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34 HAZEL ST - BUILDING INSPECTION
1 The Commonwealth ofblassac`lu . NAL SERVICES CITY OF Board of Building Regulations and Standards SALEM ± � Massachusetts State Building CociftQ40lif 1 P r 41 Revised,llar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Divelling pw� For Official Use Onl Building Permit NumbersDate Appheds to y Building Oly cial(Print N. Signature - - Date 1 E-INEORt�(ATION:� Property Address: 1.2 Assessors Map.I:Parcel Numberb ff � pL 1.1 a Is this an accepted strMap Number ' Parcel Number 1.3 Zoning Information: I.J Property Dimensions: Zoning District :.- PropLotArea(sg11) - Frontage(11) - - 1.5 BuildingSet1b eks(R) Front Yard Sido Yards Required Provided Required Provided. Required Provided 1.6 Water Supply:(M.G.L c.4t),§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipd O On site disposal system ❑ -. Public❑ Private.0. Check If, esO. SECTIONI- PROPERTYOWNERSHIPr' 2.1 Ownert ol` te�ord .fW4e(Print) ; . City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction O Existing Building* Owner-Occupied O Repairs(s) Aiteration(s) O Addition O Demolition - O AccessoryBl Number of Units_ I Other 0Specify: Brief Dgscnption of Proposed Work': i e-dz� c 2 `✓. C G q rt� SECTION a:ESTIMATED CONSTRUCTION COSTS Mou s: OfDciai Use Only ItemI(FIVAC) ials - I. Building7 1. Building Permit Fee:$ Indicate.how fee is determined: ❑Standard City/Town Application Fee 2. Electrical ❑Total Project Cost"(item 6)s multiplier s 3. Plumbing 2?Qther Fees: S 3.Mechanicalj List: 5. Mechanical (Fire S Total All Fees:S Su ression) Check No._Check Amount: Cash Amount: 6.Tutal Project Cost: rs �L V ❑Paid in Full ❑Outstanding Balance Due: MPt t QS �F_tV13G oC 3 '1Z`f;SECTIONS: CONSTRUCTION SERVICES s 5.1 Construction Supervisor License(CSL) a �s3a2 S'l3�17 _ ' ^ � _ r i } i l5: .1i,.1 License Number Expiration Uale Name ofCSLHulder T y � r list CSL'T (see below) —fir Type Description No.-,old — Street r -f,,,_ U Unrestricted((Buirdings tip-to 35,000 cu. 11. VJr d 612Z Restricted 1&2 Family Dwelling City�tate,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances -(s L �b bbb 33Sb�niti.r./ 1 Insulation Telephone Emoil aJJWs l D Demolition 5.2 Re istered if Improvement Contractor(HIC) / n ll l( <Crb (lAct.5 HIC Registration Number spirution Date fIIC m any N o HIC Registrant Name I� � IRO �6 ao3 41,-. xa No.mid Sued d /�•�-��_R 37sx 1 address Ci rown state,ZIP —D Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L,c.151.g 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 Istuance of the building permit. Signed Affidavit Attached? Yes..........O No...........O SECTION 7a-.=ER AUTHORIZATION,TO BE.COMPLETED WHEN' OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT- I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Dale SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 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.. Print Owner's or Authorized Agent's Name(Electronic Signature) Dale NOTES: 1. 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 ggi have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important inf&manon on the-HIC-Pr b—e Iotinn at teww mass eo�:'oc;t Information on the Construction Supervisor License can be found at www.ntas� 2. When substantial work is planned, provide the information below: 'total floor area(sq. R.) `S (including garage,finished basementlattics,decks or porch) Gross living area(sq. It.