60 GROVE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
1 y Board of Building Rcgulalions and Standards
FOR
\Il'Nll'll'.\Ll ll
t.' Massachusetts State Building Code. 780 C'MR. 7 edition I SI. b
Building Permit Application To Construct. Repair, Renovate Or Demolish a R,i oed.ht m ,i 1 (�
One- or Tn'u-Funtilt• Dtrellin•G
This Section For Official Use Only
Building Permit Number: Date Applied: —_
Signature: _ 31 O� -----
it g Cum mi ssi uner/ IlzWecror of Buildings Date
SECTION I: SITE INFORMATION
1.1 Pro e\y A ress: Q+ 1.2 Assessors Map & Parcel Numbers
v —
L la Is this an accepted street? yes no Map Number ('arcrl Nmnbrr
1.2 Zoning Information: 1.4 Properly Dimensions:
I rirg i?iur,a Pnipused L'se Lor l`irea Isu It) Fr.,nrcc Uri —__--
1.5 BuiMing Setbacks(ft)
---- Front Yard Side Yards Rear Yard
Required Prodded RcyuireJ Provided Required PruvidrJ
1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone' Nl on ici al On site disposal s stem ElPuh�i Private ❑ Check if yes❑ P 1 1'
SECTION 2: PROPERTY OWNERSHIP'
2.1 wt 'of Rec �o l�lJx
Name Pin ) A ess Ser e:
� �� 130 --
S gn- re "Cclephune
— —i
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition 0
g
Dernolition pJ LAcCCSS0ry Bldg. ❑ Number of Units Other ❑ Specity:_— —
Brief De �ipi�ofPpose¢t�Vurk� -
VV[C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building S -� _ L Building Permit Fee: $�_^—indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (It )6) x multiplier x
i
3. Plumbing $ t),/ 2. Other Fees: $
a. Mechanical (HVAC) .$ List: i
5. Mechanical (Fire S
Suppression) - Total All Fees:pS�
Check No1jolod Check Amount: Cash :\nn nnll:
j 0. Total Project Cost: .$ , Paid in Full 0 Outstanding Balance Due:_
SECTION 5: CONSTRUCTION SERVICES
5�.1\Licensed Construction Supervisor(CSL) 5, L `��� 5
R — a-�
ilw �� �t�(�O Y CQ License Number I:\11nation Due
Nance of CSL- Ilolder
,� t� �r1D S. List CST_Type(see below) _
T c Ucscn Ilion
aJdrc..
Ma C Unrestncied t Lip it)J?.1H10 Cu. Et.i
` R Restricted 1&2 Funiilq Duelline
Signature `\ H Masonry Only
RC Residential Rooling('menms
Telephai} \1'S Residenial Windo, end Sidmql _ __
`�� SF Residential Solid Purl liunune \pplemce liordl.w�ai 1
D Residential Demolition
5.2 Registered Home Improvement Contractor (HIC)
HIC Company Name or HIC Registrant Name-- RegtS:ratio:, Number
Address —
Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 3 2f Ci6))
Workers Compensation Insurance affidavit must be completed and submitted with this aprGcai.m. Failurr to pronde j
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... "e ........... ❑
__S _______
ECTION 7a 3 @E F.D
: OWNER AUTHORIZATION T1 :"0�11 L•E'P WHEN --
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUiL_DING PERMIT_ it
1, , as Owner of the subject property hereby
authorize_ _ _,_ to act on my behalf, in all matters
-'elative to work authorized by this building permit application.
Sien,tnu_c of Owner ---------- --... Date
SECTION 7b: OWNEW OR AUTnORIZED AGENT DECLAR.." ION
I. — , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Narne — — — ------�- - ----
Signature of Owner or.Authorized .Agent Date
(Signed undo;the 2ains and penalties of perjury)
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 M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 730 CMR Regulations 110.R6 and 1 10.R5. iespeoni ely.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.I (including garage, finished basement/attws, decks or porcht
I Gross living area iSq. Ft.) Habitable room count _
Number of tireplaces Number of bedrooms _
Number of bathrooms Number of half/baths
I'vpe of heating system Number of decker/ porches
rype of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR"1'MENT
III '/�F �J�' �• � � I \\'. 'i�%-�J: •ti L,
Construction Debris Disposal Affidavit
(reiluired lirr all demolition and renovalion work)
In accordance %%ith the sixth edition of the State Building Code, 7SO ChIR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with (lie condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal Iacility as defined by MGL c
111, S 150A.
