32 HANSON ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts Town of
Board of Building Regulations rnI Standards �
Massachusetts State Building Code. 780 CNIR. Ts edition Budding Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a
One. or Ttvu•Famils'Disellmg
This Section For Official Use Unit
Budding Permit Nu bee Dale Applied:
A132�r
Signature:
Building Commissioner/In ter of Buildings Dow
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map Ae Parcel Numbers
Sd-
M Number Parcel Number
1.1 a Is this an acce led street''yes r/no W
IJ Zoning Information: 1.4 Property Dimensions:
2omng District Proposed Use Lot Area(sq R) Frontage in)
1.5 Building Setbacks In)
Front and Side Yards I Rear Yard
Required Provided Required I Provided I Required Provided
I.f Water Su Ir(M.G.I.e.a0.lsq 1.7 Flood Zone loformallon: I.g Sewage Dis oast System:
Ions: Outside Flood Zone? Municipal On sire disposal system O
Public Pivate O Cheek i(yeso
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'or Record: /
Address for Service:a/�Name IPrint� C9 l
signature Telephone
SECTION J: DESCRIPT19141 OF PROPOSED W RKt(check a hot apply)
'New Construction O Existing Building Orl Owner-Occupied Repairs(s) Alterations) Ilf I Addition O
Demolition O Accessory Bldg.O Number of Units z Other O Speciy
Brief Description of Proposed Work
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials�. I. Budding f 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
J2 2 Electrical f O Total "act Cost'(Item 6)x multiplier x
U ) Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) f List:
P It Mechanical (Fire f Total All Fees. f
17 Su re.mon Check No. _____Check Amount: _ Cash Amount:
6 Total Project Cost. f ,Jd ❑ Paid in Full ❑Ouwandinit Balance Duer
7/
SECTION !: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
C!5 fe�ee)
r, Licen.e Number Esptution Oate
4,4rse of CSL. ItplJer Lnt('SL Type IrY below)
AJdress Description
seneted u ro l3.000 Cu. A
aed IA2 Famd nif
5rgnuture Mason-
ACUnl
ential Raofin Coverm
Telephone [WRSR,s,den#--1 Window and Sidmenl Solid Fuel Burnet A hence Insullaban
mtsl Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISJ./ ISC(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 of the building permit.
Signet)Affidavit Anschetl7 Yes.......... O No........... D
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Own" Date
ION 7b:O Rr OR AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent hereby declare
that the statements and information on"retoing application are we and accurate, to the best of my knowledge and
behalf. a�3
Print Nuns
f2 2. O
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
NOTES:
1. An Owner who obtsins 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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J1A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS,respectively.
2. When substantial work is planned• provide the information below;
Total Goon area(SQ. Ft.► (including garage, finished basemenUanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Vumber of bedrooms
Number of bathrooms Number of half baths
Tvpe of healing system Number of decks/porches
Type ofcoohng system Enclosed Open
1 "Tool Project Syuare Footage-may he suh,muted for 'Total Project Cost"
r
i'W \lassachtisctlt - Department nl Public SarctI
Board of Building Rey_ cation% and Standards
Construction Supervisor License
License: CS 69780
vp
Restricted to: 00 g
ERIC M EASLEY
PO BOX 4542 r
SALEM, MA 01970
i
Expiration: 5130011
1 ..rnu.....i...wr Tm! 15316
I
CITY OF S.UI &Nis ILA.SSACHi;SE"ITS
BL'l1DLvIG DEP.IRT%MSiT
120
W.ti I i IGTON STREET, r FLOOR
T L (978) 74S-9595
FAX(978) 740-9846
w.,BERLEY DRISCOLL THOMU ST.PIERAS
MAYOR
DIRECTOR OF Pl:gLIC PROPERTY/gl'QDLVG GOSORSSIONF1
Workers' Compensation Insurance AMdavit: guilders/Contractors/Electr(clans/Plumbers
>nnlicant lnfnrmation Please Print Legibly
Nairte (tlusine. OrOrWizatiorbinJrvidual): L2 ✓e C:h's P' LCjr—y
Address: G - �ax y�%2 SCe � lytf� 0/970
City/State/Zip: Phone M:
Arel yo ■employer'Check the appropriate box: Type of project(requlreQ.
