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31 HAZEL ST - BUILDING INSPECTION (3) i,. The Commonwealth of Massachusetts `1I Department of Public Safety Massachusetts State Building Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling ,.. _ (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) 3/ 107-el- ST 0/972 No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building�L Repair 6E Alteration Addition❑ TDemolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? I Yes ❑ No ❑ Brief Description of Proposed Work: 6 S 17 .//S7{Y// UV/7 2 = o � f SECTION 3:COMPLETE 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 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): 'SECTION 4:BUILDING HEIGHT AND AREAa- Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) ao Total Area(sq,ft.)and Total Height(ft.) `r000 Z,S "Poo 2.S SECTION 5:USE GROUP(Check as applicable) A: Arsrmbly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ -_.. B: Business ❑ -_ - E: Educational ❑ - - F: Facto F-1 ❑ F2❑ I H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2-NL R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑. SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) ' Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public Check if outside Flood Zone Indicate municipal A trench will not be Licensed Dsposal Site❑ required Igor trench or specify Private❑ or indentify Zone: or on site system❑ S�G permit is enclosed❑ Railroad rigbt-of-Way: Hazards to Air Navigation: MA Historic Commission Review Process: Not Applicable� Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ o Yes❑ No ❑ SECTION 8%CON T T OF CERT ICATE OF OCC NCY" ' a Edition of Code: Use Group(s): Type of Construction: Occ ant Load per Floor: Does the building contain an Sprinkler System?: Spi,5Vf pulations: --- 4r�v-�'e� SECTION 9:PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Il// 0/1/6 /�Ae1e 22 128 � �ony� t/b9C&fir . Cd>� Title Telephone No.(business) Telephone No. (cell) a-mai address If applicable,the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owners behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2), ;,(If buildin is less than 35,000 cu.ft.of enclosed s ace and/or not under Construction Controlthen check here and ski Section 101 ,. a10.1 Registered Professional Responsible for Construction.Control r Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2.General Contractor Company Name , t1// kj�"w os6 Z/3 Name of Person Responsible for Construction License No: and Type if Applicable 6'7 L efrc N s 72 c C-E SALe m . m s� Street Address City/Town State Zip ,79/-W- o 411 / -W_o Telephone No. (business) Telephone No. cell e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.C.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? Yesyi�No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor .5.3 OO O -- - add Materials). Tota]Construction Cost(froir,Item 6)_$ 1.Building $ 00 0 Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ 12 000 appropriate municipal factor)_$ 3.Plumbing $ 20 0 - 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact munici ity) 9 Op 5.Mechanical Other $ Enclose check payable to W 6.Total Cost $ j 3 aO O (contact municipality)and write check number here SECTION 13 SIGNATURE OF BUILDING PERMIT APPLICANT - By entering my 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 of my knowledge and understanding. FIN�N/p /3A-E/46!!? 