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25 HIGHLAND ST - BUILDING INSPECTION (2) The C'urnrnunweallh of Massachusetts hoard of Building Regulations and Standards CITY OF �r ;✓ Massachusetts State Building Code, 780 C'NIR SALLM Building Permit Application "for Construct, Repair, Renovate Or Demolish a One-or Tnv-Fumill'Un el(it{q This Section For OlTcial Use only Building Permit NumberDate • plie Building 0117cial(Print Ntune) Signalurv--�- '_ Date SECTION l:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Nlap arcel Numbers j N16NLJ1& Sf _ I.-la is this an accepted street?yes no_ M1lap NumM:r Parcel Numta:r 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed lJse Lol Area Isy It) Frontage(Il) 1.5 Building Setbacks(it) Front Yard Side Yards Rear Yard Required Provided Required Provided Required 4 Provided 1.6 Water Supply:(M.G.1.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public 0 Privale❑ Zane: _ Outside Flood Zone? Chock if es0 Municipal ❑ On sih disposal system ❑ SECTION2: PROPERTY OWNERSHIP 2. Ownert of Reco- d: �ocr�cx0 JbcLai�'-7 Namc t P uu) (Z FOfLES% P-o/ W T 3 34// 2 3S-�7 v No.an q d Street a•/UG��Gz GOLJ(JOIGr q ), c dy7 Telephone Email Ad ress SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply) New Construction❑ Existing Building :11'; Owner-Occupied ❑ Repairs(s) Aiteration(s) V Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units�9— 1 Other ❑ Spccil'y: Brief Description of Proposed Work-: = C, /��T$ /r — E/7E Nt IND0 P#1T)ANG• volts r fYooQS Frw sht>aw ShEV ,2ESioi2 zQ& SECTION a: ESTIMATED CONSTRUCTION COSTS item Estimated Costs: (labor and \laterials) Offlclal Use Only I. Building S (900 ac, I. Building Pertnit Fee: E Indicate how fee is determined: 2. Electrical S ❑Standard CitytTown Application Fee ?. Plumbing S ❑Total Project Cost'(Item 6)x multiplier _ x _. Other Fees: S q. \kchaniatl ill\'.\('1 S List: i ?. .\lechanic:d (Fire S .--_-- - --- _.._ ----- Su„ression) �J fot:d \1I Fees: S _ a. Total Project Cust: S p{O�I•t�J ('heck No. _ _Check:\nwwtt ❑Paid in Full ❑Outstanding Buhutce Due: SECTION 5: CONSTRUCriON SERVICES 5.1 Constructim Supervisor License(C'SI.) 2.._ p -- -- - q License Number I'w iral nl Dale N;unc of l'SI. Ilnlder List CSi.1)pc)sec halosv)_ IS ��fi-Z_INSIj --_.____--_______.__—. h)R Description N,,, and street 1 {� tt �q [� I (hlrcstncteJ(Buildings a to 15,UIIl al. tl.l M1 I\�4.�uE�11 Ij�p!L' . R a"Iriet'd 1&2 I:amfly Dssclhn C'itwifoml.Stte./IP M %lason RC' R,wlin ("%erin WS Window and Siding SF Solid Fucl Burning Appliances Iluulation I'ele hnite Fntuil aJJress U Demolition 5.2 Registered )tome Improvement Contractor(HIC) 11 (1 61 TQ S 2a .3 OVA tJ \',CTIonl h�rl �1,SL.ING IIIC' Rcgistratiun Numlxr lis irati n Dalc lk Cogan)(INJ� or I1('Registrant Name � Email address City/Town.State,ZIP 'fcic hone 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 ..........A No........... O 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 IBHAs Aw to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owvner'S Nume(Iil ct nic Signature) D; e CTION 7b:OWNERI 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 accura a to the best of my knowledge and understanding. �nASz INQi P tl 2 h Print Ow,wr'a or:\wharireJ Agent's Nunn(Flectronic Signature) aW NOTES: I. An Owwner 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 no have access to the arbitration program or guaranty fund under.M.G.L.e. I J2A.Other important information on the HIC Program can be found at „w,,, n .n. w v.l Information on the Construction Supervisor License can be found at"\,,, m.h<5.w dp, 2. When substantial wvork is planned,prow ide the information below: Total fluor area(sq. f1.1_ (including garage, finished basement attics,decks or porch) Gross living area I sq. It -- _ ----_-- _ -- Habitable room count Number of fireplaces.