28 1/2 GROVE ST - BPA-08-1051 KIT, ROOF, REPAIRS r 1'he Conunonwcalth ut i� ;I55;1Chn5et11
t Bo'lyd kit l3uilding Regulations and Standards PI Ht
S ,� VlassaChusetts Slate Building Code. 7S11 ('N1R. 7 edition �L
'r Rrrur,l aI I
Building Permit Application To Constntrt. Repair. Renuc:te Or Drn (>lish a
One- nr Tu o 1-*umi1v Duelling '00S
This Section For Official Use OnlY
Building Permit Number: Date Applied: - (7 --—_---
Signature: - — s—k- --------
131r 'unmtuaonei/ In. 'clot t dines Dale l
SECTION I: SITEI INF'OR-MA HON
LA) rly Address: 1�2 :Yssessurs Map & Parcel Numbers -------
I.la Is this an accepted street.' ves___ no__ Map \'umber Pori Cl ,NW11hC1
1.3 7,1ylin Information: pp 1.4 Property Dimensions: ---J
Zoning District Proposed Use Lot Area(sq 11) Frontage (it)
1.5 Building Setbacks (ft)
Front Yard Side Y:ads Rear Yard
! Required Pro,ided Regwrcd Provided Required Pnnided
i
1.6 Water Supply: (M G.L c. 10. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public ❑ Private❑ Check it yes❑ Municipal ❑ On Site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
,27,.1 Owner of RecoA3
e (P t I Address for Service:
e?,7P SRO —
St¢n Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ I Existing Building IV Owner-Occupied ❑ Rept us(s) o" Alteration(s) ❑ Addition ❑
Demolition � Accessory Bldg. ❑ Number of Units_ Other ❑ Spectly:
Brier Description of Proposed Work': Al
j r
Z a
SECTION J: ES'rIN1ATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials) _
I. l3uilding ) 0 O I. Building Permit Fee: S Indicate flow Ice is determined:
_. Electrical ,4- 0 0 0 C7 Standard City/Town Application Fee
S ❑Total Project Cost (Item 6) s multiplier c
1. Plumbim_ S 0 O� 2. Other Fees:
4. 'Mechanical (H VAC) 5 List:
5. Mechanical (Fire
S Coral .All Fees: S I
Sup rC11iUn)
Check No Cheek :Anoun: Gash .-Amu nut:—
Total Project Cuss: (� _---
1 D D I ❑ Paid to Full ❑ Outs':mdille Balance Utz:._____
SECTION 5: CONSTRUCTION SERVICES
rlLicensed Construction Supervisor (CSL) 1_ieensc Nunhcr I:.,pinanun DoteCS L- IIuIJer
I.(,( C'SI..Tvpe (sce helow)
Wdres> fr c Deseri tion
L in esuIcled (u r(o 3i.000('u- 1-(.)
R Restricted l&,2 Fanny D%%c[ling
Si_n:uurc \t Maxon'\ Only —
I
RC Res(dcnnul R oa line C'uscrim_
l\•lephonc \\'S KoiJcnnal \\'mdo,, .ind slidine
SF Item Jcnu.(I Suhd (ucl Bunu11L' \ppli.incc 11 11( 11I.mIn1�
D Re,ldenual DenwhWm
5.2 Registered Home Improvement Contractor (HIC) �✓ ✓ Z/
III Company Nun or FIIC atra t Numc 12eg(strauon Nunber
n rn � a,t•>� c�r y�3 3
ExpKation Date
S,enamrr 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. F:ulure to pnnide
this affidavit will result in the denial of the Issuance of the building permit
Signed Affidavit Attached? Yes .......... ❑ No ........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property hereby
authorize 50(1, to act on my behalf. in all mallets
relative 'v rk authorized by this application. l
Si atone of Owner Date
SECTION 7h: OWNER( OR AUTHORIZED AGENT DECLARATION
I. ✓l(/ StY16i as Owner or Authorized Agent herchy declare
that the statements and information on the foregoing application are true and accurate. to the best of my knowledge and
bdf. l GYiC, S�
Signature of Owner or Authorized Agent Date
(Sieved under the l2anis and penalties of erjurv)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregislered cuntraCor
(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. I42 A. Other important in formation on the HIC Program and
Construction Supervisor Licensing (CSL) can be tound in 780 C'MR Regulations I M.R6 and I I0.R5, re,pecticely.
