154 HIGHLAND AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T°edition OF SALEM
Revised Jurruury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. =0014
One-or Tivo-FaTi4v Dwelling
^ This Serifion F Official Use Only
Building Permit Number" I I IDate/AApplied::
-� Signature:
Building mmissioner/I pector of Buildi Date
SECTION 1: tTE INFORMATION
1.1 Property�A�dress: V 1.2 Assessors Map& Parcel Numbers
l.la Is this n accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq B) Frontage(11)
1.5 Building Setbacks(B)
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ F y
SECTION 2: PROPERTY OWNERSHIP'
2.1 er'of ecord•
a ri Address for S ice:
( f,772) aa�_avgz
at ep oh nr
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work'-: ' ✓Yvd vL /e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011tcial Use Only
Labor and Materials
I. Building S / I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due: l X 4 q0
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
l License Number I:rpimti�r/ A
Name of C'SL- I IulJer
- .3 n !, /3 U� list C'SL fype(see below) K
Address c � r. f Description a
U I Unrestricted(up to 35.000 Cu.Ft.
Sign u R Restricted I&2 FamilyDwelling
?::E � M Mason Only
Z
lam' RC Residential Routing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Reglst red Home Im�prJoove t Contractor�(HIC) /
e'f'('i7.�t'i i(/4 �r/
HIC Company Name or t�C �istran a Registration Number
Address ,a —� t!�I�
2.1
�j Expiration to
Signature ' elephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.1 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S A NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i
�.
as Owner of the subject property hereby
Jauthorize to act on my behalf,in all matters
e ve t w hori a building pe6nit application. -
ore er Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
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.
Print Name /
SignalVo of Owner or Authorized gent Date
(Signed under the pains and penalties of 'u
NOTES:
I. 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 FQl have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115.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. FL) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half7baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SALEM
' PUBLIC PROPRERTY
X DEPARTMENT
-.J 4n.`Rt uY DRISCI tl.l.
�d.iY<hN 12C WAiHIN610N S'fnEL'r •SALhs4,M.\s&\ci n it:'I is 61970
Ti,iI 978-745-9595 • 1'a X:978.74v 7%40
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
:k 3 ylicant Information pp Please Print Le ibiv
Name(Busiacss OrganizatioNlndivrlual): t r/
Address: 6239 i-r�e —3 p
City'Starei%ip: �G/ v+ e rr. G�9 7D Phone i': 9�� / l ` 5
Are you an employer!Check the appropriate box: 'Type of project(required):
1.❑ I am a employer with 2- 4. ❑ 1 am a general contractor and 1 6. ❑ new construction ".
employees(full andilor part-time).` have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet. :
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
To workers' comp. insurance 5. ❑ We are a corporation and its
I p•
required.] officers have exercised their 10.❑ Electrical repairs or additions
right of exemption a MGI. I I.❑ Plumbing repairs or additions
3.❑ 1 um a homeowner doing all work- g P P'
myself.[No workers' comp. c. 152, g 1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. LNo workers' 13.❑ Other
comp. insurance required.]
-Any opplicaut that chucks box hl must also lilt out the secaen t)elUw showing their workers eumpensation policy information.
' I lemeuwners vhu submtl this affidavit indicating they are doing all work and then him outside contractors must euhmit a new amilavit indicating such.
:Contractor,that check this box must attached an additional sheet showing the mole of flu sub-contraelors and their workers'comp.policy information.
I tun air employer that is providing workers'c•ompen.cnlion insurance fur my euployees. Below is the pulicy and job site .
infmvnation.
Insurance Company Name: _ of _...._.JUU.S�.Cy.�1/.,.�_.-----------._---
Policy 4 or Self-ins. Lie.L':�. �1g.GG N^ � Expiration Date: 'Tot —aZ-U
Job Site Address:---.-. C�--l- X.41 Cityrstawizip: 4 P/i
:attach it copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
I-'ailurc to secure coverage as required under Section 25A of.IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500,00 and/or one-year imprisonment, us 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
Invcsligations ol'thc DIA for insurance coverage verification.
I do hereby certify it d'r the pains curddp nalt ••i•ofperjury that the information provided above is true and correct.
Sig t m t
Date•
/lGf/✓ h�c ro
Plu n:c t+:
Ojjicial use only. Do toot ivrite in this area, to be completed by city or tolvn nj]iriul.
Citv or Town: Permit/lAcenil'.y—___-_--
Issuing:%uthoriiv(circle one):
I. Board of health 2. Building Department 3.City/f not n Clerk 4. Electrical Inspector 5. Plumbing luspcctor
6. Diller
Contact Person:—_.. .. . . . ._.--_ Phone th
Information and Instructions
\lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer 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 an 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, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL 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, MGL chapter 152, y25C(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 presented to the contracting authority."
Applicants
Please rill 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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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.
['lease be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennidlicerrse applications in any given year,need only submit one 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. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he OI)ice of Investigations would like to thank you in advance for your cooperation and should you have:my questions,
Please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-05
www.mass.gov/tile
............
CITY OF SALEM
PUBLIC PROPRERTY
DEPART'N/1ENT
,d A.�;)11\(.;ONmiuj r # ,,%i i m, %I
I 978-74; );95 0 1 NX: 978 74vi')14t,
Construction Debi-is Disposal Affidavit
(I-CLIL61'ed fior all demolition and ICIIOValiOn work)
In accordance with the sixth edition ofthe State Building Code, 780 CNIR section 111.5
Dcbris, and the provisions ofMGL c 40, S 54;
Building Permit s issued with the condition that the debris resulting front
- i
this work shall be disposed of in a properly licensed waste disposal facility.as defined by MGL c
I 11. S 150A.
The debt-is will be transported by:
iname of hauler)
I lie debris will be disposed ofin
Ait-Aizz C4
(name ul laclItty)
oi(ldress of facility)
N11411inule Of permit applicant
2 X�
date
,OV13/2010 06:55 9786833147 PAGE 01/01
CERTIFICATE OF LIABILITY INSURANCE
oATSWM/DD/YYYY)
THIS CERTIFICATE I$ ISSUED AS A MATTER OF INFQRMATIpry pryly qND CONFER$ N0 RIGHTS UPON THE CERTIFICATE HOLDER. TH$/13/2010
DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND DR ALTER THE COVERAGE AFFORDED BY THE pOLtCIES
F.CeRTIF,ICATE
epOW. THIS CERTIFlCgTE OF INSURANCE DDES NpT CONSTITUTE q GONTRAGT BETWEEN THE IS$UIN6 INSURER(3), AUTHORIZEDREPREENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER.
IMPORTANandT: U the ions Cato holder ie an ADDITIONAL INSURED,the poi-- ( s)moat be endoBed. If SUBROGATION I$WAIVED,autlJeCt to
me Mane holder
er in ens pf the policy,certain poilelae may BquIB en entlemement. A statement on this CBMfICdte dopy not Confer Nghp to the
certlBoate,hoWor In NBU of gUCh pntlOBpmant(p).
PRODUCER
M P RO$ERTs INS AGCY INC NA E:
1060 Osgood: Street HO NPIC E.u: f 97B)6B3-8073 ,
North Aadoverr, MA 01845 ADDRESS:PMU1a@mprobertS ' Surance m78� 683-3147
OUST ERIDO,
INSURED STEVL', HADLEY CONTRACTING INauReRMI AFFORMINP C0VtM0E
INSURER A:ATLANTIC "'N0P
STEVE HADLEY DBA CASUALTY INS CO
239 JEFFERSON AVENUE INSURER B;
SALEM MA INSURER C;
r 01970 w$uRER D:LIBERTY MUTUAL INS CO
INSURER E
COVERAGES INSURER F
CERTIFICATE NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED
NUMBER;
INbIGATEO. NOTWITHSTANDING ANY REOUIRfJ,gENT, TERM OR CONb IT'ON OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPE THE CT 70 WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED WERE ND 13 SUBJECR TO ALL THE TERMS,
EXCLUSIONS qND CONDITION$OF SUCH POLICIES.LIMITS SHOWN MAV HAVE BEEN REDUCED By PAID CIJVIMS,life TYPE OF INSURANCE
GENERAL LIABILITY INeR MNp POLICY NUMBER MM/OOM'Yy MM/DDIy
LIMITS
X COMMERCIALGENERAL LLABIIJTy EACH OCCURRENCE $ 1 1000,000
CLAIMS.NAItE CI OCCUR PREMISES Es c renee $ 100,000
A L143001235 07/08/10 07/08/11 MEDEXP(Arry one Parson) If 5,000
PERSONAL 8 ADV INJURY 3 1, DOr DO
GEN'L AGGREGATE LIMIT APPLIES PER; GENERAL AGGREGATE S 2, 00,000
POLICY PR' LOC PRODUCTS-COMP/Op AGO s 2, ODr OD
AUTOMOBILE IIABILRY I 8
ANYAUTO COMBINED SINGLE LIMIT
(Es acoyOeM) 8
ALL OVMEO AUTOS BODILY INJURY(Pvr person) $
SCHEDULED ALPI BODILY INJURY(Per eeddem) S
WIRED AUTOS PROPERTY DAMAGE
NON-0WNEO AUTOS (Per eceide p $
S
UMBRELLA LIAR OCCUR S
EXCESS LIAR CLAIMS-MADE EACH OCCURRENCE S
DEDUCTIBLE AGGREGATE S
RETENTION S S
WORKERS COMPENSATION
AND EMPLOYERS'LIABLITY $
D AI+'I ra°PRIEIM EXCLUM-0lwevr ry—N WC1-31S�-329064-040 07 08/10 07/08/31 x � LIMIT D
Ossels. M an ExcLUO=m ❑ NIA / ER
It atd nye Na - EI„EAcngcaDENT $ 50 r 00
DyS descrllro Omer E.L DISEASE.EA EMPLOYEE S 5 Or 00
DES�RIpTION OF OPERATIONS bblPw
E.L.OISEA$E-POLICYLCMIT $ 5O r00
IESCRIPTION OF OPERATION[:I LOCATIONS/VEHICLES (Allach ACORD 101,Motional Remarks$chedelA II meta BPsea le required)
'LIBERTY MUTUAL WILL ISSUE A CERTIFICATE OF INSURANCE TO YOU DIRECTLY*
AX: 978-740-9846
ERTIFICA—� T—�
CANCELLATION
CITY DE' SALEM
BUILDING INSPECTOR SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
120 WA$'.HINGTON ST THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
SALEM NA 01970
ACCORDANCE WITH THE POLICY PROVISIONS.
A REP TATI
I
*RD25(2009/09) -[988.2009 ACORD CORPORATION. All rightg reserved.
The ACORD name and logo are registered marks Of ACORD '