-- Number of bedrooms Num her ofbathrooms - - Number ofllall'hmhs Number of Jecks, porches Fnclosed O. .I _ ... ._.._ I\ we Uf iOUlnlq i15Ie 111 we❑ j }, "Total Project Square Footage"ma) be substituted fit"foul Project Cost- %09 CITY OF SALEM `ti`► ,J/ RER PUBLIC PROP TY �,r Y DEPARTMENT MI4, I1 \INPrI I!�\rAlfrl.\G Iu.\jCr Ck l' � j.111'N,bl.1 U.N.I It 411a�1'/),^, Workers' Cumpenaatian Insurunce tNldwiC UulldcrvCuntracturvka trlcl tnvPlumban l I Illtaut In nrmrllo PI • .� In Le 'hl VJIIIc I IlliulKaal)rpanvni�uvinJlr.,luu11: I RR���®VA �Jdrrs.v;. IS N1G� lies �� _ Cily,Sfafo,%i(1 IYRI�I.r✓�1Eleb )1fl Phone Oil: `l�l 1�-21 g32I .\rv) Iu all vogrlbyvr'! Cheek tha apprriyrluta bus: 1.0 114111 a cmplu)ur NO,ilk 0. I al l a yunural cuuuxtor and I hyPa n/prnJvet(nqulrvtl):nlpluyvcm(lull umYur pai IinN)• have hint the.ruh•cunvuclara ' Q u I Kuw construction ,un a aule pmpricur or partner• lislad an tha a d nache .ahcet : rllip idol have no vinpluyccs These aub-contrsctars have �' SW Relnodalin� 11601 Air mu In any i apucily, workan'comp mauronea. �' ❑Damoliriun INn w001411'comp, insurance J. ❑ Wa an a cnlporuinn and iq nyuired.) 9, ❑Ouddind addiliun 3 Q 1 nnl a humvowncr Jilin#Al work otrcerns right of ac a athle I.vud their 10,Q Electrical repairs or jPjgI na myael/,(Na anrken'an'IP• e. 132. )IN),�nd 1 Puhmle no 1 I'Q Plumbin rc inauruncu rcyuired.J tr pairs Of aJditinry employees.(�'o warkelY I�❑Ruul'npaira M11I insuranw leyuind,I I y❑Other •b'y•,Iphcu�IhW<haih Iw#I Must.dw lilt"Ihe We hay Iwlar ' I I„mw,r,wn�.hr1 aWmlit'his cllleav1,Indl- tin it" awPr'na Phyir'+wYwr'cum Cworwrun Phu aMrt Ihu a +w#sins al ,,ill PMw AMr We 9 ,Pmw tars 1'Wrcy nAinPrrliuP� Wax,alwl urraMd,m tdarliayW•1M1 dlurinr Ploy Ihm31M still*t two Inwl wIw1Y a nrr aR ra i /stiff un amplayer that If prlrv/d/qr rvurAvey'rum/trnrnNan hhrantnca/ar Ix aM I htr rwfrA' rNtayPtm�vw1, CO"'I•nrdrey PnRlrnlufry irr/annwlns 'I �.t pl/w.R 9i/uty/r Mi pv/liy arse/a1.�ito ImurunceCumRarlY •Vamt LiEf"12-ry IIi,ITU•�L 1'ullcy a-it Svlr•ins. Cic.M: WC�=3(; ZS C}L Eapirulrun Dols: lob Site dJJrc..+; 't7 l �r FF ��af\uucA n cagy urfha Irorkvn'Cuitov zip; mpenraflun pulley Juclarallun yoga(showing the policynum6ur�,atplyaf'+ data), Pulluro la wears cuavnrya streQwreJ unJer Scniun_'fir\ul'.\IGl c. 177 eau lead ro tha Imposition of ernninal ivuliumpenelli date). '1"'v IIp nl St )00.(4 indlur uuvynr imprirmm�cnt, uA r1Cll,la cull flenulhca ill Ihv lours ura STOP 1V ' ,1/Iql rn j?JO M1,I Jay rwrlet Ih♦vlul.uar. lit advi wit th4i a cony urlhth.uutcmcm mu h D(iK ORDER and ,�mnu ut:hu UL1 ;or nnar.u've er�acru a tint ;L• l eu liuhun, y c lur'h arJuJ Put IN Ullicu ut• /,/u hcrr•ny a,rnh rrndv t nri Ir r r ours/nit v /prr/nry thw rho in/urrnarlow yrvriJa� bury if uai Par,/conecR 181 2q ,ry ' .rl//Iciu/,rrr u,r/y. /)o,rnr larir.In d,H un•a N D.cv,,,yh•Irr b a;l y yur(oPvn,y/Icwt ritrir 11nrn; Irauin .