144 HIGHLAND AVE - BUILDING INSPECTION 7-ysys�
_- The Coniolomceallh of MassaehusellN
t t Board of Building RCgulalions and Standards I'c At
y \II Nil II' \I II l
t Massachusetts Slate Building Code. 7S1) ('!SIR. 7"' edintui
Building Permit Application To Construct. Repair. Renm ate Or Deniolisit a K. :nr,l l unn„
(An'- [,/ T,ro-Fmnih D,reF/irt,q
-1
This Section For Official Use Otlly
---I
13 Building Permit Num •r Date .applied:
------ - -
,.1
Signature: --- -
Buddmg Cumnns.uwcr/ In.per) wldm�s I ale
SE '1'I( N I: SITE INFORMATION
1.1 Pro ertt Arulress: 1.1 Assessors Nlap Ni Parcel Numbers - -
� �f6ltiLR�,.D
t'7•s all accepted sueet! Yes a Map Nuu:her
1 1.3 Zoning inform ttrt:n: - I 1.4 Property Dimensions: I te
i
( - _- - .___ .— --.-.__— L:i:?fC❑ti li) --- Foua-e (it)
7u;..,,5
L.' Siuiiding Setbt•cks(171)
Fnmt Yard S-de Yards Rear Yuri:
! Required I __ Prev sided Requued Pruo Wed Rcquu cJ Pr ,•.:drJ
L6 1Ya[er Sapl,fy: )M.:;.I_c. 10. 4 51) 1.7 Flood Zone Information: LS Sewage Disposal System:
Zone: _ Outside Flood Zone., Municipal ❑ On ,itc Jis lusul s .[an ❑
Pubic ❑ Private C Check if yes❑ p I }
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of RRecord;��i �� Lh
� .� t/ e
r 1
N.ure f Prin[t Address fix Service: _
- Telephone __^
ienruue -- -II
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
_ —i,
1view r un.,r tn•,n ❑ Existing Buildim); C Owner-Occupied Q Repairs(s) ❑ Alteranon(s) C \dJY�nn ❑
•eir Amon ❑ Accessory Bldg. ❑ Number of Units _- Other ❑ Spcafy:_
Br,ef De a spoon ,:! Proposed
SECTION I: ESTIMATED CONSTRUCTION COSTS
— -�
Estimated Costs: Official Use Only
Item (I a`hor and Materials)
I. )building $ b/j'-O6 , GG I. Building Permit Fee: S Indicate hose fee is determined:
❑ Standard City/Town Application Fee
?. Electrical 5 ❑ Total Project Cunt' (Item 6) x multiplier .x
\. Plumbing S 2. Other Fees: g I
- 1. Mechanical IH1 ICI S List _--
�. Mechanical (Fire
1 �upprcesinn)
fond All Fees S
r O C� ('heck No. Check :\mount: (-ash \moon(:-- _-.
n total Project Cost S 6sa°` 11 Paid inFull 0 Outstanding, Bal:ulce Due:__-_-- -
SECTION 5: CONSTRUCTION SERVICES
5•I Licensed Construction Supervisor(C'SL) --11
06&J3 �
�Le,� �z� Llcrn,eNumhrr I`,pu.IWlnU.ur a
Nalgc oI('111 0 Jcr Rom . � v ----
LV yJ Lot CSL, 7\pc I,ce below I
- I-me De"rl qwn
\Idles,
( ( III'CfII1CICJ �11l1U :i.IN)U( ll. I'li
-- R Restricted I -' Famil\ Dw cltinc —,
Signature M \1:oonn lhtl\
RC Re,IJennal Ruuline
fclephunc \\'Sal \\lndw, Sind IIJI�u
SF Re, Jeml.11 SuIJ fuel Ifw Hill_ Ai.lu., Ll� .l .11nm
- D R.•.IJeuli.J Urnwhunn __ _{
5.2 R�g�ter I ome_I�riprurement Contractor (IIIC)
1 C ff/it"mp:ury4�ILI�Revlstr In Name �/ Raeutrauun Number a i
ildre . y
S // b F.yn rauun Uutc
Slgt lure Telapluuw
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 2506))
Workers Compensation Insurance atfidav it must be completed :md .,ubmi tied with this applica(ion. Failure to prelude
this affidavit will result in the denial of the Issuance I-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
1. as Owner of the subject property hereby
authorize to act on my behalt. in all m:umn
relative to woI k authorized by this building permit application.
i
Si nature of Owner Date
SECTION 77bb: OWNEW OR AUTHORIZED AGENT DECLARATION
1• ,�7�/V -'r�-�-�5 , 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 knowledLe and
behalf.
