9 GREENWAY RD - BUILDING INSPECTION (3) T13 - Irk - 1 -5gq 4� 4003 $ gLfob
< The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEIV CITY OF
Massachusetts State Building Code,780 CNMSPECT"NAL E SALEM
E�eVXE$far zo11
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling 1#14 AUG
This Section For Official Use Only
Building Permit Number: I Dat Ap lied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
°I Gk£fNt-/Ay 4DAig SAC&i
L is 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(sq fr) Frontage(ft)
1.5 Building Setbacks(ft)
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 Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
ZI&I E T ReA Q —SAYE 5AL.lFM MA 0 1 C1 70
Name(Print) City,State,ZIP
5 �RE�E•vtyA AoAD G �. �5"q 100
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': A .S ALL OEcIr Zz r X I� O�✓
R,EFiR O� J'I_ /fb.viP_ AN,✓J / NSTA4L F�10NT 00/`
AEMAI w.4 y ZPOi4 /n/ SA<Fire til A
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate bow fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List_
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $/��QD 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
I6
PA'FKjCK License Num er Exp ation ae
Name of CSL Holder
List CSL Type(see below) U
PO �jo X _ 1 l.la •uc�
Noo.M.and Sheer- + i- + ��'" " ` Type Description
'J�Q��)��� M A -O 1 Q ohs" Unrestricted Buildin s u to 35,000 cu.ft.)
City/Town,A!J State, [P R Restricted 1&2 Famil Dwelling
M Maso
RC Roofin Coverin
WS Window and Sidin
P a r/'[614(V 06gC7a4 SF Solid Fuel Burning Appliances
97 9, 7y0. /007 CydiJe?gn)E 5 . CO-11 I Insulation
I cle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
OSGaap PArn11/,IC SEA VlCE t H`3�Zrao ��/ Zo
HIC Registration Number xpvation Date
HIC� Com any Name or HIC Registrant Name /�Ct rr/Gt�CJ PS�X I I l I O
No.and Street { sy Ol7dCOrri_/_J_���5' C.pi"t
t14AAZ F,►E,a.0 MA y1 j b /OQ 7 Emil address
City/Town, State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.g 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 ..Y✓.... ❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 's Oeth �ub' pro erty,hereby authorize__ CA' rA jc& Nf C7S�pp%�t to m ers relative to work authorized by this building permit application.
N2�t�/Print Owonic S' afore) / Date
SECTION 7b:bwNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest unde a pains and penalties of perjury that all of the information
contained in this p cation is true ccurate to the st of my knowledge and understanding.
Ai tut
Print Owner's or thorized Agent's a(Electronic Signature) SG00 D -T'—� Date
NOTES:
1. An Ow who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not r tstered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov%oca Information on the Construction Supervisor License can be found at www.ntam.eov/dns
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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
i
CITY OF ScU—ENI, NL- SSACHUSETTS
13LILDING DEPARTNWNT
120 WASHLNIGTON STREET, 31D FLOOR
T EL (978) 745-9595
F.A-v(978) 7404846
1U.,(gFRt FY DRISCOLL
5,kAYOR T HoNw ST.PMRAS
DIRECTOR OF PUBLIC PROPERTY/BUILDING comlISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbere
At t licant Informatinn SS r1O/� / Please Print Le ibl
ValJ Inusin¢ss()rganiration'ImliviO:l , VJ
Address: PO /3ox / ll I
City/State/Zip: MARS .F#fA Phone #: 4 79, '7q a /Da J
Yrc nu can empldyer7 Check the appropriate box: r 'type of project(required):
I.�I am a employer with S 4. 0 I am a general contractor and I 6. [?New construction
employees(full and/or part-time).' have hired the sub-contractors
2.0 Lint a sole proprietor or purmcr- listed on the attached sheet. I 7. ❑Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working Yin me in any capacity. workers'comp. insurance. q. 0 Building addition
jNo workers'camp. insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 I ana a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers' Gump. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' j3.❑ Other
cutup. insurance required.)
•Any upplm.,1 Ilwl checks but 01 rlu al also rollout the section below showing their welkaa'<umpmuliun policy intummatlon. '
'I romeowrwn who whmit this alfl,invit indicating Ihry are doing can work and Ihcn hire uaside caatracton mast mahmil a new afr?davit indicating such. -
$'innmaun Choi chak this box oral atlacho.1 can additiuwl shral showing IN name of the"b.umneton and(heir wnrkera'camp.policy infurmmion.
ant can employer that/r providing workers'conlpensadmn insurance for my enrplayees. Qeloty/s the policy and Job sale
lnforrnatian.
Insurance Company Name: 47�— n` LL.A_j [N S UA A31J e sk .
it '- 4 or Self-its. Lie.N: y W[ 10 o. ko/2-6-.73 Expiration Date: 7A i1S"
fob Site Address: 01 �' -A/ A City/State/Zip:Sag AAA t7 19 7 0
,attach a copy of the Ivor 'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as requl under Secfion 25A of NIGL c. 152 can lead to the imposition orcriminal penalties ofa
tine up ro S1.500.00 and/or one-year im 'mnment, as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S_'50.00 a Jay�gdiitst�Iie Jiula t ilyised That a caipy:uf this sraiemcnt may be forwarded to the of icc of
Inecstigwiunt ol'lhc DIA f ills ante cnvemyc iticaliun.