\ulhuril ---- Variniul.lnnra 1 4 y (circlo nnvb I IL,.rrJ r(IIr.Jlll !. IIuIIPbm, G. 011IaI u. IIyLIrluPcnl I. I:ili-A nPl C'la•rk a, l'leefric.11 hlr lac(ur i. I Plumpiny ImyKtvr I1 '.. PJ,HI I'arwu: information and Instructions \l.l)),,chu.eits U,;nerjI Lamy 04":f I7I Icywras�Ilevery pa{on In thers to �sary Ja ut mull c amlelr nny confect of hire. an rm luvwa Is Jetined aY I h,nu.utl IO IItIY +IaWla. p Iw0 Ot mare ;'Press of nnPhaJ, oral or tvrluan." \a,•,nplupar Is Jctincd "an mdsvidual, Pannar'"'assuetanoa,corporattun ur other leaf ornery,Of attNowv r the the IN enlerprlre, and Including{the h:yu1 reptesenutives of� JeceuscJ eto. Hcf,or rjo umenh,p, assoetallots or other 1ct{ul.nary,employ Mill amployeu. .1 the loregumt{enb1, of Ina 1 1 lecetver or ousted of.ul indiv, in* p to � tom w Jo muimanunca,cunsituction ar repair work an)itch dwalline house uwnet of a dwelling house h�whu emp not 'riots Pe than three aPa�e,use f s ch employts Ind who resid'1111 e ent'be deemed cu be an cm play or. ,Imrlllna house,If an urteri thereto shall not be r ,m the.rounds or building 4PP CSC 6 also surest that"ever)'state or local Ileenslag auroey sAYU withhold the issuance or >lGL chapter 152,clo se O ulrad-' Uena wllA the insurance i csI subdivisions shall rena)vsl of a Ilccnse o1 prnduad acc+ptable evldee a of sump truer bufldings to tny of i4 Pat moawruit or a „ppllcunl „he hag n P , )SC(71.rutas"Neither the cammonwcaldt nor Ce \Jdlliunully, NGL chupter 152, i- ublic murk until acceptable evidancst ufcunlDliarlco with the insurance coot into any contract for the Parfomtance it p 1 raqu into an of this chuptdt haw been pre anted to the conitacting authofiry,' Ilcut4 kin rha baxa that apply to your situation and.if VV chore f eame(4,adtkess(ao)and phone number(s)&long with thek ea,nPlOyu(s)Of pla;,:lst till out the workers' compensation atlidavit completely,by s LLP)with no amployt.�ss other than the naccYYary, supply sub contractors) have insurance. Limited Liability Companies(LLM or Limited Liability Partnership worker' eomputaetiboen bmiroad to the Dap otma t of�lildavi l members or partnstn1 an required. 9�advisot reluired to ed hat this allidnvit IneY �tmcnt of amPloyaat a policy is req a Also be sure to slgo Itnd data The ue�nd,not M1eDapwit should �ecidanis far contlmtation of 11s mcca c v'con far the permit or license 1s being requested,to obtain a workers' ha rclumad to the city or town that the a n questions regarding the low of if you ate requited anies should entor their Industrial,Accidans. Should you have any 1i stall s1 the nulnbat listed below. Sdf instited comp compensation policy,Vlease call the Oeptsran salr•insurancol lican,te number on the a ro fiat's line. my of.rawo OfAelels p rovided u spud at the buttula the sDplieant. please he .urst that the affidavit is wmpletst ,md printed lofInve The De aistent us P hcant of rha affidavit fur you to till out in tho event rhst OITia of Investigations his to cantata you regarding err, head out utblmt cost affidavit indicating current 1'I.asc ba aura ro till in the put applications nwnbar which will b+used:Is a rGfere�e number, In addition,an up hat mo or at suttinit multiple pennitslics,tad applications in any given y be rariJcJ to the that inl'm militia(if necessary) and unddr"Job Site Address Jth at rjiltiladrbysdte city oretowe Inay loop o y nsmn6"A eupY of the my davit that has bun riloffe forlly sump. tuwn) , u proof that a