Print Name '
Signature o wrier or Authorize)0gent Date
1 Si reed tin er the pains and penalties of erju I
NOTES:
I. An Owner w'ho obtains a building permit to do his/her own work,or an owner who hires an unrcelstered cwitra.elr
(nut registered in the Home Improvement Contrac(or (HIC) Program), will not hace access to the arhitrat ion
program or guaranty fund under M.G.L. c. IJ'_A. Other important inGamanon on the fill' Program :Ind
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS. iespecti\ely
' When substantial work is planned, provide the information below:
Total floors area iSq. Ft.) (Including garage. finished basement/attics. decks I,r pinchl
Gross living area ISy. Ft.) Habitable room count
Number tit tlreplaces Number tit hedroums
Number Irt hathioolns Number Id half/h.uhs
1'cpe of heating ,vstem _— - Number tit decks/
Type Ili cnohng System _ Iincll�seJ _ __Vpcn
1. -Total Project Square Footage- may be ,ubstitu(ed fw "final Project Co,(-
aCORQ. CERTIFICATE OF LIABILITY INSURANCE ATErAMMON s)
PRODUCOR (781)438-5000 FAX (781)43E-SO2E THIS CERTIFICATE IS ISSUED AS A(MATTER OF INFORMATION
MainEngland Heritage Z95trraRCe Agency Group, Inc. ONLY AND CONFERS NO RIGHTS uPON THE CER71FICATE
33 Main
5 HOLDER.THIS CERTIFICATE DOES NOT AMEND EXTEND OR
33 Street , ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Stoneham, NA 02190
IHS1.11082$AFFORDING COVERAGE NAIL#
INSURED A S Carnes,rac. WSUPARA: Essex Insurance Co.
30 Arrmdmkkd Fatty Rd. BISuRERR AIG ARMCAN INTERNL GROUP 131C
Boxford, NA 01921 INSURE C;
D:
INSURERE
VE
THE POLICIES OF INSURANCE LISTED BROW HAVE BUN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED-NOTWITHSTANDING
ANY REQUIREMENT.TERM OR CONDRION OFF AMY 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
POUCtES.AGGREGATE LVAITS SHOWN MAY HAVE.BEEN REDUCED SYPAIDCLARMB-
M TPE OFIMIRNUU ;E POUCYKIq� PO/.ICII EFFEO'TIVE R POLICY EXPIRATiOM LIaQTg
GENERAL LMSMM TBD 03 18/2009 03/18/2009 EAcxocCURRECE S 1.000,001
x COMMERCIAL GENERAL UABVITY DAMAGE RENTED $ 50,001
awws MADE ®OCCUR LIED EXP WWo Pawn) $ 5,001 _
A - PERSDr a ADv INJURY S 1,000,001
GENERAL AGGREGATE $ - 2.000,00(
GENL AGGREGATE LIMIT APPLIES POL PRODUCTS-COMPIOP AGG $ 1,000,004
POLICY LOC
AUTOMOBILE UABIItfY COMBINED SINGLE LWR
ANY AUTO (Ea acdda ) $
ALLOWIEDAUTOS
BImav IwuRr S
SCHEDULED AUTOS (PF Pam) ..
HREDAUTOS
BODILY INJURY S
HONOVARM AUTOS (Per waderd)
PROPERTY DAMAGE $
(Per eaiVaM)
GARAGELNBMITY - AUTO ONLY-EA ACCIDENT S
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG S
EXCESSRIMISRELLAUAWITY EACH OCCURRENCE f q
OCCUR a CLAIMS MADE AGGREGATE S
S
OEWCHBLE S
RETENTION f S
WORKERS COMPENSATION AND MC 844-90-76 03/31/2008 03/31/2009 ' WATU- OTH-
EMPLOYER5 LIABRM EL.EACH ACCIDENTS 1,000,
UDC
B ANY PROPRWrORRARFER& E0UnVE
OFFICHLMBMBHN EXCLUDED? E-L DISEASE-EA EMPLO S 1,000,00(
aSPECfAL PROVISb16Odor - El OISFASE-POLICY LIMB S 1,000,00C
OTHER
DESCRIPTION OF OPHNTIDNA/LOp1T W M9/T/H8CSE8/EIEGLU670NB ARID 67/BRORPMIT I SPECIAL PROVISIONS
ontractor Subject to terms, conditions, endorsements and exclusions on the Policy.
CER71FICATE HOLDER
SHOULDANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
ODVRAHONOATETREREOF.THE ISSUING INSURER WILL ENDEAVOR TO MAIL
10 DAYS WR"TEN MOD"TO THE CERRRCAIE HOLDER NAMED TO THE LEM
BUT FANAIRE TO WAR SUCH NOTICE SHALL 1184ME NO OBLIGATION OR LIABILITY
"PROOF OF INSURANCE COVERAGE ONLY" OF ANY gRDUPON TMIMSURETR,ITS AGENTS OR REPRESENTATIVES.
SPECI!'IEN COPY ONLY AUnroWS=RPRESENTATWE f I
William Kell
ACORD 25(2001M) zarnpn enoonDATInAl 4002
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:J V I9 H i P.l':M INC,u.t.