The debris will be transported by:
�FrA r Sdy�
I nomc n[hauler)
I he debris will be disposed ofin
(name ul Ihcility) ` n (�
:�I�ie 1 cX 1 , `O"',
luddres. ut( vlirvl
nulam • of Penn t dpphcant
dale
CITY OF SALEM
irk PUBLIC PROPRERTY
DEPARTMENT
.I\tn:HI PY:AINC, I
�I Est A 12C WMHI\d(U\S-(aeh'r • SAU.M,MAi.+.\Citt it.'I ISO197C
7T.1.:978.743-9595 • PAx: 978-74C.I846
Workers' Compensation Insurance Af idavit: Builders/Contractors/Electricians/Plumbers
truant Information ( �/�"""/�A Please Print Leeibly
V 81T1.: lBusiucsyOr;;anir:uinrvindrvulual): J�\V Q u1 L�('OA7 ST C 0 -1 'v C
Address: 1 uj G st5 I 3
City,Slaw,zip: 1�jE) ! CLy I MW Phone 'U:-908 V u
I .tire you an employer? Check the:appropriate box: 'Type of project(required):
I. 1 all,a employer with_ ...— A. ❑ I am a general contractor and 1 6. ❑ New construction
employees(full and/or part-time).' have hired the sub-contractors 7. ❑ Remodeling
?.❑ 1 am a sole propric[or or partner- listed on the anachcd sheet. :
These sub-contractors have 8. Demolition
ship and have no employees
working for me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
IKo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
officers have exercised their
ion per MCI. 11.0 plumbing repairs or additions
3.❑ ro .] right of cxen[pt
1 ant a homeowner doing all work S C. 12.❑ Roof repairs
myself. INo workers' comp. employees.
ces. [No workers'
have no
insurance required.] t emproloye 1(4),and 13.0 Other
comp. insurance rt:quircd.]
•Wi :yaphcaua that checks box ill must also till out the sa,ctian Ixluw showing their wurkui cumpenwlioo policy intinnwaion.
'lit)ry meuwnen whu•tdamil this affidavit indicating they ate doing all work Atw then hire outride cutumelon must euhmit a new affidavit indiuiing such.
that check this box must Sowh.d an addilimul sheet+hawing the name of the sub-eommctors and their workers'comp.puGry informarion..
/om an employer that is providir{q workers'compen.vation incurrutce for my emplu}'ee.+. Below is the puticy andlob sale
information yt��y(1,e1
Insurance Company Name:-��-.__- 1 1"'��� ,av
laolicv 4 or Self-ins. Li/c._*7:� (? (� ` - Expiration Date: lyJ��
JobSitz .Address: (OD V`" 1�-��� _ City;Stateizip; .S/7L'GJ�' L—
Attach IL capy of the workers' compensation policy declaration page (showing the policy number and expiration dale).
I-'ailurc to sccurc coccrage as required under Section 25A ol'.%IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 31.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 is day agaiMt the violator. lic advised but a copy of this statement may be lorw'arded to the Office of
I u+'rsngaunns of the DIA ibr instuar.ce coocra,-I; .ciilicauon.
l do her.•by c:riif iiii,ler the pain.+'mtd/l enultics of perjury that the iufurmution pruvided�e is true and correct.
IC) t ` o
I)ate:
�ieaamre: pp n
19t • :i 1., S
O�/iciul use only. Do not write in this urea, to be completed by city ur torus official. -
City or'I'own: -. Permit/license 0._
Issuing:\uiliurily (circle one):
I. lluard of lle:dth 2. Building Npartincut 3.Cit%ffown Clerk d. L•'Icctrical luspcetor 5. Plumbing Inspector
6. 01tier
Cuutact Pcnon: _ . .__ Phone it:
r
Information and Instructions
,Vavachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuaru to this statue,an emploree 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 orother legal entity, or any two or more
of the toregoing 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."
SIGL 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, hIGL chapter I52, $25C(7) states"Neither the comirionwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence ofcompliance 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) namc(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 confutation of insurance coverage. Also be sure to sign and date the affidavit. The al'tidavit should
he 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 till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicerse 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 tilled 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he i)ttice of Investigations would like to thank you in advance fur your cooperation and should you have:my questions, _
pleuse do not hesitate to give us a call.
