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30 GROVE ST HOUSE - BUILDING INSPECTION • S The Commonwealth of Massachusetts ' OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR Revised Mar 20/1 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Divelling This Section For Official Use Only. Building Permit Number-, Date A lied•-': -0 Co f LG Building Official(Print Name). 'Sigrkrure Date SECTION 1:SITE INFORMATION L1 Property Address: 1.2 Assessors Map& Parcel Numbers V at (HOUSE) ''.. I.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(sq it) Frontage(11) 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❑ SECTION2: PROPERTY OWNERSHIP' 2.l Ownert of Record: Proprietors ve AtArly Salem, MA 01970 �me(Print) City,State,Z / 30 Grove Street 978-744-0554 N/ g No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORIV(check a)1 that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': t/1i 1�� 't- 'n T Utiv`' SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Labor and Official Use Only Materials) I. Building $ 1. Building Permit Fee:$ - Indicate how fee is determined: ❑Standard City/Town Application Fee - 2. Electrical $ ❑Total Project Costa(Item 6)-x multiplier x . 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: . 5. bfechanical (Fire $ Su)pression) Total All Fees:S Check No. Check Amount: Cash Amount 6. Total Project Cost: $ Cl Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES , 5.1 Construction Supervisor License(CSL) /'e— O B 98 0V -J ey-"�F SI��a $ License Number Expirotion Date T Name of CSL Holder List CSL'fype(see below) No.and Street Type Description . � '^'r_,, Q U Unrestricted(Buildingsu to 35,000 cu. 11.)Pro� (2 J Y "" b I a 3 R Restricted 1&2 Family Dwelling Citylrown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding Q1� SF Solid Fuel Burning Appliances Insulation Tcle hone Email address D Demolition 5.2 S Registered Home Improvement Contractor(HIC) f -7) O 2-D Z ) V L-"F V Z B k HIC1Registration Number Expirotion ate HIC Compmay Name or HIC Registrant Name/ - 1O 3�PrtvxC S� PC) No.and (�tJyell0 �� 1�� 928-7SD-3b62 Email address Street Ci[ /Town,State,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 f the building permit. lit Signed Affidavit Attached? Yes ......... No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BECOMPLETED WHEN, OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Administrator I,as ert=r of the subject property,hereby authorize SGFf- 5-( 9?o I S t4 act on my behalf,in all matters relative to work authorized by this building permit application. Margie K. Lavender, Administrator Se t S a91 � Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW 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 t�h' application is true a accurate to the best of my knowledge and understanding. 13 Print Own s of i\41iorfzcd Agent's Name(Electronic Signature) Date NOTES: L 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 M.G.L.c. 142A. Other important information on the HIC Program can be found at avw.v.mass..,,ov�ota Information on the Construction Supervisor License can be found at www.nanes.eov/dps 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" CITY OF SAL.EM, NtASSACHUSE'ITS BuILDNG DEPARTMENT • 120 WASHLNGTON STREET, 31D FLOOR TEL (978) 745-9595 FAX(978) 740-9846 K11tBERLEY DRISCOLI T MAYOR Fi06tAS ST.PIFn 9 F DIRECTOR OF PUBLIC PROPERTY/HCILDNG CO%LVISSIONER 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 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 MGL c 111, S 150A. The debris will be transported by: 4 -J-e� s l e o i'e (name of hauler) The debris will be disposed of in G ryeAl o —_.._._._ (name of facility) address of facility) si a re of permit applicant date dcbriia�f dew !ee CITY OF Siu_Emll INLALSSACHUSETTS Ouimi:NG DEPARTMENT 120 WASHQVGTON STREET,3'iD FLOOR TEL (978) 745-9595 FA.e(978) 740-9846 CINfBERLEY DRISCOII THOStASSr.PtEQRH MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING COSMIISSIO.iER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlcfans/Plumbers Atnalicant ln(ormation Please Print Legibly Va1nC(0wincss,Organi:atiorvindividual): ��1 S I eD r S Address: City/Stata/Zip: M-13 Phone hl: °I 79 ~r/- _b -3(, (� 2 Are you an employer?Check the appropriate box. Type of project(required): I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New,construction ipioyees(full and/or pact-time).