30 HATHORNE ST - BUILDING INSPECTION 02/22/2008 10:48 7815937260 O7=(i DUFFY INSURANCE AGCY PAGE 01
ACMAD, CERTIFICATE OF LIABILITY INSURANCE oi%22/2 0
P4YOYL� (761)593-1Z00 FAX (761)593-7ZOO THM CERTIFICATE 191SSUEO AS MATTER OF INFORMATION
Duffy,Ins�hHnce Agency, Inc, ONLY"AND CONFERS NO RIGHTS UPON THE CERTIFICATE
.I HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR
317 Broa ONBy ALTER THE OMMRAGE AFFORDED BY THE POLI RE8 BELOW.
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IMPORTANT
If the certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.A statement
on this certificate does not confer rights to the certificate holder In lieu of such endorsement(s). !,
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 endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between -
the issuing insurer(s),authorized representative or producer,end the certificate holder.nor does it
affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon.
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February 22, 2008
Salem Building Department
120 Washington Street
Salem, MA 01970
RE: 30 Hathorne Street
Application for Permit
To Whom it may Concern:
Please be advised that the members of the 30 Hathorne Street Condominium
Association, individually and collectively, approve of the application for a building r
permit for bathroom renovation to Unit#2 of 30 Hathorne Street. »`
Thank you for your consideration of this request.
i
Sincerely,
C , C
k
genj a Rich
e urns
30 Hathome Street Condo Assn.
I 1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
Ij Massachusetts State Building Code, 780 CMR, 7"' edition NIUNICIP:CLI'h1'
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Rrrisrd Jamtoi r
One- or Tiro-Family Duelling 1. 2008
This Section For Official Use Only
Building Permit Nu — - Date Applied:
Signature:
Building Commission r/ Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
I
L lu Is this an accepted street? yes no_ Map Number Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage iIt)
1.5 Building Setbacks(ft)
Front 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 Information: 1.8 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2 Owner' Re Old "_AIr,\o #1
Name(P ) Address Vor Service:
Sig ature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) 1$1 Alteration(s) ,QI Addition ❑
Demolition t$ Accessary Bldg. ❑ Number of Units Other ❑ Spectty:
Brief Description of Propoggye�i Work':
C, CAC r',C Lwte 4 G E C
1�' `'"� SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ u 6a I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ 1��,� ❑ Standard City/Town Application Fee
❑Total Project Cost' (Item 6) x multiplier x i
3. Plumbing $ ` o
i ,7a� _. Other Fees:
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su) ression) $ Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 5 ❑ Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
f1ILrn\�1 / 0'�) m��S�`J•s� License Number Expiration Date
io
NaVn'11Ai\\ t CAS�L` I1 r List CSL Type(see below)
Descn tion
Add 's U Unrestricted to to lS.000 Ctt. Ft.)
Restricted I&'_ F:In111 Dwellin¢
Masonr v Only
to arc M
RC Residential Root)ne Co verht
V. Telephone \VS 12csidrnual \Vinduw :md Sidine
\\ SF Residential Solid Fuel Ilurnine A>>liunra Insiall:uion
D Residential Demolition
5.2 istered Ilo Improvement Contractor (HIC)
\ Registration Number
HIC company`Name or HIC egistrant Name
Address —ll V Expiration Date
Telephone
Signat -
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L.c. 152. § 2506))
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
as Owner of the subject property hereby
I, to act on my behalf, in all matters
authorize
relative to work prized by this building perm>i lication.
Z�or
Date
Si nattir o Owner
SECTION 7b: OWNEW OR AUTHORIZED AGE DECLARAT,I N
as Owner or Authorized Agent hereby declare
I,
that the stateme t u d information on the foregoing application are true and uceurat to o he-best of my knowledge an
behal Z Z L o I/
Print me
Signature of Owner or Authorized Agent
Da[c
(Signed under the Rains and penalties of per u ) 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 730 CMR Regulations 110.R6 and I IO.RS, respectively.
When substantial work is planned, provide the information below:
(including garage, finished base ment/attics, decks or porch)
Total floors area tia Ft.)
Habitable room count
Gross living area(Sq. Ft.) Number of bedrooms
Number of fireplaces
Number of half/baths
Number of bathrooms
Number of decks/ perches
Type of heating system Enclosed I O ten
Type of cooling system
3. "Total Project Square Footage" may be substituted for "Total Project Cost"