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50 HALSEY - BUILDING INSPECTION ao The Commonwealth of Massachusetts l Department of Public Safety 6lassachusetts State Building Code(780 CNIR) Z 7 Building Permit Application for any Building other than a One-or"rwo-F mil D i (this Section For Official Use Only) Building Permit Number: Date Applied: Building Official SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) SI> t�Sry liA��--� O/970 No.and Street City/Town Zip Code Name of Building r 6(if applicable) SECTION 2 PROPOSED WORK Edition of NfA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair rllturation ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied ns part of this permit application? Yes ❑ i o-) -10 Is an Independent Structural Engineering Peer Review re aired? Yes ❑ No ll� Brief wDer riptionfo f Proze.d Work: RMB 0. o 7 f •'STr.v io r ..+ S WLr• �.t - e SECTION 1 CONIPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780.CNIR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA t Existing Proposed NoRFactoF- of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.) (sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as a licable) ly A-1❑`A-2❑ Nightclub ❑ A-3 ❑ A4❑ AS❑ B: Business ❑ E: Educational ❑ F-1 ❑ F2❑ H: Hi h Hazard fl-1 ❑ H-2❑ H-3 ❑ H-4❑ FI-5❑ onal I-1❑ 1-2❑ 1-3❑ 14❑ Nf: Mercantile❑ R: Residential R-I R-2❑ R-3❑ R4❑ S-I ❑ S-2❑ U: Utility❑ Special Use❑and pleasedescribebelow: SECTION 6:CONSTRUCTION"TYPE(Check as a licable) IA ❑ IB ❑ IIA ❑ IIB ❑ IfIA ❑ IIIB ❑ IV Cl I VA ❑ VB ❑ SECTION 7:SITE INFORMATION(refer to 730 CNIR 111.0 for details on each item) Water Su I Flood Zone Information: Sewage Disposal: 'french Permit: Debris Removal: PP Y Public Check if outside Flood Zone❑ Indicate municipal A trench will not be Licensed Disposal Site Private❑ or indentify Zone required or trench or specify: or an site system❑ permit is enclosed❑ . Railroad right-of-way:/ Hazards to.Air Navigation: - VIA t I t r man Si n I v en Not Applicable I� Is Structure within airport approa h area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No f� Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code Use Group(s): "1'ype of Cunstntction: Occupant Load per Floor:. Dues the building run taro an Sprinkler System?:_ special Stipulations:_ SECTION 9: PROPERTY OWNER AU'ITIORIZAT'ION J Nnme and Address of/Property Owner I r4hAC//4%5A ,7>COOOwJ�L TD t7AlStV 94D �S/�TYh F �h O/ 70 Name(Print) Nu.and Street City/Town 1 Property Owner Contact Information: t! 34 �.QCo6o w,& 4 � 9�_-7 3g, — —— L,'sa I do,. +z[aT.�c�� k �/-s o•yr Title _ Telephone No. (business) Telephone No. (cell) a-mail address If applicable, the properly owner hereby authorizes /3R,77" S 4i..er y / 9 K'.r Name Street Address City/Town State Zip . to act on the property owner's behalf, in all matters relative to work authorized by this building ermit a lication. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If buildin is less than 35,000 cu.ft.of enclosed s ace and ornot under Construction Control then check here O and ski Section lU.l 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. c-nail address - Registration Number Street Address City/Town State Zip Discipline Expiration Dale Y 100..22 General Contractor Q . Company Name / ,a'Re7' S• � - r- y sf• c/.a� os�3NN cs Name of Person Responsible for Construction License No. and Type if Applicable /4 K4 //ry Rb M4 o1970 Street Address City/Town State Zip q7 Jr- MO - Z63S -TY+�- ZG3� en...ry (� co a.cc.sT. He- Teie hone No. business Telephone No. cell ,, a-mail address SECTION 11:l\'ORR11R5 (Q%11'6.\SN1I(?N INSIJR;\\(_I :\f1'11 l;\Vll' M.G.L.c.152.