6 HERBERT ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standar Ulm CITY OF
assachusetts State Building Cod SALEM
M e,��i`IIj� A� RVIC ° dMar
i Reviseed Mar 2011
Building Permit Application To Construct, Repair, novate ��
We o h
One- or Two-Family Dwellinl b JUN 13
This Section For Official Use Only
t Building Permit Number: Date Ap i d:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers
e b N«3(�r
1.1 a Is this an accepted street?yes 11� 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 Provided 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?
Public C—� Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Ive IV,,) V Ntc t4c P VI- J M6- al �i7 11
Ng(� eA- � � City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List: �J V
5. Mechanical (Fire $ Total All Fees: $
76Totat
ession)
Check No. Check Amount: Cash Amount:
Project Cost: $ SJ.6,00 ❑Paid in Full ❑ Outstanding Balance Due:
M P<I L_C-5 lD TD U C I t
SECTION 5: CONSTRUCTION SERVICES
5.1� Construuction Supervisor License(CSL) G S— 0�(p't G 1 1 — O 8—20 t(o
lJ ct
I, \" ' Pl 2c,1 f-\t ic) License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
P' ( n l�E.(�1�4Z1 ➢ Type Description
Noo..and Street
J� p U Unrestricted Buildings u to 35,000 cu. ft.
� ) l 15 R Restricted 1&2 Family Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) (1 G 5- 9 c\ of 60�
f( t p. o Cu^Srsr u c %-_o N C� a HIC Registration Number Ex nation Date
HIC Company Name or HIC Registrant Name
t06 Cu h S � f2 V'tcrc,'cti> -P ( c1
No. and Street Email address
Cit /Town, State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 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 o e building permit.
Signed Affidavit Attached? Yes .......... No ........... ❑
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 po.w� l�err t an u /�a�c�'wh �r��7 St'✓�`c F " Cd�!'s
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's N"(Electronic S r lure) Date
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
c Tmai"
ned in this application is true and ac rate to the bestof my knowledge and understanding.
O(o 111 ) /�
Print Owner's toAuthorized Ag 's Name(El ctronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.uov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. fl.) (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"
i CITY OF SALEM, iN•LxSSACHUSETTS
• BUILDLLNG DEPARTMENT
` p 120 W.sSHLNGTON STREET, Soo FLOOR
TEL. (978) 745-9595
Rex(978) 740-9M
KI\tBERLEY DRISCOLL
MAYOR DIRECTOR
ST.PtFxRs
DIRECTOR OF PUBLIC PROPERTY/BuiLDLN3G CONMIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Leaibiv
Tattle (Busitt &Organization/Individual): / ���Ltq�fl dowc cad tJ
Address: f00 !u uwt aLS CM
lS✓try Y.7—tp
City/State/Zip: 49eel d. t i4 /�6e Phone #:6-03 �3L f069
Are vaurlan employer?Check the appropriate box: Type urproject(required):
i.69 I am a employer with Z 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.% 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. !Q Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 LCI Plumbing repairs or additions
myself. (No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.}t employees. [No workers' l3 ❑Other
comp.insurance required.}
•Any applicant that chocks box Of most also fill out the section below showing their workers'compensation policy infunnation.
+I honvowners who submit this affidavit indicating they are doing all work and then him outside contactors most submit a maw amdavit indicating such.
=Centmetan that check this box most attached an additional sheet showing the name of the sub-comactoa and their workers'comp,policy information.
I am an employer that/s providing workers'compensation Insurance for my employees. Below Is the policy and fob site
information.
Insurance Company Name:. /f/Or2. fruA+4,7
Policy#or Self-ins.Lie.#: MA-tz 6 27aE S Expiration Date: ////zRL/E, '
Job Site Address: ic l��«BrwT %�:: City/State/Zip: S4-(6of 0& c) If70
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby ce er the pu s rued enabler ofperfury that the Information provided above Is true and correct.
Sianalure: Date, bllj/(�r
P one#•
OJJleiat use only. Do not write in this area,to be courpleted by city or town off&iaL
City or Town: PermiUl.tcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cilyrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Phone#:
I
noeSe Begat/r a k
��e Uaperinnrvrne�r(f f
O[flee o[Coesumer ABairs&Sass CTOR
ENT CONTRA
NON£IMPROO9 Type:
"Lgwattort Y
37 Cotporatonxv
F,
- - 6,pkath 1t
MARCIANO CONSI'$ O
P.
v
t2
PAUL MARCIANOR_ E2 y
100 CUNNINGS CE _. iluderseeretery
%&OERLY,MA 01915
CITY OF S.U.EM, \rLxSSACHUSETTS
• BuILDLNG DEPARTM&NT
• 130 WASHINGTON STREET, 3�FLOOR
d TE:L- (978) 745-9595
FAX(978) 740-9846
KINtBERLEY DRiSCOLL
MAYOR 'I�[oAIAS ST.PIF1tRli
DIRECTOR OF PUBLIC PROPERTY/BL'II.DLNG CO\L\IISSIONER
Construction Debris Disposal Affidavit
(required for 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 # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
AV dond C I fA' CfiiJAj
(name of hauler)
The debris will be disposed of in
(name of facility) /�
203 C. r0,", Sa . Geo✓� e
(address of facility)
signature of permit applicant
date
dcbrvwlldm
,y►coizde CERTIFICATE OF LIABILITY INSURANCE
0611012016
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(les)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 endomement(a).
PRODUCER CONTACT
NAME:
Automatic Data Processing Insurance Agency,Inc. PHONE
FX No]:
1 Adp Boulevard ADDI ESS:
Roseland,NJ 07068 INSURER(S)AFFORDING COVERAGE NAIC S
INSURERA: NorGUARDblwnnee C011panY 31470
INSURED INSURER B:
110 C CONSTRUCTION CORP INSURER C:
110 Cabotbot S!
Beverly,MA 01916 INSURER 0
INSURER E
INSURER F
COVERAGES CERTIFICATE NUMBER: 603568 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.
LTR TYPE OF INSURANCE I POLICYNUMBER I'POU
CYEI� POLI LIMITS
CCY
OMMERCUIL GENERAL LIABILITY EACH OCCURRENCE E
CWMSIdADE OCCUR PREMISES Ea axurtanz §
MED EXP(Any oneperepn) S
PERSONAL BADV INJURY $
GEN-L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE S
POLICY JECT LOC
PRODUCTS-COMPgP AGO E
OTHER: §
AUTOMOBILELUA3ILRV Ee epddeAl $
ANY AUTO BODILY INJURY(Perpenoa) S
ALL OWNED SCHEDULED (Peraadden0 f
AUTOS AUTOS BODILY INJURY
HIRED AUTOS NONOWNED
AUTOS Per ecddenI E
S
UYBRF1lA LIAR OCCUR EACH OCCURRENCE E
EXCESS UAB CLAIMS-MADE, AGGREGATE §
DED RETENTIONS Is
BtS
AND EMPLOYERS'
MUM STA E R
ANDEMPLOYERS WBINER YIN x
A OFHYFIPddaryin 1BER'vPF�cAciuDE � NIA N MAWC697265 11/26/201fi 11128=16 E.L.EACH ACCroENT § 100,000
(MandebrybNN) E.L DISEASE-EAEMPLOYE S 100,000
e yes.deauibe Hitler 100,000
DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMB E
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD 101,Addithmal RemaM SeMduK maybe aBaehed Jim.spaea M meulmd)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
WENDY MEIGS ACCORDANCE WITH THE POLICY PROVISIONS.
6 HERBERT STREET
Salem,MA 01970 AUTHORMn REPRESENTATIVE
--7t �x1
®1988-2014 ACORD CORPORATION.All rights reserved.
ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD