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6 HAMILTON ST - BUILDING INSPECTION (3) J The Commonwealth 01'Massachuscua Board of Building Regulations and Standards CITY OF SALEM Massachusrtu State Building Code, 780 C'MR, 7,n edition Rrs•isrr/Jarruwy Building Permit Application To Constrlfct, Repair, "novate Or Demolish a / n -ar Avo-Fumifv Ow ng is Section For Pfficial Use Only Building Permit um Date Applied: It 4 't7 Signature: H ( Yl? uildin Cummissionert tar of Buildings Dole SECTION I:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map A Parcel Numbers G 11A) I/roA/ S,,yg f r I.la Is this an acce ted street?yes no Map Number Porcel Number IJ Zoning Informallom 1.4 Property Dimensions: Z ming District Proposed Use La Area(sq 11) Fromage 111) 1.5 Building Setbacks(R) From 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 Informatloo: 1.2 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yeso SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: it/ I f/ Gi /1i7/n/Ir0/IJ ar` Name(Prim) Address for Service: Signaure Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building,91 Owner-Occupied Repairs(s) ❑ Alteration(s) AdditioJO Demolition ❑ 1 Accessory Bldg.6 1 Number of Units_ Other, ❑ Specify: Brief Description of Proposed Work':/- 7/II G de� / LYJ S E GYi zic v SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OMCIBI Use Only Labor and Materials I. Building S -72'Q0 1. Building Permit Fee: S Indicate how fee is determined: 2. Electrical Is ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)s multiplier x ). Plumbing S 2. Other Fen: S 4. Mechanical (IfVAC) s List: 5. Mechanical (Fire S Su ression Total All Fees:s at: S Check No. Check Amount: Cash Amount: 6. Total Project Co 719(v 10 Paid in Full ❑Outstanding Balance Due: i SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Super/vJ��or(CSL) 1 j7 SIC/��1� / I.i.cnx Number I:apin n e Name of'CSL• I lul`�fr l.is1CSL-r)pe(see below) 60O L-1✓Gf�!!'IS/QCr �Y r I Description :Address j � / U llnmuicted u to 35,000 Cu.Ft. !i [/r 7 Restricted Id2 Family Dwelling Signature1/zl M M. thtl RC Residenrial Raclin Covering 1'elephune WS Residential Window and Siding �z 9J v SF Residential Solid Fuel 8umin A lia w Installation D Residential Demolition 5.2 RK iste pw Im j flrnenl airs (IC) �4 �S ��/! /1/ Registratim umber I IIC CompanY�a�e oft C e Address Esv i ion Dole G_ Signature Te ephune SECTION 6: WORKE COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2.f 2SC(6)) Workers Compensation lissinfmce affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Irsu «of the building permit. Signed ARdavit Attached? Yes ..........V No...........O SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, f ILJ l N irnV f-(2 as Owner of the subject property hereby authorize C 14121 e 1Y A -Se AH-qe P,1% U bW to as on my behalf,in all matters relative to work aulhorizqd by this building permit application. f 1121 I I✓) SiansturcoTOwner kDate SECTION 7'b/: O t OR AUTHORIZED AGENT DECLARATION 1 - / fv / yl^ - ,as Owner or Authorized Agent hereby declare that the statements and inFormalion on As foregoin application ore true and accurate,to the best of my knowledge and behalf. ��77 Print Name 10— 3c � /o Signature of Owner or Authorized Agent Date (I i under the ins and penalties 'u NOTES: 1. An Owner who obtains a building permit to Jo his/her own work,or an owner who him an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will W have access to the arbitration rhZitng ram or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and struction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and 1 10.R7, respectively. n or work is planned,provide the information below: rs area(Sq.Ft.) - (including garage, finished basement/arics,decks or porch) ing area(Sq. Ft.) Flabitable room count f fireplaces Number of bedrooms f bathrooms Number of halfPoaths eating system Number of decks/porches ooling system Enclosed Open ). "Total Project