/do hereby crrtijy r der t e ' s and praa/tlrs of per' deal the informutlmt provided above is true and correct
Si-gym t re' Date:
PH , •,t: q 40 1 0.0
Of/idol use un1y. Du not wrile in this area,to be completed by city or tosvn o/)lria4
i
City or Town: _ PermiMcentc I
Itsuiag Authurily (circle one): -_- --�- ---
1. (Board of Ilcalth 2. ❑uildlnq Department 1.Ciiylrwt n Cferk J. Fleetrical Inspector 3. Piumhiag Ills pc 1.1
6.OUter
Contact I'c rsnnr Phamc;t: I
QTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120WASHNGTON STREET,3ADFLOOR
++ TEL. (978) 745-9595
KIMBERLEY DRISOOLL FAX(978) 740-9846
MAYOR THoNiAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 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 properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
LMC. D15PoSAL
(name of hauler) CDurAPSrg�
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
g�'yl,Y
Date
Massachusetts -Department of Public Safety
^ Board of Building Regulations and Standards
Construction Supervisor
License: CS-091643
I 1.
PATRICK M OSG'00
PO BOX 1111
MARBLEHEAD MA
J..L.� -" Expiration
Commissioner 0 5/281201 5
Office of Consumer Affairs and Business Regulation
- 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 134220
Type: DBA
r, i _ _ Expiration: 10/12/2015 Tr# 245802
OSGOOD PAINTING SERVICES :;'
PATRICK OSGOOD
PO BOX 1111 - ---
MARBLEHEAD, MA 01945
Update Address and return card.Mark reason for change.
s0A 1 O 20M-05/1 1 ❑ Ad ress ❑ Renewal F] Employment Lost Card
�P inovm uu�>lI�2�C%ltaa�ac/r�uPCG
Office of Consumer Affairs&Business Regulation License or registration val for individul use only
OME IMPROVEMENT CONTRACTOR before the expiration date. f found return to: -
_ _ egistration 134220 Type: Office of Consumer Affairs ad Business Regulation
-- .'Expiration 10/122015 DBA 10 Park Plaza-Suite 5170
Boston,MA 02116
OSGOOD PAINTING::SERVICE&
PATRICK OSGOOD ,:'
44 FOX RUN RD. �,,,2
TOPSFIELD,MA 01983 Undersecretary o alid ut signat re
NOTICE OF ASSIGNMENT w cotAp polley
EMPLOYER: COMBO LD. STATUS OF EMPLOYER
OSGOOD PAINTING & CONTRACTING SERVICES LLC 000171251 Limited Liability Com
15 ROPES STREET
SALEM, MA 01970 COVERAGE GROUP
0171251
Coverage under this assignment
The Waiver of Our Right to applies to Massachusetts
Recover from Others Endorsement operations only. For coverage
is available on Pool policies. outside of Massachusetts, contact
Contact your agent for details. the appropriate Pool or Plan for
that state.
INSURANCE COMPANY:
AGENT SEGREVE & HALL INSURANCE ASSOCIATES INC AIM MUTUAL INS CO
OR LARRY HALL
PRODUCER: 305 NORTH MAIN STREET Judith Barry
54 THIRD AVENUE
ANDOVER, MA 01810 P 0 BOX 4070
BURLINGTON, MA 01803-0970
AGENCY FEIN:043120728 (800) 876-2765, Ext: 8704
CLASSIFICATION OF OPERATION CLASS ESTIMATED RATE ESTIMATED
CODE TOTAL ANNUAL PREMIUM
REMUNERATION
CARPENTRY-DETACHED ONE OR TWO FAMILY DWELLINGS 5645 $16, 000 8.68 $1,389
PAINTING OR PAPERHANGING NOC & SHOP OPERS, DR 5474 $56, 000 5.09 $2,850
CLERICAL OFFICE EMPLOYEES NOC 8810 $15, 000 0.09 $14
CARPENTRY-DWELLINGS - THREE STORIES OR LESS 5651 $0 8.68 $0
CARPENTRY NOC 5403 $0 9.61 $0
ROOFING NOC & YARD EMP, DRIVERS 5545 $0 30.99 $0
EMPLOYERS LIABILITY 100/100/500 9845
STANDARD PREMIUM $4,253
EXPENSE CONSTANT 0900 $338
TERRORISM CHARGE 9740 $26
TOTAL POLICY MINIMUM PREMIUM $500 -
TOTAL ESTIMATED PREMIUM $4,617
.DIA ASSESS. 3 .4% $145
TOTAL EST. PREMIUM PLUS ASSESSMENT $4,762
INSTALLMENT BASIS: Annual . DEPOSIT PREMIUM: $4,762
THIS IS NOT A BILL
r
COMMENTS
Coverage effective 12 :01 AM on 07/23/13 .
Subject to 07/21 Anniversary Rate Date.
DATEOFNOTICE: 07/24/13 PREPARED BY: Paulette Hoffman
EXT 514
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street • Boston, MA 02110
(617)439.9030 • FAX(617)439-6055 •www.wcribma.org
NOTICE OF ASSIGNMENT
LETTERID: * * VOLUNTARY DIRECT ASSIGNMENT
4001435
The Workers' Compensation Rating and Inspection Bureau of Massachusetts
101 Arch Street • Boston, MA 02110
(617)439-9030 •FAX(617)439.6055 •www.wcribma.org
I