODUCTS-COMP/OP AGO $ POLICY PIFcT RD LOC $ A AUTOMOBILELIABILITY COMBINED SINGLE LIMIT $ 1,000,000 (Ea accident) ANY AUTO 28495400004 04/06/2011 04/06/2012 BODILY INJURY(Pe,person) $ ALL OWNED AUTOS - BODILY INJURY(Per awident) $ SCHEDULED AUTOS PROPERTYMACE $ CSL HIRED AUTOS (Per ecGderd)tlent) NON OWNEDAUTOS $ $ UMBRELLALUB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIEWADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B wORKERSCOMPENSATION WCV00880100 04/19/2011 04/19/2012 we RI STA - oeHg AND EMPLOYERS'LIABILITY ANY PROPRIETOR,PARTNERIEXECUTIVE YIN E.L.EACH ACCIDENT $ 500,000 OFFICEPoMEMBER EXCLUDED? ❑ NIA (Mendetory In NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 Ifyes,deswbe udder 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONSI LOCATIONS I VEHICLES (ANac ACORD UH,Add$bnai Remarks Schedule,If more spew Is required) CERTIFICATE HOLDER CANCELLATION t SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENT,TAAATIDMVE�J./,fi�f^/f ,LJ ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Massachusetts - Department of Public Sal'en } Board ul' Buildint Ite-ulations and man(hu-ds Construction Supervisor License License: CS 75111 Restricted to: 00 JAMES S BEAL 27JASPER ST SAUGUS, MA 01906 Expiration: 1/5/2011 ( nnuuisioucr Trg: 8229 . rA /.B Too�zrl?4?+t[iea ✓�'rama r� ly\.. , '�\ GS??ce of Consumer V1mrs C usm c.,[eFn' t f ME IMPROVEMENT CONTRACTOR -. Req?strWaona 146571 - II Ekpiratlor 5/32011ia! Tr4! 239353 t F , Type:. Indnrldiial _ , 10CGILLEY.ROOFING' CONST,-' - THOMAS MCGILLEY .. 6 EASTSIDE AVE SAUGUS,MMA 019�o '- --7 � "„ Uodersccrutarr ,. .. a I l CITY OF S'Ut Emj j�L�SS.�CHL'SETTS BLItDLNG DEPARTMEINT 120 WASHLNGTON STREET, Y°FLOOR TEL (978) 74S-9595 FAX(978) 740.9844 KI\mERLHY DRL4COLL MAYOR IHomu ST.PIEnas DIRECTOR OF PLBLIC PROPERTY/sCII.OLNG COMMISSIONER Construction Debris Disposal Aft3davit (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 # 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 b1GL c 111, S 150A. The debris will be transported by: 4(ne f hauler) The debris will be disposed of in CU e 4-'ptx �_���� ` (nam o! f fac,lity) (address of facility) Signature Of per ap licant atC �♦hn 4ir•i.R