• have hind the subcontractors . 1 am a sole proprietor or partner. listed on the attached sheet.t 7• L1 tcamodeling ship and have no employees These subcontractors have a. ❑ Demolition working fur me in any capacity. workers'comp.insurance. 9. El Building addition [No workeri comp. insurance 5.'❑ We are a corporation and its rcquirc l.) offtcers have exercised their 10.❑Electrical repairs or additions ).❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§101,and we have no 12.❑ Roof repairs insurance required.]t employees.[No workers' I1.0 Other comp:insurance retuin:d.J. •Any applicant that shoals hex r I mutt also rill uut the saclloa below showing thou workers'companwdun policy information. r I Ltmeuwtam who submit this affidavit indicminy they an dotna all work and Aca hire"laid*contractors maul submit a taw aMdavit;ndiainO such. !Contradon teal check this box mesa arlachcd an addieumt that thuwina the time of the sub c ntmdun and their wurkao'comp.polity Informalloe. fain a r euployer that is pruvfding ivorkers'rompatrratlan lhtsnranae for my employees: Below is the policy and Job sill irjornrulfam Insurance Company Name: Policy U or Sc1f-ios.Lie. 0: Expiration Date: Job Site Address: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of STOP WORK ORDER and a tine of up to S2S0.00 a day against the violator. Ile advised that a copy of this statement may be furwurded to the Ofiee of InvestigWiunty ul'the OIA for insurance covemga verification. /do hereby cerdjy under thr paW and pensdles ojperjury t/rat the hifurnnuNat provided above is true and c•arreet. ii��nnur�� Data• ��/� Phone,l• OJJlcial use only Oa not rvr/te its this area,to be carrpleted by,city or lawn afflc ful. I City orl'uwn.- Permit/f.lcense'q I.suing Aulhority(circle one): 1. Dourd of Ilealth Z. Iluildinq Department .1.Cilyffown Clerk 4. Electrical luspector 5. Plumbing; Inspector 6.Other � Concoct Person: Phpne ti: [ A� ® CERTIFICATE OF LIABILITY INSURANCE DA09/04/2ODl 3Y) O 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 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 Mark Collins Phil Richard Insurance, Inc. NAME` PHONE27 Garden Street UUC_N (978)774-4338 x120 aC Na: (978)774-1318 Unit I E-MAIEss: mark@masspayinsurance.com ADDR Danvers,MA 01923 INSURERS AFFORDING COVERAGE NAIC M INSURER A: INSURED Sirois&Sons Construction INSURER B: 2 Franklin Street Apt 1 Danvers, MA 01923 INSURER C: 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 TYPE OF INSURANCE ADOL SUER POLICY NUMBER MMIDCY EFF MODIDY EXP LIMITS LTR GENERAL LIABILITY TBD 09/03/2013 09/03/2014 EACHOCCURRENCE $ 1,000,000 DAMAGE TO RENTED 1 OO,000 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ CLAIMS-MADE V OCCUR MED EXP(Any one person) $ 5,000 PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea a.loant $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ NON OWNED PROPERTVDAMAGE $ HIRED AUTOS AUTOS Peraxident 8 UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ WORKERS COMPENSATION TBD 09/04/2013 09/04/2014 WC STATU- DEN EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUIVE YIN E.L EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED' NIA (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ 100,000 es,describe under 500,000 DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT 8 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washington St 3rd Floor ACCORDANCE WITH THE POLICY PROVISIONS. Salem, MA 01970 AUTHORIZED REPRESENTATIVE /f7 ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD � �.�'r�rnrc t`"e�Oim ra airs `�irc`5 + 71 C* '' _— HOM.E IMPROVEMENT CONTRACTOR Ty' � Regi"strauon �171020 r 4lndmdu � . Expiration 2I1I2�014 F ! - EY S SIROlt '- F 12^� ,lEFFREY SIROI�� k 10 ADAMS ST. /r� g t DANVERS', MAO1923 / Unders cretary Massachusetts -Department.of Public Safety Board of Building Regulations and Standards Construction Supervisor License: CS-088804 JEFFREY S SIROO P.O. BOX 51 r n DANVERS MA 0192A s Expiration Commissioner 06/23/2014