1. I am a employer with 4. 0 I am a genmal contractor and 1
employees(full and/or part-time)." have hired the subcormrcrors 6. ❑New constnactitsn
2.0 I am a sole preprietmr or partner- listed an the attached shtft : 7. [ Remodeling
;hip and have no employees These sub-contractors have V. 0 Demolition
working for me in any capacity, workers'comp.insurance. 9. [] Building addition
[No worker'comp, insurance S. 0 We are a corporation and its
required.) officers have exercised their lo.(ErElectrical repair es additions
3.0 1 am a homeowner doing all work right of exemption per MGL I I.Gi numbing repairs or additions
myself.(No workets'comp. c. 152,41(4),arul we have no 12.0 Roof repairs n
S
insurance required.)t employees.INo workers' 1).[a Odrer +� /CahK.X =/�S
comp. insurance required,)
•Any applicant ihse sucks ban el muse alms fill oa Ise ascuea balow showing their workrra•raxnpnaseftm policy mfumtaeeta
'I hvmestwlwa who submit this anldwil indicating they an doing all wort and than Ain outside eennowi n muse mhmb a now,arltdavit indica ing ruck
t'.,miunars that abash this ball mud anachod an addititmed chat showing the name of dw ahsymnpmr and ilind,worhrra'comp.pdiry iorpmnows.
I am an employer that Is providing workers'romporwar/on Inanrenee for cry employe" glow b the poiley andm sllr
informwiow
Insurance Company Name: �h /I? S !�t�.r/a 2
Policy 4 or Self•ins. Lice Expirmion Date:
Job Sire Address: 3 City/Statd2ip: S v s / of 97a
,mach a copy of the workers'compensation policy declaration page(showing the policy member and explrsdom slate).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a Roe
Of up to S250.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of
1nvcstlgalione afthe MA for insurance coverage verification.
/do her ebya rrnyy under h m dpenftrlurlr that the informer/on provided above is crone and ranret
�icruntrt: Date: Z Z o S
O/flfial car attly no not Wife in this/feat fo be.urnplefe/by a'ity or rows o/J&•idl
City or fawn: Prrmit/Llccnu M
Issuing Aulhurity (circle une):
I. Ituard of Ilralih I. Building Department J. C'ily/town Clerk 4. Electrical Inspector S. Plumbing Impector
6. Other
l.uttlact Person: _ ._. _.. Phone N:
r
CITY OF SALEM
s S PUBLIC PROPRERTY
DEPARTMENT
M-.,,-n h_'Q V('.%;t nvt;;iw 5 rnrrr •5.st rst,
17t:Y78-N3.9395 • 1:.%s:978J40-4846
Construction Debris Disposal At'tidavit
(required fur 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 to . _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
?lea 4
(name of hauler)
The debriswill be disposed of in
_. . .__
(nameut acimy)
tad ress of facility)
signature of permit applicant
J Z/!
'date
Ichu.�a Lot
ACORD CERTIFICATE OF LIABILITY INSURANCE OPID JL DATE(MMNDM YY)
YELSAEC 12 02 09
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Dan Hurley Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Chestnut Green, Suite 24 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Seven Federal Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers MA 01923-3620
Phone: 978-777-9394 Fax:978-777-3306 INSURERS AFFORDING COVERAGE NAICS
INSURED INSURER A: Granite State
INSURERYe;s B:
Eric X.
Co. ,EaInc. INSURER C:
Eric x Easley
PO BOX 011 NSURER D:
Salem MA 01970
INSURER E:
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
ff
LTR N TYPE OF WSURANCE POLICY NUMBER DATE M DATE MMIDDIYY LIMITS
GENERAL LIABILITY EACH OCCURRENCE 5
COMMERCIAL GENERAL LIABILITY PREMISES(Ea o Mw) $
CLAIMS MADE ❑OCCUR MED EXP(Any one person) S
PERSONAL&ADVIWURY S
GENERAL AGGREGATE S
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO S
POLICY PERUO LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea eradent) %
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIREDAUTOS BODILY INJURY S
NON WNEDAUTOS (Peramdent)
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY AGG S
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR CLAIMS MADE AGGREGATE S
S
DEDUCTIBLE S
RETENTION S $
WORKERS COMPENSATION AND X TORY LIMITS ER
A EMPLOYERS'LIABILITY WC007435262 07/08/09 07/08/10 E.L EACH ACCIDENT s100000
ANY PROPRIETORMARTNERIEXECUTIVE
OFFICERR.IEMBER EXCLUDED? SEE ATTACHED NOTE E.L.DISEASE-EAEMPLOYEE $100000
Us,describe under
SPECIAL PROVISIONS bNow E.L DISEASE-POLICY LIMIT $SODDED
OTHER
DESCRIPTIONOFOPERATIONSILOCATIONSIWHMLESIEXCLU K SAWEDSYENDORSEMENTISPECU PROVISIONS
As per policy.
CERTIFICATE HOLDER CANCELLATION
SALEM04 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO TIE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
City Of Salem IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR
ATT Building Dept
120 Washington Street REPRESENTATIVES.
Salem MA 01970 AUTHORIZED REPRESENTATIVE
Daniel J Hurley
ACORD 26(2001108) O ACORD CORPORATION 1988