valid affidavit is on fill for tLt an Palmist of tieemat. t new a0 sines trust m filled out eae ennit not related to any business ur Camillo venture 'Pr t burn leaves ate.) +aid Peroun Is NOT required to complete this affidavit. y star. \Yharo a ol, owner au citi¢en is obtaining a liansd or P stet arm hasu.m yuuhmts. I D d you Y ,1 Jul{ our coo entice and shout I he I)Ilicc of ltve)ti.utiunY Iwuld Ilvd to dtatk you in advance Fitt y P hlca.a Ju nut Milt to ulve us a call. f he Ucp.uunant's aJJra+s, telcphurFa and ru number. The Commonwealth of Massachusci" Department of Industrial Accidents once of IsvadQadans 600 W&SWIltae Street Boston, MA 02111 fel. N 61 7.727-t900 ext 406or 1-817•MASSAFE Fax N 617.727.7749 1 srww.mass.jov/die lasNachusetts - Department ot public Safety f—Ul el"rA a zrzli Isine- SS � 1�rlon onsBoard ol' Ruildinu, Remilations and Standard, ofticc a ?"I HOME IMPROVEMENT CONTRACTOR Type:146850 W—j construction Supervisor License Registration: 89905 License: CS Expiratiwrc 512012013 Private Corporation - Restricted to: 00 �C N CONSTRU(JIONA kEMQDLEiING INC. TOMASZA WABNO 15 HIGGINS RD TOMASZ WABNdr MARBLEHEAD, MA 01945 15HIGGINSRD. MARBLEHEAD, MA01945 Undersecretary Expiration: 6/4/2012 Tr#: 26405 Av CERTIFICATE OF LIABILITY INSURANCE DATE("MID"""") 7/13 11 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 temps 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 endorsemengs). PRODUCER CONTACT NAME: Circle,Business Ins. Agcy, Inc PHONE L Pat. 978 777-5619 No: FAX (978) 777-4898 247 Ndtabury Street ADM ss: PaulaHalas@Circle Insurance.net Danvers, MA 01923 PRODUCER 1061 INSURE S AFFORDING COVERAGE NAIC A INSURED INSURERA:Northland Ins Com an Nova Construction S Remodeling INSURER B:Travelers Insurance 15 Higgins Road INSURER c:LibertyMutual Marblehead, MA 01945 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: 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 rypE OF INSURANCE ADDL SUM POLICY EFF POLICY EXP LTR POLICY NUMBER MM(DDIYYYY (MMDYYYYI LIMITS GENERAL IIABIDry EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GEPERALLIABILITY WS073626 5/18/11 5/18/12 DAMAGETORENTEDPREMISES IF =Tancel $ 100 DDD CI—AIMS—MADE Fx1OOCUR MED EXP(Aryone person) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENTAGGREGATE LIMITAPPLIES PER PRODUCrS-COMP/OP AGO $ 2,000,000 POLICY PRO JECTLOC AUTOMOBILELIABILITY COM3INED SINGLE LIMB $ B ANYAUTO BA1427R926 5/18/11 5/18/12 (Eeaccident) ALLOWPEDAUTOS BODILY INJURY(Par Person) $ 100,000 X SCHEDULED AUTOS BODILY INJURY(Per accident) $ 300,000 ' HIRED AUTOS PROPERTY DAMAGE $ (Per accident) 100,000 X NONOWNED AUTOS $ $ UMBRELLA Lim OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE RETENTION $ AND EMPS COMPENSATION X WC STATU- OTM- AND EMPLOYERS'LIABILITY IN C ANY O IFFCERMEMBERIEXCLNUD EXCLUDED? Y� N/q WCl-31S-366560- 5/18/11 5/18/12 E.L.EACH ACCIDENT $ IUD OOD (Mandatory In NH) E.L.DISEASE-EA EMPLOYEE $ESddescrib10D 000 If yes8 under DRIPTIO N OF OPERATIONS below E.L.DIS EASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Adlitioned Relmrks Schedule,if more apace is requ red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN City of Salem ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington St. , 3rd Floor Salem, MA 01970 AUTHORIZED REPRESENTATIVE oau�ys° Paula HalasD. '..1-...".:.�°°�°h ©1988.2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD