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21 HARBOR ST - BUILDING INSPECTION ` L The Commonwealth of Massachusetts Town of ,� Board of Building Regulations and Standards \ka I Massachusetts State Building Code, 780 CMR, 7ih edition Braiding Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a ' One- or .Tiro-Fmnily Divelling T 5rScCtion For Official Use Only Building Permit Numbe . Date Applied: Signature: Build g Commtssto / s for of But dings Date ITE INFORMATION 1.1 Proppe9rty dress: 1.2 Assessors Map& Parcel Numbers �( a// f7 Ct✓ r f I.1a Is this an accepted street?yes_ no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required ProvidedE Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public Private❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: E896Q 9&lK X Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Constmetion❑ Existing Buildings Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units 1 Other ❑ Specify: Brief Description of Proposed Work': SUPPqLT/nlg, Mi&-TIAZ4, g 7( I tJS'7Ysf l JVIST 1 IrknbE25 .� EX(VI G EfA7lA SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials 1. Building $ I. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical 8 ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: 5 41=_7 4. Mechanical (HVAC) S List: 5. Mechanical (Fire $ Total All Fees: S Suppression) Check No. Check Amount: Cash Amount: x 6. Total Project Cost: 4 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES �• 5.1 Licen d Construction Supervisor(CSL) O 0��O License Number EApiratron Date N'ame of CSL-H Wer n� All" kl(0111-0,TX� � List CSL Type(see below) tJ�1 A ess TY0 Description Unrestricted Jup to 35,000 Cu. Ft.) Si nat a Restricted 1&2 Family Dwelling M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF I Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Re istered Ho a Im llovement C ntra for(HIC) Flo w Sri. n/�I tact cef.— I�C 6 HlEgiripany Name or HIC QQRe Registrant Name ! Registration Number -17 ee,W"et J� �r IdAd—s�' V O e; ".- V-6 Expindtion Dfite Signature Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(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. Signed Affidavit Attached? Yes .......... ❑ No........... ❑ 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 to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION 1, ,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 Name Signature of Owner or Authorized Agent Date (Signed under the pains and penalties ofperjury) 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 780 CMR Regulations I 10.116 and I IO.RS, respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" .ACORD CERTIFICATE OF LIABILITY INSURANCE OF ID DATE(MWDDNYYY) 3PINO-1 04 O1 08 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Sanviti Insur. nce HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 699 Broadway ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Hvere:.t MA .02149 Phone: 617-389-2020 Fax:617-389-?418 ' " , tINSURERE: ORDIN INSURED :tttZ Spinosa Maintenance & Repalir Brad Spinosa 16 Harvard Street Everett MA 02149 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. LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE IMMIDDIYY DATE MM/DD/YY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A K COMMERCIAL GENERAL LIABILITY NC519124 03/31/08 03/31/09 PREMISES(Ea occurence) $ 100000 CLAIMS MADE ® OCCUR MED EXP(Any one person) $ 5000 PERSONAL&AOV INJURY $ 1000000 GENERAL AGGREGATE $ 1000000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1000000 POLICY PRO- JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS Y I BODILY ODILNJURY cn) $ ODILPer NJ HIRED AUTOS NON-OWNED AUTOS BODILY INJURY(Per (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY y- AUTO ONLY-FA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ i AUTO ONLY: AGO $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION $ ' WORKERS COMPENSATION AND EMPLOYERS'LIABILITY TCRY LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? H yes,describe under E.L.DISEASE-EA EMPLOYEE $ SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS MAINTENANCE AND REPAIR CERTIFICATE HOLDER CANCELLATION SERVICE SHOULD ANY OF THE ABOVE DESCRIBED POLICIES Be CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 3 0 DAYS WRITTEN SERVICE MAGIC INC NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL KATY MITCHELL 14 023 DENVER WEST PARKWAY IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR GOLDEN CO 80401 REPREs IVES. +4 / !$ AUTHOR17,Bp A E M' i ACORD 25(2001108) Nj ©ACORD CORPORATION $?'" i CITY OF SALEM PUBLIC PROPRERTY '�. DEPARTMENT ,I.n'_ N I\' 1141141'11 set I or SAt 1%4. AfAsv.\t III it I IN 3197. •p11.715.95'+5 • 1:t.x 9711-74C J146 w'urkers' Compensation Insurance 11,I'frdu.it: Builders/Contractors/Electricians/Plumbers li 1 )lieant Information Please Print Le ibly V 11Ind l8u�uwsy 1�rpanir.tlinNlndivduaU: /17 d SCA- Address: C��J Gly,Srarc.%ip ///r[! /l ct Q��Y 4 I'huneI!: .\re you an employer'!Check the appropriate box: 'type or project(required): 1.Cl I .In pluycr with 4. ❑ I :un a guncral contrac1have h. ❑ new construction nployccs(full antL'ur part-time).• Ilucu hired the sub-cun 7. ❑ RanodelinQ d I aai a sole prnprictor or partner- listed oil the attached s Ship and have no cinployccs These subcontractors g. ❑ Demolition Lurking tin me in any capacity. workers' comp. insura9, ❑ Building addition IKo workers' cum insurance 5. ❑ We are a eniflordtinn a P 10.