\I'twtR 12C WASHI.\i;TpV STIILLT * SAL EM,MASSACIn sr:I:ISO 197,^,
Tt,i.:978-745-9595 • FAX: 978-74C-9846
Workers' Compensation Insurance Affidavit- Builders/Contractors/EI c ace Print Leeiblv
rs p ilicant Informrtion
Name tBusinees�sOrkan�irati�njNi'`"`�lndivulual):
Address. J 6) f7yC'-'(0
City'Stare'Zip. � � Phone 0- l 7L
,%rc vo , employer! Check the appropriate box:
Type of project(required):
1. I Yam employer with 4. ❑ I am a general contractor and I g, ❑ New construction
have hired the soh-contractors � ❑ Remodeling
ell
(full and/or port-tints).` listed on the anachcd shcet.
2.❑ I ant a sole proprietor or partner-
ship and have no employees These sub-contractors have 8. ❑ Demolition
workers' comp. insurance. 9. ❑ Building addition
working for me in any capacity. S. ❑ We are a corporation and its
('o workers' comp. insurance 10.0 Electrical repairs or additions
required.] officers have exercised their
ri ht of exemption per MGL I I.❑ Plumbing repairs or additions
3.❑ 1 am it homeowner doing all work C. 152,§1(4),and we have no 12.❑ Roof repairs
myself. [No workers' comp. amployces. LNo workers'
insurance required.] 13.❑ Other
comp. insurance required.]
-.nnc.5wplicant that el:ocks box dl must also fill nut the sec' --------------------
run lxluw showing their workers cumpensation pulley intirrmulium .
' I lomaiwm:n who submil this a17davii indicuing they are doing all work and then hire outside contractors must suhmil a new al'fdavil indicating such.
C' in ct rs that buck this box must auxhcd an additional sheet sh. mi;the name of the subaontraclom and their workers'comp.policy infonnariun.
1 ant air employer that is providing workers'c•ompen.cntion insurance jot uiy eurplojreev. Before is the polity and job vile
injorutution.
/, r�^ �L,�C�. 7lj -
Policy a ur Self-ins. Lic *: fQ/ _ Expiration Dater`
Job Sits Address:
i YIf ('f//�� LGI1 .. City%State/'Lip:— L
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>IGL c. 152 can lead to the imposition of criminal penalties of a
fine up of 51.500A0 and/or one-year imprisonme t!.5 well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. advivd that a copy of this statement may be forwarded to the 017ice of
Invratigatirnu of the DIA for insurance 'tvcragc vcii lication.
l do hereby certify under the pair sad prrmltics ojprrjury that the injonnutiwr provided above is foie uud�c'orre'— -
lh 7 J r--/ � rrG
()fjic•ial use only. Do not ivrire in this area, to be completed by city or town ojjiciaL
Permit/l.iccnse X.------
City ur'fnwn: ..._ - - - -.
issuing :%uthurity (circle one):
I. 1Suard of Ifealth 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. plumbing Inspector
6. Other --- - -
Phone H:
Contact Person:
Information and Instructions '
,Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pnfsatant to.this statute, an empluree is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An ernplaycr is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of,in individual, partnership, association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance, cunstruction or repair work on such dwelling house
or un the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.%IGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, bIGL chapter 152, 625C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been In to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confimmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he remand to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the pennit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicemse applications in any given year,need only submit Vine affidavit indicating current
policy information(if necessary)and under"Job Site Address" the applicant should write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses.,A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. it dug license or permit to ban leaves etc.)said person is NOT required to complete this affidavit.
I he Office of luvestigations would like to thank you in advance fur your cooperation and should you have any questions,
Please do nut hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
itcviscd 5-26-05
Fax #617-727-7749
-
www.mass.gov/dia
•;, CITY OF SALEM
Y S.. J f
Aa: ' PUBLIC PROPRERTY
DEPARTMENT
'.t r I'. \\ \;I INt. ,NSrat:rr # S.u !-\t, \L\,s
11:1. V78-'43-Oi;6 ♦ 1:\Y:')7N .74.'15i6
Construction Debris Disposal Affidavit
(r«lui ed 1br all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 1 11.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
( me of facility)
(address of lacility)
trig aturc ; permit ullllhCant
3
date —._..
e Jac
e,�B ar of 9uil 2 egu I Cons tandard
kWj
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registration
Registration: 100733
Type: Private Corporation
Expiration: 6232010 Tr 267195
A. B.CARNES, INC.
Barry Carnes
30 Arrowhead Farm Rd. —
Boxford,MA 01921 -- - -- --
Itpdatc Address and rourn curd.Mark reason for change.
Address ' Renewal ❑ Employment Lost Card
L:rS ' 0 Spf4e]M-CLBa9J J �%
✓M tPo4hel0Jxt "d
Swrd of Budding Regetmlans untl Smndards
Co Imolon Supervisor License '
Licanse; CS 68139
- Expiration: 11,,20f0 TrtI 12607
Restriction: DD
KENNET R CARNES
8 DORIS ST
GROVEL 'D.MA fl mu ..__-... .