6424 crL ?B12 Z3 'I 4� -7 2 / Please print and sign name Title Telepho o. Date 2 /ZtlDnly' ,S t/Lt�� e�/�.r✓� 4 1 Street Address City/Town State Zip Municipal Inspector to fill out n this section upon applicatio approval. -. �. . • ,a_. Name °` Dat _ J Appendix 1 For the demolition of structures the building permit applicant shall attest that utility and other service connections are properly addressed to ensure for public safety. Please fill in the information below and submit this appendix with the building permit application. The building permit applicant attests under the pains and penalties of perjury that the following is true and accurate. Property Location (Please indicate Block # and Lot# for locations for which a street address is not available) No. and Street City /Town Zip Name of Building(if applicable) For the above described property the following action was taken: Water Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Gas Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Electricity Shut Off? Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑ Other (if applicable) Appendix 2 Construction Documents are required for structures that must comply with 780 CMR 107. The checklist below is a compilation of the documents that may be required for this. The applicant shall fill out the checklist and provide the contact information of the registered professionals responsible for the documents. This appendix is to be submitted with the building permit application. Checklist for Construction Documents* Mark'Y'where applicable No. Item Submitted Incomplete Not Required 1 Architectural 2 Foundation 3 Structural 4 Fire Suppression 5 Fire Alarm(may require repeaters) 6 HVAC 7 Electrical 8 Plumbing include local connections 9 Gas Natural,Propane,Medical or other 10 Surveyed Site Plan Utilities,Wetland,etc. 11 Specifications 12 Structural Peer Review 13 Structural Tests&Inspections Program 14 Fire Protection Narrative Report 15 Existing Building Survey/Investigation 16 Energy Conservation Report 17 Architectural Access Review 521 CMR 18 Workers Compensation Insurance 19 Hazardous Material Mitigation Documentation 20 Other(Specify) 21 Other(Specify) 22 Other(Specify) 'Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work so identified must not be commenced until this application has been amended and the proposed construction document amendment -has-been approved by the authority having jurisdiction.Work started pr orto approval may besubjected to triple the original permit— ---- fee. Registered Professional Contact Information Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zi Discipline Expiration Date OT-29-2011 10:08AM FROM-CLEMENT ARCHER INS. AGENCY 978-922-9276 T-943 P.001/001 F-092 ACORD 07/29/2 CERTIFICATE OF LIABILITY INSURANCE DATE Y9/2011 PRODUCER (978) 922-4600 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION .ARCHER INSURANCE ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 271 CAHOT ST ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. BEVERLY MA 01915- INSURERS AFFORDING COVERAGE NAIC 0 INSURED INSURERAWESTERN WORLD INS CO Andrew Balboni DBA Northwind Builders LLC INSURERB:LIBERTY MUTUAL INS CO 87 Leach St I GURERC: NSURER D' Salem MA 01970- INSURER C.- COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSL RED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. LLTR INSRO TYPE OF INSURANCE POLICY NUMBER ADIYL DATE(MMIDDIM D.ATE(MMM�IY»N LIMITS A GENERAL LIADILITY "V1259098 01/26/2011 01/26/2012 EACH OCCURRENCE S 1,000,000 X COMMERCIALGENERALLIAB:UTY OAMAGETORENTED SO,000 PREMISES ES OGcumn<n 5 CWMS MADE Fx1CCCJR / / / / MFO EXP w PMW) S 5,000 RSONAL PE B ADV INJURY $ 1,000,000 GENERAL AGGREGATE 1 2,000,000 GEN'LAGGREGATE LpIIMpIT.APPUES PER: PRODUCTS-COMPIOP AGO $ 1,000,000 POLICY IPECT LOC AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY ALTO (Ea ecddmq 5 ALL OWNED AUTOS / / / / BODI LY INJURY $ SCHEDULED AUTOS (p"PP n) HIREDAUTOS / / / / BODILY INJURY -� NON-OWNEDAUTOS (Pare aImt) $ PROPERTY Dq AGE (P rx dmt) $ GARAGEUABIUTY AUTO ONLY-EA ACCIDENT 5 ANYALTO / / / / OTHER THAN EAACc 5 AUTO ONLY: qGG S EXLESSIUMBREUAUABILITY / / / / EACH