Square Footage" may be substituted lor"Total Project Cost" Otiice-)"Copspmer airspes"salGpu•- HOMEIMPROVEMENTCONTRACTOR Registration 105872 Type: Expirandn 712V2012 Individual C TOPHER B Qitjf<It4 - Christopher Quinrf., 500 Edgemere Road - 4 Lynnfield,MA 01940 Unde rctary . ➢assachusetts- Department of Public Safety. Board of Huildim-, Re-ulationx and Standard+ Construction Supervisor License License: CS 46114 - Restricted to: 00 - CHRISTOPHER B QUINN 500 EDGEMERE RD t' LYNNFIELD, MA 01940 x' Expiration:..9/12/2011 Q4u�mii>s{Doer - - ?r#: 4400- -e. _ CERTIFICATE OF LIABILITY INSURANCE OP ID KO BATE(MMIDDIYYYY) l0i 10 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 endomement(s). PRODUCER NAME: PHONE Marchionne Insurance Agency ac,Na Erd: I MNo): 11 Independence Ave- ADDREss: Quincy MA 02169- PRODCUSTOMERIDS: QUINN-1 Phone:617-471-5010 Fax:617-471-1386 INSURER(S)AFFORDING COVERAGE NAICM INSURED INSURERA: Ar Ia Protection Ins. cn. 41360 Chris Quinn 500 Edemere Road INSURER B: Lynn£ield MA 01940 INSURERC: INSURER O: 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 NAMEDABOVE FOR THE POLICY PERIOD INDICATED_ NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OFANY 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 LTR TYPE OF INSURANCE INSR WD POLICY NUMBER (MWDDIYI'YY) (MMIDD/YYYY) LIMITS GENERAL LIABILITY EACH OCCURRENCE $1,000,000 A X COMMERCIALGENERALUABIUTY 8500022100 05/13/10 05/13/11 PREMISES(Eaomf m) E100,000 CLAIMS-MADE (Fil OCCUR MED EXP(Any one person) s5,000 PERSONAL 8 ADV INJURY $1,000,000 GENERALAGGREGATE s2,000,000 GENT AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG $2,000,000 POLICY 7 JEC LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea a ern) ANY AUTO BODILY INJURY(Per Person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Pet maderd) $ NON,OWNEDAUTOS $ $ UMBRELLA IJA OCCUR EACH OCCURRENCE $ EXCESS UAS CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER ANY PROPRIETORIPARTNERIEXECUTWEM E.L EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? IA (ManE ryin NH) E.L.DISEASE-EA EMPLOYE $ If yas,des W under DESCRIPTION OF OPERATIONS belOx EL DISEASE-POLICY LIMIT 1$ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AtlacN ACORO 1D1,AdUNbrel Remarks SrJreEule,U nare spare k requbed) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE WITT002 THE EILPIRATION DATE THEREOF,NOTICE WILL BE DE RED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Ben Wittner Hamilton n Street Salem ii(�l�a%-e-o�✓+ao ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD CITY OF S.AL&%I, UxSSACHUSETTS • BUILDIING DEPARTMENT 120 WASHLNGTON STREET, 3'D FLOOR TEL (978) 745-9595 FAX(978) 740-9M (QJtgERLEY DRISCOLL MAYOR THOMAS ST.PtERRB DIRECTOR OF PUBLIC PROPERTY/BUHMII IG CO%WISSIONER 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 : p�960 n (name of facility) h �/ (address of facility) signature of permit applic /UI12 2/G date aa,d��rd.x CITY OF S:u.E.NrI, , 1,XSSACHI;SETTS BL'ILDDZG DEPART-NIEINT • 120 WASHINGTON STREET, 3'a FLOOR TEL (978) 745-9595 Filx(979) 740-9846 KISIBpRi EY DRISCOLL THONIASST.PIEAaR MAYOR DIRECTOR OF PUBLIC PROPERTY/BU ILDIN'G CONL%1MIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A r licant Infnrrnation / Plea,.Plea,.w Print Legibly Natne tausi,xv organimttiiomindividual): / /��s� //f� Address: 2 o0 A9211,0 City/State/Zip: Z)1k1V)t:�/A�o AW Phone #: Are you an employer?Check the appropriate boa: Type of project(required): I.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction era Io ees full and/or part-time)." have hired the sub-contractors p y ( p 7. ❑ Remodeling 2. I am a sole proprietor or partner- lined on the attached sheet: ship and have no employees These sub-contractors have V. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions required.] officers have exercised their right of exemption r MGL 11.❑ Plumbing repairs or additions 3.❑ 1 ys a homeowner doing all work c 6152,91(4),and we have no 12.