'. When substantial work is planned, provide the information below:
Total flours area lSq. Ft.) (including gm'age, finished basement/attics, decks otpoichi
Gross living urea tSq. Ft.) Hahitable room count
Number of fireplaces Number of bedroom, ----
Number of bathrooms Number of hall/ha(h,
'1-vpe of heatine system Number of decks/ porches -- __---
Type of cooling S)'stem Fnclosed Open
"Total Project Square Footage" may be substituted fin "Total Project Cost"
ACORD" CERTIFICATE OF LIABILITY INSURANCE DATE,MMIOOIYYYY)
rw 02/26/08
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
FRIENDLY INSURANCE AGENCY, INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
471 WESTERN AVENUE ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
LYNN, MA 01904
781-593-4344 INSURERS AFFORDING COVERAGE I NAIC N
INSURED wsuft[a A A[-LERI CAN INT NA COMPAN ERNATIOL IES
ERIC SOK ( INSURER B'.
ES HOME IMPROVEMENT INSURER C:
164 DAYTON STREET i11sURERD
DANVERS, MA 01923 INSURERS.
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTV:ITHSTANDING
' ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT !`IIITH 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 SUG1
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Ili$P��AT)4'E POLICY EFFECTIVE POLICY EXPIRATION j
LTR IIN-% TYPE OFINSURANCE I POLICY NUMBER CATS MMIOO!YY 9AIE(MMIDDIYY) LIMITS
GENERAL LIABILITY
EACH OCCURRENCE 5
PREMI ES(EA..TE�
GONMERGIAL GENERAL LIABILITY PREMISES(Ea occu,ence) S
CI-AIMS MADE a OCCUR AEG E%N(Any ene Oasan) _I E
—~I PERSONAL$ADV INJURY 5
IGENERAL AGGREGATE 15
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS COMPIOPAGG I5
POLICY LIEGE LOG
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
(Ea acuUanp 5
ANY AUTO
A ALL OWNED AUTOS 5
_ BODILY INJURY
SCHEDULED AUTOS BODILY
ILY INJURY
HIRED AUTOS BODILY INJURY
(Per accitlenq 5
NON�OWNED AUTOS
PROPERTY DAMAGE 5
(Per acnCeet)
GARAGE LIABILITY AUTO ONLY�EA ACCIDENT 5
-� ANY AUTO OTHER THAN EA ACC S_._
AUTO ONLY: ADS j $
EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE 5
OCCUR El CI-AIMSMADE AGGRGGATE 5
DEDUCTIBLE s
RETENTION 5 5
A WORRERSCOMPENSATIONANO WC9975929 11/10/2007 11/10/2008 N`Ic sTATu- oTR.
—L TORY LIMITS ER
EMPLOYERS'LIABILITY E.L EACHACCIOENT 5100,000
ANY
PROPRIETOWPARTNEWEXECUTWE - "No
OFF ICERIMEMBER EXCLUDED? EL DISEASE EAEMPLOYEE 15500,000
11
m yes,aescr,oe aer
SPECIAL PROVISIONS below E.L.DISEASE POLICY LIMIT III5 IDO,000
OTHER
I
.I DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS AOGEO BY ENDORSEMENT I SPECIAL PROVISIONS
I
I
I
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF, THE ISSUING INSURER INILL ENDEAVOR 70 MAIL 10 DAYS WRITTEN
I NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO 00 SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER. ITS AGENTS OR
REPRESENTATIVES.
1 i AUTHORIZED R[PRESE'aATI:'E � vY
ACORD 25(2001108) IF ` ACORD CORPORATION 1988
s License or
for
ul
on
vi
Board of Building �0 4 Staa, r before the a pi atioln date.i if foundlreturn only
ENT CONTRACTOR Board of Building Regulations and Standards
IN�Mnti 135311 One Ashburton Place Run1301
W2?12010 TAt 265782 Boston,Ma.02108
E r s NONE ltrPNOVE""E"IT ,��%'
eBc aoa
16$DAYMN Not valid without signature
DAWNV .1m 018¢3 Administrator
e f
s
CITY OF SALEM
PUBLIC PROPRERTY
n� DEPARTMENT
-', tllP'tl -1' :IY IiI `I
\Ll�,'lc - I_': \C.l,nc:�;!-.��i�!u.t.r • <.v!-xL \In•:.t� rn .r i :. :1'1^. '.