OCCURRENCE S OCCUR CWMS MADE AGGREGATE S S DEDUCTIBLE - / / - / / $ RETENTION S - - $ P WORKERS COMPENSATION AND WC2-31S-377173-010 04/17/2011 04/17/2012 X I TOA MTIWS D7 EMPLOYERS'UABILTTY ANY PROPRIETORIPARTNERIEXECUTIVE E.L.EACH ACCIDENT E 100,000 OFFICERiMEMBER EXCLUDED? / / / / E.L.DISEASE-EAEMPLOYEES 500,000 SdKCIN_FROM GO NS AMb E.L.OI$EASE-POLICY LIMIT $ 100,000 OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEWLLESIEI(LLUSIONS AWED BY ENWR5EM SPECIAL PROVISIONS JOB SITE: 31 HAZEL ST SALEK, NA. 01970 CERTIFICATE HOLDER CANCELLATION ( ) - (781) 207-4793 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER TALL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BIL T ANTONIO BARLETTA JR FAILURE TO W 50 SHALL IMPOSE NO OBLIGATION OR UABIUW OF ANY KIND UPON THE 2 MEADOW ST INSUREP.ITS AG P ENTAT AUTHORIZED REP NT _ SALEM MA 01970- N ACORD 25(2001108) Q)ACORD CORPORATION 1988 ftni INS025(moa)oS ELECTRONIC IIISER F RMS.INC..(BDgG 7-05AE Pmu 1 u12 m is �: d: h �i' — tv m �3 r `:: ,. �. 0`- -m dg _ _�� � �' I a ii i i e The Official Website of the Office of Consumer Affairs & Business Regulation (OCABR) Mass.Gov Consumer Affairs and Business Regulation Home > Consumer> Home Improvement Contracting > Home Improvement Contractor Registration Lookup The list is current as of Thursday, July 28, 2011. ...__...- You can search/filter the registration list by any of the criteria below. RELATED LINKS Search by Registration Number 4 dome Improvement ____ __ Contractor Registration ;Search Registration Nu mber Home Page Search by Registrant Name Balboni j Search by City Beverly � � Zip Code 0191 ___ m .5 , Search Registrants Click on the registration number to view complaint history. You can also view arbitration and Guarantv Fund history. Search Results ' I l_----_—___.____ ---.__________---_.__------— REGISTRANT RESPONSIBLE REGISTRATION ADDRESS EXPIRATION STATUS NAME INDIVIDUAL NUMBER DATE ANDREW J. i BOLBONI, 110 SUMMIT AVE. 1164885 11/30/2011 'Current i BALBONI _..__.._>ANDREW— —_ 1 MA 01915mmm _ `- - -- ©2011 Commonwealth of Massachusetts Unofficial Property Record Card Page 1 of 1 Unofficial Property Record Card - Salem, MA General Property Data Parcel ID 33-0320-0 Account Number Prior Parcel ID 51 -- Property Owner NOT AVAILABLE Property Location 31 HAZEL STREET Property Use Three Fam. Mailing Address Most Recent Sale Date Sit 511994 Legal Reference 12745-345 city Grantor WENDELL PAMELA P Mailing State Zip Sale Price 148,000 ParcelZoning R2 Land Area 0.084 acres Current Property Assessment Xtra Features Card 1 Value Building Value 203,900 Value 200 Land Value 76,600 Total Value 280,700 Building Description Building Style Muiti-Garden Foundation Type Brick/Stone Flooring Type Hardwood #of Living Units 3 Frame Type Wood Basement Floor Concrete Year Built 1870 Roof Structure Gable Heating Type Elec Base/B Building Grade Average Roof Cover Asphalt Shgl Heating Fuel Gas Building Condition Average Siding Vinyl Air Conditioning 0 Finished Area(SF)2812.5 Interior Walls Plaster #of Bsmt Garages 0 Number Rooms 15 #of Bedrooms 6 #of Full Baths 3 #of 314 Baths 0 #of 1/2 Baths 0 #of Other Fixtures 0 Legal Description Narrative Description of Property This property contains 0.084 acres of land mainly classified as Three Fam.with a(n)Multi-Garden style building,built about 1870,having Vinyl exterior and Asphalt Shgl roof cover,with 3 unit(s),15 room(s),6 bedroom(s),3 bath(s),0 half bath(s). - - - -Pro petit Images ` Disclaimer:This information is believed to be correct but is subject to change and is not warranteed. http://salem.patriotproperties.com/RecordCard.asp 7/29/2011 Page 1 of 1 17 OFP OFP jp 10 OFP 17' 20 9 UAT 55 SFL FFL BMT (1250) 35 15 1 8 , 90 http://salem.patriotproperties.com/sketch/7000/309001.jpg 7/29/2011