❑ Electrical repairs or additions officers have cxcrciscd their required•] 1 1. Plumbin r rc airs or additions 3.❑ I am a homuuwnur doing all work right of exemption per h1C7L ❑ b P' Myself (Ko workcrs' comp. c. 152, ¢1(4),and we have no 12.❑ Ruuf repairs Insurance required.] t unpluyuus. (Ko Lock ' e rs 13.❑ Other colnp. insurance ruquired.] •... .•,tphcaut Iuat checks box rt must also till tnn the.ecuoll Inluw,lluwina their w•urkwv cunipens ion lwary uniunutiun. ' I fume,,.n,n whu...unia this affidavit imlicauny ihu)an doing YII.Wrk irYl iticr,him wiside cuonrxtun ntW1.uhmil a new itf:,tavil indi"'nx.Jch. -C',.mrxuir.that Check Ihis box mtnl+Itxhed an addiliunal+heel.hiiwifa the n:ulw of the sub-conlrxtun and their wurkan'Bump.policy tnfwmatiun /unr un eorpfoyer that is pro riding workers'conspenvadon husurance for lily rurpluyecs. Belrnv is the pulicy and/ub..ite information. y'n "� In.urancc Company Vane: U p--- s -. - -------- P „olicy 4 or Scif-im. Lie. ft: / cC I9fl/' ___. .. . .. __ Enpiralion Date: of Job Site Address: _-_. City:Swte/Lip: .mach n copy of the workers'cuinpcnsatlun policy declaration page(showing the policy number and expiration date). Failure to secure co.erage as required uodur Sudiun 25A ul'.\IGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51.500.00 antYur une-year hnprisunincnt, as Lell as eivd penalties in the form of a STOP WORK ORDER and a fine ,,full to S250 00 it Jay against ale violaior. III:advised that a copy of Ihi% atatunent may be for%arded to the 0111ce of Im..n,auum ul •.he DIA :or i,marcc icnlical:un. /Ju hrrrhy c:nijr unrfer air rune an purr tier ufperjr y thut the;nfurroutfon provided ubo ve is vu cud correct.. �yt- ° :I•I J011-, tJ(/iriuf n.e reap. /yd not write in Mix ureu, to be,completed by city up town o1jit iu/. ( iiv ur fn.vn: _... __. PermitiLiecnsc 0. Issuing .\uthurily (circle filch I. IL,ard ff llvallh 2. Ifaddin:; ncpartmcot i. CCitf.•I'uivtl Clcrk J. L•'Iccirical Inspector i, Plumbing Iu.ycNor b. Other _ Phone it: Information and Instructions >lansadhusctts General Laws chapter I i2 requires all employers to provide workers' compensation f»r their cimployces. Pur.u.mt to this .salute, an ernpluree is defined as " every pctson in the service of another under .my contiad of hire, eaprees or implied, ofil or written." An ernpluper is defined as "in individual, partnership, association, corporation or other legal entity, or any two or more .a the t,,regomg engaged in a;utnt enterprise, and including the legal representatives of a deceased cmpluyer, or the feCel%cr or trublee of all 111drvtdual, paalllChhlp, 4ssOCLJl1Or1 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 dwvelhng house of another who employs persons to do maintenance,cun%truction or repair work on stich dwelling house or on the.rouads.or building appurtenant thereto bhall not because of such employment be deemed to be in employer." w ,%1GL chapter 152. §75C(6) also states that "every state or local licensing( agency shall withheld the issuance or renewal of a license or permit to operate a business or to construct buildings in`the corrmunweallh for arty applicant who lias nouproduced acceptable evidence of compliance with the insurance coverage required." Additionally. MU chapter 152, g25C(7)crates "Neither' the commonwealth norra m ny of its political'iubdivisions shall enter into any contract for the perfomnince of puhlic work until acceptable evidence of compliance 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) 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, ire not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Se advised that this affidavit may be submitted to the Department of Industrial .Nee idents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The aff idavit should Lie retilrned to ilia city or town that the application for the permit or license is being requested, not the Department of industrial Acndents. 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'rown Officials Please he 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 not in the event the Office of Investigations his to contact you regirding the applicant. 1'Lmse be sure to fill in the pennit/license number which will be used as a reference number. In addition, an applicant than must submit multiply:permit;license applications in any given year,need only subunit one affidavit indicating current Policy information(if necessary)and under"Job Site Address"the applicant should write "all locations in (city or town)." ,% copy of life affidavit that has been officially stamped or marked by ilia city or town may be provided to the applicant as proof that a valid affidavit is on file f'or future permits or licenses. A new affidavit must be filled out each year. Where a hume owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I 11J t)t11ce UI In�cstt.Jtlona wvuuld llee to thank you in idvallce fur your cooperation aad should you ha%C airy quemioni, please do not hesitate to give us J call ncc Deparuncnt's address, telephone and fax number' The Commonwealth of Massachusetts ; Department of Industrial Accidents'. J - -. OtHce of.Investipttons— --_ _-_—-- ---- -- 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 www.mass.gov/ilia