The D.parunent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents,
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
R:vi,ed 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
JUL-31-2008 09:48 From:UGONE-JOHNSON INS. 9788875517 To:9787409846 P.2/2
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE ID(MMD/YTYY)
---T '" 0713 1/20 08
PRODUCER 978-887.8304 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
UGONE-JOHNSON INS.AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
DALE JOHNSON HOLDER. THIS CERTIFICATE DOES', NOTI AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY T:HF_ POLICIES BELOW.
10 S. MAIN STREET, SUITE 208
TOPSFIFLO,MA 01983 INSURERS AFFORDING COVERAGE NAIC#
IHsuacD
,NSURERA.; FARM FAMILY CASUALTY INSURANCE
.IONQUILL CONSTRUCTION INC. INSURER E.
9 ACCESS ROAD INEURCR C: _
BEVERLY, MA 01915 INSURER O: .., .
INSURER E.
COVERAGES
THC POLICIES OF INSURANCE LISPED BELOW HAVE BEEN ISSUED TO THE INSVRED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWlrHBTANDING
ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHCR OOCUMCNT WITH RESPECT TO WHICH PHIS 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.AGGREGATE LIMITS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS. i
INSR OU' POUCY NVM6$R POUCYRFPGCTIVG POLICYRYPIRRTION
Wpm OF INSURANCE LIMITS
CENERALIJAOILITY CACI'I OCCURRENCE. $
1,000,000A MAE
r MMF,RUALNFNFRALLIAHILIIY 2005L6535 11/20/07 11/20l08 YHI suRNal e 100000
CLAIMS MADE n OCCUR MED EXV(Any one emun s 5,0.00
PFRSONAL$IAOV INJURY $ 1 DDD,D00
GENERALAUOREOAvE S 2,000,000
GEN'LACGREORI'E LIMITAPPUES PER: PRODUCTS.COMPMP ACC, $ 1,00QOL10
POLICY PRO- LOC
A AUTOMOBILGLAMUTY COMBINFO SINGLE LIMIT $
ANY AUTO 2001 C4873 11/20/07 11/20/08 (Ed
ALL OWNED AVIOS —
NUUILV INJURY 5 5001000
X 3OREOULEO AUTOR (Per Unread
HIREDAUTOS
NON-OWNFO AIJTOR (Po'.gldom)NY = 1,000,000
PROPERTYnAMAGE 5 100,000
(Po,.,idPRl) -
DARAUELIAMW AUl'O ONLY.EA ACCIDENT $
ANY AUTO OTHER THAN EAACG $
AIITO()NI,Y AGG $
63CESSIUMCRCLLA LIABILITY EACH OCCURRENCE S
OCCUR u(:LAIM$MADE AGGREGATE §
§
DEDUCTIBLE
RCTENTION § $
A WORKERS COMPENSATION AND 6 ATtI� OTH•
$MPLOYOR$'LIAOILR 2005W6914 11/20/07 10/23lOD -TEH -
MyPKOPRIETORlPARTNER/EXECVTNE E.L.EACHACCIDENT, $ 500.000
OFFICERMEMSEREXCLUDEDT LL.OISEAK.CACMPLOYC $ SO0,000
II yyee CSxdlre undw
SPECIAL PROVIRIONS h,,I. E.L.OISEASE-POLICY LIMIT 5 52001000
OTHER
DCSCRIPITON OR OPERATIONS I LOCATIONS I VBHWLRS I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
LIABILITY POLICY INCLUDES LANDSCAPE GARDENING, SEWER MAINS AND CONNECTIONS, EXCAVATION, STREET CLEANING.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OP THS ABOVE O$$CRIBED POLICIES BC CANCELLED EEFORR TNB UPIRAMON
CITY OF SALEM DAYS THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN
PUBLIC PROPERTY DEPARTMENT NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 80 SHALL
NU
121 WASHINGTON STREET IMPOSC NO ORLAT01 OR LIAWLITY OF ANY KITID UPON THE INSURER,ITS AGENTS OR
SALEM, MA 01970 REPRESENTATWCS.
978.740.984E AUTHORISED RBPRESENTATIVB
TP Johns n
ACORO 25 120D1108i 1 0 ACORD CORPORATION 1989