❑ Roof repairs myself. e re workers'comp. employees. LNo workers' insurance required-]t 13.0 Other comp. insurance required.1 -Any applicant that ducks boa rl must 21"fill Out The section below showing their woken'Compensation Policy inlurmutiun. t I l,"o"ren who,ubmit Ibis aflidevit indicating They an doing all work and then him outside contractors most submit a rxw aflidavil indicating such =Comraron that chwk this box most attachod an uWiliuml sheet showing the name of the sub.contnctoo and their worked comp.Put icy infUmLltian. l um an employer that is providing workers'comprnsadan lnsaranee for my employees. Below is Nye policy and jab.rite information. Insurance Company Name: —_ policy N or Sclf-its. Lic. p: Expiration Date: Job Site Address: City/State/Zip: ,%itacb a copy of the workers' compensation policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a zinc up to S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to$250.00 a day against the violator. 13e advised that a copy of this statement may tin: forwarded to the OI6co of Investigations of the DIA for insurance coverage verification. /do hereby certify undeer t put d p to 0 ry at atfurmatlon provided above ix tru and cur ca Datw Sic alurcl OJJlcid use only. Ou not write in this urea,to be completed by city ur town n/f1c1a4 City or Town• ---- . . Permit/f.lcenseq_--._— .._-- ..-- IssuinK Authority(circle one): 1. Board of licalth 2.nuilding Department J.Cityfruwn Clerk 3. Electrical Inspector 5. Plumbing Inspector 6.Other ._-- ....___-. _ Cuntacil'crson: _ _ . ._. ... Phone#: ] Information and Instructions \'l assachusetts Gcneral Laws chapter 152 requires all employers to provide workers' compensation fir their employees. Pursuant to tilis matule, all rmplurrd is defined as"...every petson in the service of another under any contract of hire, capress or implied, oral or written." An e,nploJ•er a defined as"an individual,partnership,association,corporation or other legal entity, or any two or more ' ,r the foregoing engaged in a joint enterprise,and including the legal represemanves of a deceased employer,or the receiver or trustee of .ua individual,paaamcrship,associanou 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." `IGL chapter 152. v.25C(6) also states that "every state or local licensing agency shall withhold the Issuance or renewal of it license or permit to uperate 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." Additiunally. MGL chapter 152, j25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance ul'publie work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Plaase fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractors) name(s), address(es)and phone nuniber(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. [fan 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 dute the affidavit. The atf idavit 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 of if you are required to obtain u workers' compensation policy,please call the Department at the number listed below. Sclf-insured companies should enter their self-insurance license number on the appropriate line. City or Town Official Please he sure that the affidavit is complete;old 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. Plaasc 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 penniWicense 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 f Mitre p,dr6ts or licenses. A new affidavit must be filled 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 dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. I Ile r)I flee of Investigations would like to thank You in advance for your cooperation and Should you have any questions, pleas du nut hesitate to give us a call The OcpartinciWs address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Offles of Investigations 600 Washington Street Boston, MA 02111 Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE a.ci.ed _'4-us Fax N 617-727-7749 www.mass.gov/dia