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths 'type of healing system Number of decks/porches Type ofcoolingsystem— Enclosed Open 3_ "Total Project Square Footage'may be substituted for"'rota) Project Cost" Unofficial Property Record Card Page 1 of I ' Unofficial Property Record Card - Salem, MA General Property Data Parcel ID 33-0074-0 Account Number Prior Parcel ID 51 -- Property Owner BLAIS REALTY TRUST Property Location 34 HAZEL STREET BLAIS MARY JANE TR Property Use Two Family Mailing Address 2 MADELINE AVENUE Most Recent Sale Data 7/2612005 Legal Reference 24606-564 City SALEM Grantor BLAIS ARMAND R, Mailing State MA Zip 01970 Sale Price 0 ParcelZoning R2 Land Area 0.070 acres Current Property Assessment Card 1 Value Building 159200 Xtra Features 2,400 Land Value 81,000 Total Value 242,600 , Value Value Building Description Building Style Muiti-Garden Foundation Type Brick/Stone Flooring Type Hardwood #of Living Units 2 Frame Type Wood Basement Floor Concrete Year Built 1870 Roof Structure Gable Heating Type Forced H/W Building Grade Average Roof Cover Asphalt Shgl Heating Fuel Oil Building Condition Fair Siding Wood Shingle Air Conditioning 0% Finished Area(SF)1980 Interior Walls Plaster #of Bsmt Garages 0 Number Rooms 10 #of Bedrooms 4 #of Full Baths 2 #of 3/4 Baths 0 #of 112 Baths 0 #of Other Fixtures 0 Legal Description Narrative Description of Property This property contains 0.070 acres of land mainly classified as Two Family with a(n)Multi-Garden style building,built about 1870,having Wood Shingle exterior and Asphalt Shgl roof cover,with 2 unit(s),10 room(s),4 bedroom(s),2 bath(s),0 half bath(s). Property Images f F s al A A, - Disclaimer:This information is believed to be correct but is subject to change and is not warranteed. http://satem.patriotproperties.com/RecordCard.asp 3/17/2016 ,4coR0® CERTIFICATE OF LIABILITY INSURANCE DATE(MM DDM YY) `/ 1 3/17/2016 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 endorsement(s). PRODUCER CONTACT Sandra Grover NAME: Ambrose Insurance Agency, Inc. PHONE FAX 70 Munroe Street, Suite D ADDRESS:egrover@prescottaadson.cm INSURE S AFFORDING COVERAGE NAIC0 Lynn MA 01901 INSURERAMEStern World Insurance Cc INSURED INSURER B: RFR Development, Inc. INSURERC: Robert Rogers INSURER D: 26 Wildwood Rd. INSURER E: Danvers MA 01923 1 INSURER F: COVERAGES CERTIFICATE NUMBERCL1551120744 REVISION NUMBER: THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR 7ypE OF INSURANCE A UBR POLICY EFF POLICY EXP LTR POLICY NUMBER IMMIDDrYYYYI IMWDDfYYYY) LIMITS X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 DAMAGE TO RENTED A CLAIMSWADE 1XI OCCUR PREMISES Ea ccartence $ 50,000 NPP8290218 5/7/2015 5/7/2016 MED EXP(Any one person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER GENERAL AGGREGATE $ 2,000,000 JECT POLICY PRO- LOC PRODUCTS-COMPIOP AGG $ 2,000,000 X OTHER: S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea a.Id rn ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED AUTOS AUTOS BODILY INJURY(Per accident) $ HIRED AUTOS NON.OWNED PROPERTY DAMAGE $ AUTOS Per accident S UMBRELLA LIAS OCCUR EACH OCCURRENCE $ EXCESS LULB CLAIMS-MADE AGGREGATE $ DELI I I RETENTION$ $ WORKERS COMPENSATION PER OTH- ANDEMPLOYERTLIAMUTY YIN STATUTE ER ANY PROPRIETOMPARTNER ECUTIVE E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? El NIA (Mandatory In NH) E.L.DISEASE EA EMPLOYE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may bar attached N more apace Is requinW) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE City Of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Salem, MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. AUTRORIZED REPRESENTATIVE J S Scholnick/SJG ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD INS02519m41111