17 HERSEY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7`s edition OF SALEM
Revised January
Building Permit Application To.Construct,Repair,Renovate Or Demolish a 1, 2008
/1 One-or Two-Family Dwelling
JT is Sect' For Official Use Only
Building Permit Number.' Date Applied: U
Signature: ���f l
Building Commissioner/Inspect rB o dings Date T
ACTION 1:SITE INFORMATION
1.1 Property Address., 1.2 Assessors Map&Parcel Numbers
n HFe si-EY
1.1als 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 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
A NHn1CY /'J f1rTiLdi 57: �.4(�.N 4 G1S�
Name(Print) Address for Servic 62
: '
ignature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied 0 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other D/Specify: eV1AC ,Ah
Brief Description of Proposed Work': 2aisraLcdUfr Y I SvV� � afemf n!T 1 sn no S acua , u�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials Official Use Only
1.Building $ 11-7 _ 00 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:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ) I "]�. p 0 ❑❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: 'CONSTRUCTION SERVICES i
5.1 Licensed Construction Supervisor(CSL)
_CQ?lU(Z'S l/J/l/�rArP...F License Number Ex imti nDate
Name of CSL-Holder S
�t M A List CSL Type(see below)
MOPE, W
Address :T Description
U Unrestricted(up to 35,000 Cu.Ft.
Signature R Restricted 1&2 FamilyDwelling
M Masonry Only
I)s' —�2 52c. RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
�Ac7LAllH�AY €N1) 2PALSE-S ,7Nt' 13�67�
HIC Company Name or HIC Ri egi'strap N e Registration Number
_ 2 - Tlt N S
cT
Address /(,
�� 373-,_p 1 Fxpiration Date
Signature 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 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
I, /UAL a4wm 4/t as Owner of the subject property hereby
authorize ogjjran/(,.z �VZLC 4itsFg�. �G to act on my behalf,in all matters
relative to work authorized by this bui ding permit application.
��aa lea
SS mature of Owner ate —�
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION'.
I, �'gj70it/(r•L��i ENG��!/�/tLC ��/�. ,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.
�tp-tS
Print Name (/
Signature of Owner or A61borized Agent Date
(Signed under the pains and penalties of
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 fand 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 I1O.R6 and I IO.R5,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"
CITY OF S.U.E.`I, NLASS.-ICHL-SETTS
BL ILDDIG DEPARTMEINT
• 120 WASHINGTON STREET, Ye FLOOR
TEL (978) 745-9595
FAx(978) 74Q9&W
KI\IBERIEY DRISCOLL
MAYORIlmms ST.PrEns
DIRECTOR OF PL BLIC PROPERTY/BL'ILDLNG CO.%L%BSSIO\ER
Workers' Compensation Insurance Allidavit: Builders/ContractorslElectrlcirns/Plumbers
Annlicant Information Please Print Legibly
Vacne(Business.OrpnuatiomIndivldual): (A STonl(—()P Y Z'nfTl` e{12J:�Sy 'T-AIC
Address* `i00 L,IG.`M P—(�) St)i/E aZ C
CitylStatdZip: P02TSnx,,,-n-I A11 GS O ( Phone0: 60-,%-37 Ca(f
Are you me employer?Cheep the appropriate boa:
Type of protest(required):
1.❑ 1 am a employer with 4. 0 1 am a general contractor and 1 5. ❑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 shccL 7. ❑Remodeling
ship and have no employees These sub-contractors have Il. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp, insurance 5. 12fWe are a corporation and its
required.l officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.INo workers'comp. c. 152,1I(41 and we have no 12.0 Roof mpairs
insurance required.)t employees.INo workers' I3.[ Odiv K�OI/afF/YI vL �j
comp6 insurance required.)
-AnyappttcanlItdchocbsbann mineatwt fill out Ibrmitew below showing sbeirworkes-caoppopMMshmPush InfumtuWa
'I hm+ruwtwMM rho subole this aNhlwA indicating itlry m Joins all work sed shop hire outside o nreebn mug submit a low a ndavil indicating a nk
{.m mion shot clink ibis bon opus stlechrd an aJditiudwi.hops showing Ind lmly or tits ab.Narretlan Meet Illek-who .ramp.policy imfm,womee.
/one an employer that&providlnR workers'rompensuden Insurewefor my empleyt I. QNow/s the pour y awdM rile
information.
Insurance Company Name:L?4x �% Msi1VA C
Policy a err self-ins. Lie.a: W e c_ ,; — 3�- S�ly - OIq Expiration Date: 7 .o
Job Site Address: n /-I FQ.CC 4r ST City/StaWZip: S_f4 M� MA OCq�O
.httacb a copy of this workero'compensation policy declaration pap(showing Ibis policy number and asplrsdoo data)`
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 ro 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 5230.00 a day against the violator. Ik advislxl that a cupy of this stalcmcnt may be rurivarded to the Off ice of
Ilri'i allgallUM of the DIA ror Insurance coverage vetll%:a1W11.