§ 25C 6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estiated Costs:(Labor floor Estimated Materials) Total Construction Cost(from Item 6)=S vy G9 1. Building $ y G Building Permit Fee-Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor) 3. Plumbing 'S iti alit Note: \lininuun fee=S (contact melt P• Y) d. Mechanical (FIVAC) i 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ yCf& q (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering illy name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this Application is true and accurate to the best ofof•my/knowledg icn e and understanding. Please print and sign name Title Telephone No. Date /9 Jf' 9,5' / - 501..... o/gYo Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: Name Date r CITY OF SAL.E1d, XIASSACHUSETTS • BUILDLNIG DEPARTNIEZNT 130 WASHINGTON STREET, 3'°FLOOR TEL (978) 745-9595 FAx(978) 740-9846 Ki,%,iBFRT RY DRISCOLL ST.PIERR& M.iYOR 'TH03IAS DIRECTOR OF PGBLIC PROPERTY/BCILDiNG COSLMISSIONER 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: (name of hauler The debris will be disposed of in (name of facility) (address of facility) signature of permit ap rcant 91 . Z9f ,, 13 date dcbrisal(dx to�nr l l 1 o C S 1L LYEm, ASSACH UrS L S BUILDIINING DEPARTM&NT �y I 120 WASHGTON STREET, 3"' T °FLOOR. �s�`td id` +• E . (978)745-9595 - FAX(978) 740-9846 KIJBERLEY DRISCOLL TiiobiASST.PiERR& MAYO;t DIRECTOR OF PUBLIC PROPEATY/BI:iLDLVG COJL\IISS[ONEA Workers' Gnnpensatlon insurance Affidavit: Builders/Contractors/Electricians/Plumbers 4nnlicant (nformatton / Please Print Legibly Name(Bueiiass,Organieatiotvindtvidual): - Address: /9 +//+y R- City/Statc/Zip: J��� n Phonehl: 474P ' 8'� " ZG3 Are-*A,Ifacmployer?Check the appropriate box: Type of project(required): I. I am a employer with 8 4. ❑ I am a general contractor and 1 6. ❑Now consu=tion employees((ull and/or part-time).• have hired the sub-contractors 2.El1 am a sells proprietor or partner- listed on the attached sheet t 7. ❑Remodeling ship and have no employees These subcontractors have V. ❑ Demolition workingfor me in an capacity. workers'camp.insurance. 9 y p ry. [] Building addition (No workers'comp.insurance 5.'❑ We are a corporation and its 10.❑Electrical repairs or additions raquiretL) officers have exercised theft 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workers'comp. c. 152,$1(4),and we have no 12.0 Roof repairs insuranctsrequired.)s employees.[Nosvoriters' 13.0 Other comp:insurance mquimd.j •Any applicart that ehwka boa el must alw fill but the uctiou below showing their worke s'compensation Polley infiumorlon, r I Lvnvuwnte wheisubmil this affidavit indicting they ate doing all wank and than hire olltiidismiractote must ruhinit a new anldavil indicting such. =Contmloa that chak this bos meet attached an adtatlund shao showing tho numo of the sub-contractors and their worked comp,policy informatlen. f um an eurpluyer that/s pravldfnll workers'compensation hrsurance for my employees: Below fs the policy and fob site infornrutian. Insurance Company Name,. 1,>71a�^��l Policy 4orSclf--its. Lic. M: L3RwG Ne/9 8'' Expiration Date: Job Site Address: S.9/Gp-, l Md SP City/state/zip. dl ell'70 'Utach 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 MOIL c. 152 can lead to the imposition of criminal penalties of is, tiny up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to S230.00 a day against the violator. Ile advised that copy of this statement may be furwurdcd to the Office of Invcsligatiuts uftlte DIA for insurance coverages verification. /du hereby verilfy dethpul Id perraldes a per/a t the inforinarfar provided ubuve is true and correct. .Se Data: y O Phone 1• 9/ ` �ri ?: = 17J/ie iu!wr wrl'A <)a imr wrire in r/ai r urrus m be cunrp/erad by city at lawn nJfTcluL City or town: ___ Permiti'Llcense.a I.,suing,\W purity(circle one): 1. Board of liealth 2. Building Departuleat 3.Citylrown Clerk 4. Electrical 6upcctor 3. Plumbing limpeetor b.Other Contact Penns: _._.- ._ Phoned:, i DATE(M9r0aww) AC a CERTIFICATE OF LIABILITY INSURANCE 9/19/13 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, tiIe policy(i e en s) must be dorsed. 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 erdorsemen s). IMN AcrPROWCER _ INGRIDBenevento Insurance Agency Inc E 781 599-3411997 Humphrey StreetLESS: Swampscott, MA 01907 INSURE S AFFORDING COVERAGE NAIC0 msURMA:Commerce Ins Cc INSURED 1NSU RFRB_Guard ,Ins Co Emery Construction Corp. INSUR_ERc:_ — Brett Emery INSURER o;__.__ ------- 19 Kelly Rd. INsuRERE__ ---— ---- Salem, MA 01970 - 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 OFSUCH POUCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS— __ _ ___..._.__ —_.___--_ --FOUCYEFF--�POIJCY E%P k-6m SUER-__ INSR POU CYNUM3ER MWN MAIDaVYYY LIMITS A TYPE OFINSURANLE A IGENERAL WBIUTV 9/5/13�1 9/5/14 DAMAGE TORENTE 5 1,000,000 N BDSJXD DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISESAEe omurrence7._.i$ 100 000-- CLAIMS4ADE X-I OCCUR MEOEXPCAnyr,reperea 0_n) S - 5 00 -- PERSONAL&ADVINJURY JS 1 000 000_ GENERAL AGGR EGATE $ 2 000 000__ w GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-CO MRCP AGG 5 2,000,A00 - PRO- F LCC S — g POLICY Lim COMBINED SINGLE LIMIT S WTOMOSILELIABIUTY BODILY INJURY(Per w man) S ANYAUM �——_—_— ALLOJJPED SCHEDULED BODILVINJURV(Per accitlent)I .8 AUTOS AUTOS PROPS WY DAMAGE g NON.OWNED (Per ecc'tlan0 L HIRED AUTOS —AUTOS 5 HUMSREL UAB OCCUR EACH OCCURRENCE 5 EXCESS LIAR CLAIMS-MAOEI AGGREGATE _.— L�I— 5 B REENTIOS _WC_❑ED 9/e/13 9/t19 TORVLIMITS --ER_WORKERS COMPENSATON BRWC999788 XJ - _ AND EMPLOYERS'UAaILITY YIN EL.EACH ADD DE NIT 5 100,000 _ ANY PRCPRIETORIPARTNERIE XECUTVE NIA OFFICERMIEMBEREXCLUDEDP EDISEASE=EA EMPLOYEE $ 100,000 (MenEamry in NH) —.L — IfYas,tlazaibe�ntler E.LDISEASE-POUCYLIMF S 500,000 DESCRIPTION OF OPE RATIONS below MSCRIPTONOFOPERATONSILOanONSIVEHICLES (Atl hACORDIUI,AWMonal Remrka ScMauk,Hm.re pmLmgdr ) Carpentry LOCATION 52 PICKMAN RD SALEM MA 01970 CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVER50 IN AMERICAN PROPERTIES TEAM, INC ACCORDANCE WITH TIE POLICY PROVISIONS. ATTN JENNIFER PAPPAS 500 WEST CUMMINGS PARK #6050 AUTHOR�DREPRESENTATNE WOBURN, MA 01801 I Br an Benevento ©198"010 ACORD CORPORATION. All rights reserwa. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: b emery@comcast.net Estimate Emery Construction Corp. -- -;— — 19 Kelley Road Date Estimate.#.._...� Salem Ma, 01970 8/2112013 E13- 122 978-880-2638 Lisa Jacobowitz � � 5D Halsey Rd t Pickman Park Salem,Ma 01970 i Description J Cost E Total Deck Repairs j 0.00 Remove all existing framing,rails,decking and supports i( 0.00 2 Replace with all new pressure treated framing and rails 0.00 -Decking will be all new lx4 Cambera decking 1 0.00 Top rail will either be 2x6 Cedar or 5/4"x6 composite rail t 0.00 1 All debris to be removed 0.00 1!All permits to be obtained I 0.0D 1 4,469.00 4,469.00 j i i EfS I I T�ta�N �����$4,469.00 Breit S_ Emery tviA License a ' �E y CONSTRUCTION CORP. • I • i - - Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supen kor License: CS-059344 BRETT:S EMERY-` 19�,LEU RD ; SALEMMA �019�0 is Expiration Commissioner. '09/25/2014 .` ; SS HUSEtTS�( r VDRIVER S,LICENSE 531450790 •09-25-2013n09.25 1 r CLASS REST;£ T 'D Y fiOt MERY - tBRETTS ,� v ?, ,19 KELLY RD h'BALEM,MA 10197104314 - t S ' •_. � r'•E � .mass �'� .�.�, r �, Vlae�oas,nnwuoeml�o�UlLCuaac�rtGett4 'Office of Consumer Affairs&Business Regulation License or registration valid:for iindividul use only HOME IMPROVEMENT CONTRACTOR ibefore the expiration date. If found return to: UW- Registration: 176626 'Type: Office of Consumer Affairs and:Business Regulation Expiration: 9/10/2015 'DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 EMERY CONSTRUCTIONBRETT !EMERY _ f= 19 KELLEY RD SALEM,'MA01970 - Undersecretary Not valid withou ure