1'1 1 : 978-7 15 959; F tx: 9,-8-?1:984n
Workers' Compensation Insurance Affldacit: 13uilders/ContractorsiEleetricians/Plumbers
A 1 tlicant Information Please Print Le ib1
�;lllll: t nu.;mrs t Irgantcunnt Inds iJuall: 5 v, `-'�"'�'� 4 6 t"r'"—"`�`
Address:
City.State;Zip: J)Ciah.
tllR-IrS Phone : �C6=7�v� �J('
Are_sou an emplo)er:' Check the appropriate box: - rype of project(required):
I. I :fin a employer with 4. ❑ 1 :fin a general contractor and 1 6. ❑ New construction
enl lu ees(full and/or part-time).* Ila%e lured the subcontractors
'.❑ 1 :um a sole proprietor or partner-
ship P listed on the attached sheet. 7 Remodeling
ship and have no cnlployees These sub-contractors have 8. Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
o workers- cons insurance 5. ❑ We are a corporation and its
[N• P officers have exercised their 10.�Electrical repairs or additions
required.]
right of exemption per NI I I. Plumbing repairs or additions
3.❑ I ❑m a homeowner doing all work S P P
myself. [No workers' comp. c. 152, }1(4),and we have no 1 I.XRouf repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.]
•Any applicant that cheeks box 01 must also fill out the section below showing their workers'compensation put icy information.
t I fomeuwners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
:('omractors chat check this hoa must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l inn an employer that is providing workers'compensation insuraneefor my employees. Below is the policy and job site
information.
Insurance Company Name: Iv'•�u ��q���W
Policy d or Self-ins. Lic. q: t`-3C����' ' [ Expiration Dater
Job Site Address: 'DV� C�YpVh 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 NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S I.i0o.00 and/or one-year imprisonment. as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
InveslieationS of the MA for insurance coverage Verification.
i to hereby certi/j' fill er Ire pains and penalties ofperjury that the infimrmnution provided above is true and correct
ii n our Dm q�Oj
II n � qk 76, 1 `1
tl(jiciai use only. Do not write in this area, to be completed by city or town offrciat
Cits or Town: _— --__— -- Permit/License #—_-- _--
Issuing Authority (circle one):
I. Board of ilcelth 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person:- _ - _ — -- Phone p:__
Information and Instructions
\1.ISS. USCuS GCner[l Laws chapter I--' requires all employers to provide workers' compensation for i their employees.
I'ursu.tnt to this statute, All cutphoree is detlnCd as ".._even person in the service of:mother under any contract of hire,
evpress or implied, oral or written."
.\n entp6�rer is dalined as "an indi%idual, partnership, association, corporation or other legal entity, or any' two or more
of the lixegoing engaged in a joint cn[crpnse, and including [he legal represcntam es of a deceased employer, or the
reccivcr or trustee of an individual, partnership, association or other legal entity, employing employees. I lowever die
o,vner 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
,)r tin the grounds or building appurtenant thereto shall not because of such employment be deeuted to be an employer."
\1GL :hapicr 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 anv contract for the performance of public work until acceptable evidence of compliance with [he 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 Imestigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permitilicense 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
)ear. 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your coopetation and should you have any questions,
please du not hesitate to give us a call.
[lie Depaftutent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Off ce of Investigations
600 Washington Street
Boston, MA 02111
TelA 617-727-4900 ext 406 or 1-877-MASSAFE
Kecised ;-'(i-Oi
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
120 WASI HNG ION SCI(LET 0 SAI 1:.\I, \[A\]A( H I ti1,I ISO I'll"'
TIT: 978-745-9595 0 FAX: 978-74.,1)846
Construction Debris Disposal Affidavit
(required fior all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions of MGL c 40, S 54; -is resulting BUildin_9 Permit 4 -- is issued with the condition that the debt . from
this work shall be disposedof in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
0
(late
dcim,�!Idoc