1010 hereby certify under the pw' ales of perfury that the informmloa provided above is true and correct
Dale:
O/Jlcla/sae ally: Do nor write he this area,to be cump/eted by dry or town"/Hain`
City or ruwn: _ Yermit/Iaccnse M
Issuing.whurily (circle une): -- — - —
I. Iluard at Iivahh I. Building Deparlment I Ciiytrowa Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
lnua I Person:. Phone e•
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MU 'n 110 A'.xi111\G:jtN SIHUT S.0 F%I,%IA"
TF.1:WV43- 595 • 1'.%x:9711.7440846
Construction Debris Disposal Atlidavit
(required I'ur all demolition vrd renovation work)
In accordance with the sixth edition of the State Building Code, 780 CIVIR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 1t _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will be transported by:
��Utm 10
(name of hauler)
The debris will be disposed of in
yahSi� N1At`lafab�_?��4'D I�IMPSr�
(name of (lcllrty)
IaJdress ul 1'acllny)
signature of permit applicant
(late
Office of Consumer Affairs&Bus oess Regulation
- HOME IMPROVEMENT CONTRACTOR
Registration: 138722
log Expiration: 5/6/2011
Type: Supplement Card
Castonguay Enterprises,lnc.dba Hometown
FRANCIS LONGACRE
300 WEST RD SUITE 2 g o
portmoulh,nh 03801 Undersecretary
valid for indivldul use oonly
or registratio Gate. if Sound return ulation
License the expiration Business Reg
before ffairs and
Office of Consumer A5170
toy or Plaza-Suite
Boston.MA 02116
L
J
plot valid
With t signature e
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'PRooucER CA9T0-2 09 30 09
THIS CERTIFICATE 16 ISSUED Ag A MATTER OF INFORMATION
GOwe.n a Nein}Pright Age, ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
CY: Irlc HOLDER.THIS CERTIFICATE DOES NOT AM ENO, EXTEND OR
441i Dqt Point Road ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
DOV9r NH 03820
Phone: 603-742-2552 FnOL:603-742-4509 INSURERS AFFORDING COVERAGE n9ugeD
NAIC B
INSURER A: Concord Grcu Ineuranaa 20672
INSURER B: LU:eS Mutual 23043
30
0 0 tongv ay En ri9B9 Inc MBURER C:
Meet Aoad, Sze 2 --
POrtemout.b MR 031301 MBUFUIR O:
COVERAGES INSURER E
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THF.M6UR O NAMED ABDVE FOR THE POLICY PERIOD INDICATED.NOTWITH9TANOINp
ANY REOUDREMF.NT TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH TNIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INBVRANCE AFMRDED BY THE POLICIES DESCRIBED HEREIN 16 SUBJECT TO ALL THE TERMS.E%CLVFIONS AND CONDMIONS OF SUCH
POLICIES.AGGREGATE L(VMS BHDWH MAY HAVE BEEN REDUCED BY PAID CLAIMS,
LTR SR TVP6 Of PN9URANCE POLIGYNUMINIR DATE ANODD CA E
GENERAL UABLITY UNTO
A X COMMERCIALGENEOALLIABIUTY EACH OCCURRENCE tl 000,000
� MP3543036 10/01/09 10/01/10 PREMIB66 Aomre.Nz t50,000
CIAIMS MADE C_I OCCUR MEO EAP CA,.1A Pxeor,) E5000
PERSONAL t AOV INJURY t1,000,00Q
OEML AGOR EOATE PLpI MIT APPLE 9 PER: GENERAL AGGREGATE t 2 000 000
POLICY JECO LOC PRODUCTS-COMP/OP AGO Al ODO 000
AL/TTIANIBRE LIABLIIY
A R ANYAUTO C414745 04/28/09 04/20/10 (EA ADP�AMI ucL"LIM*Tt 1
ALL OWNED AUTO6
SCHEDUIEOAVTOB BODILY INJURY }IPAFDPsOol 11,000,000
X HIRFD AUTOS
A NONq NEO AUT03 BODILY INJURY
(Pa McbenO 1
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(PerimiAARD i
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O6BGRIPTON OF ppEMT10IIB/�T-ATON81 YLMCLB9/6%CUJSgNS ADDED SY ENDOR9fiR6Y1T/BPECIµ PROVISIONS
CERTIFICATE RDLDER
CANCELLATION
NOCF.RTS 9ROULDAM'OF THE AOOVF IN9DgIDED OOLICIES OE CAIICELL6D BEFORE T11f FAPWATgN
DATE THPREOP,TNB L9EUW0 M9VR6R WILL 6NOSAVOR TO NAR 1O OAYB WRITTEN
N0 CERTIFICATE HOLDER HpGCE TO TH6 C6gTIFlGTE HOLDER NAMED 7O THE LER,SLIT IARUgE TO DO 80 SHALL
INPOEE NO 09DGATON OR LIABL/TY OF ANY KNID WON THE INSURER,ITS AGENTS OR
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