2 HOLLY ST - BUILDING INSPECTION (5) r The Commonwealth of Massachusetts
'� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CLiR SAM1 Revised Mirr201!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This SectionFbrt9fficiel Ust>Onl
Building Permit Numb t: D5te ied,
"Building OCftcial(Print Name) Data
SECTION 1:SITE INFO TIO
1.t�yo rty Address- L2 Assess g Parcel Numbers
L i It I�s this an acceptedd street?yes V no Map Number Parcel Number
1.3 Zuninglnformation: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: Outside Flood Zone?
Public❑ Private❑' — Check if yesG Municipal❑ On site disposal system ❑
,SECTION PR
OPEM-OWNERSIiIPs
2.1 erl of Record: l _en V! S&l k/JK AAO
1�( �o
name(P ' City. tat%ZIP
zr blot 95-4 $50
o,and Street Telep one Email Address
SECTION 3: DESCRIPTION OF PROPOSED.WORV'(check ail that apply)
New Construction❑ Existing BuildingJE I Owner-Occupied ❑ I Repairs(s) N I Alteration(s) ❑ TAddition Cl
Demolition Cl Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': t S
lc l-i � ti
r orc rA F) r 4or r1tt�
SECTION I: ESTINIATED CONSTRUCTION COSTS-
(rem Estimated Costs: Offtclal Use Only.-.
Labor and Materials Y
I. Building ; 1. Building Permit Fee:S Indicate how fee is determined:
�. 6lactrical S ❑Standa[d..City/fuwnApplicadonFe&.
❑'rotat Piojcct Cost'(Item.6)x multiplier x
1. Plumbing S I- (]titer Fees
L .Mechanical ((IVAC) S List:
�. ,�laehanie.tl (Piro
lbtal All Fees:.S-
Check No. Check Antuunt: (.`.ish r\nwunt:
f ] Paid in lull 0 Outstandin" ILil.tne. Otto.
SECTION 5: CONS'l-RUCTION SERVICES t,,
S.l Construction Supervisor License(CSI.) pg_g� 3 (fit iGj ' j3
\��6� License Number Expua tun D; e
Name of CSL I lulder List CSL Type(ice below)
{ L�`C� rb"`� v \ Type Description
No. and Street U Unrestricted Duildin s u to J5,000 cu. 11.
-:r---P-6V�I I C.14 MI4, E)«3 $ R Restricted W Fainil UWC1111119
City/rown,State, zIP M Masonr
RC Ruotin Cuvcrin
WS window and siding
SF Solid Fuel Hurning Appliances
czl T 360 ��� j �LR�\r�wW C�c(NAfiil ,C [ Demotion
1'tle hone
Email address D Demolition
5.2 Registered Home Improvement Contractor(I1IC) 3
\A j A& y{Jg115 �AR P tr;Y\Si iZ`tr FIIC Rtgistrntiun Number epirn ion Date
I IIC C mpany Name or 1-I1C Registrant N noS hA �
�
adare3g
Email
City/Town,State ZI rele hone
SECTION 6: WORKERS',COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 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.......... 0 No............9
SECTION 7a: OWNER AUTHORIZATION TO DE CON[PLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Data
Print Owner's Nmnt(Electronic Signature)
SECTION 7b: OWNER'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 accurate to the best of my knowledge and understanding. }
I,1L-k A.M- /� W -`J�-1- SL—GLSK e 1 7
_ D,ut
Print Owner's or\miturired:\gau's Nantc(Elcuruntc Signature)
NOTES:
I. :ko Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(trot registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under k\LU.L. c. I42A. Other important information on the HIC Program can be found at
www m;isc.eov%oea Information on the Construction Supervisor License can be found at www.utaa.,,Lv_,IL
2. When iubstantitd work is punned,provide the information below:
rota) flour area(sq. 11.) __—__ _(including garage, finished hascinentfatties,leeks or porch)
tiros; living:u'ca(:q. tt.l ._ ilabitable room count _
Nan bcr of tirapuecs,..__-.---_— `lumber of bedranms --- -------__-- --_--_--
Number of bathrooms - ---_-.—_--_-- — Nuntl,erofhalEbadu -- ---__sy;l ----
('.pe of hc.uio,; an -... _ Number of dick,' I,urehes
Endo;ci( t teen --- -- - --
---
I\pe of
t. I,,t.il l'n. Ica � lu na Pn,rt.r;a"ui.ro he ;nh,titntt'I r0l I'.-t.il l'mjc,t l'm t '--- . . -
J'Tx `sv
CITY OF S.'1 .&NI, xasS.kCHUSETTS
' BL'ILOING.DEPARTNIMNT
a 120 WASHINGTON STREET,3"'FLOOR
'ICE. (9.78)7454595
F X(978)•740-9846
KIJBERf EY DRISCOLL
\LAYOR THOatAs STSTEM
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONWISStONER
Yorkers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumberi
Antill6rit Information `' / 1 ^ 1 Please Print Le ibly:
Maine(Business:OrganiratioMlneividuai): vv WL i,li A%- \AP S tat- ( (d,.CZPt=mrR
Address:
i
Cil /Statelzi -Me:W kcu A11L1 '
Y P «�� ['hone N: �a �60 3��
Are you an employer?Peck the appropriate box:
Type of project(required):
I. 1 am a employer with' 4. 0 I am a general contractor and l 6. []New construction
employees(full and/or part time).' have hired the subcontractors
2. 1 am a sole propncioror partner- listed on the atincheci xhcei,t 7. UkRemodelin�
ship and.have no employeca These sub-contractor's have." lit 0 Demolition
working,forme in any capacity: workers'comp insurance. g Building addition
[No'workcrs comp.insurance. 5. 0 We are-'corporation and'-its,
rcquinYl.J: ofticrrshave exercised then r• 10 0 Electrical repairs or additions
3.0 la a homeowner doing all work right of exemption per MGL,, I L[]Plumbing repairs or additions
myselP.:[iYoworkcrecomp. C.•1.51§1(4),,and we hive no es 12 ❑RaoJreepairs
insurance rcyuired.]t employe :[No workers' .
comp.insurance rcquircdOther 1
-Any appliment that checks box#1 mutt olsa fill out the sectiea bclow showing their warkers'mmpenwioa policy infurmotfoa.'
;Any
fomeuwnen who submit this afTldsvit indicing they are doing all work and then hire Milidecammenern must submit a new affidavit indicting such.
:Contractors that chuck this box must attached an atklitiond sheet she-ing the name of the sub:amrscioa and thelirworkffs•comp,palIry infartnaaon:.
employer that bprovlaling workers'comprnsatloft hrsurmrce for rug employees Below/r the policy and fob the
irrjorrnmlon
Insurance Company Name:
Policy 4 or Self-ins.Lie.#: Expiration Date-
Job Site Address: City/StatdZip:
.Attach a copy.of the workers'compensation policy declaratlae.page(showing the poiley number and expiration date).
Failure to secure coverage as required under.Section25A of y1GL c. 152'can)ead to the imposition of criminal-penalties of a
tine up to S1;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$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Invesngulions ftlte DlA for insurance c0 c age verititshun.
l do hereby Gerd#«uder the pains meal penuhles ofoeriaiy that the hrfurrrrurlan provided above iv true aird carree4
Si ntntre kl•—�� Data`�UUJ �-, i
OJfciaf use only. Dolor write in thin urea,to be complefed by city or tows 41clrtt
City or Town: Permit/t.lieense#
issuing Authority(circle one):
1. Board of licallh 2.Building Department J.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other.
Contact Person: - Phone#:
JUN-21-2013 11:34 FROM: TO:197e7409846 P.1/1
0 DATE
A61 CERTIFICATE OF LIABILITY INSURANCE 06/21/2013)
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 certifldete does not confer rights to the
Certificate holder In lieu of such endorsement a .
PRODUCER CONTACT
NA &
Sterling Insurance Agency, Inc. °M o"E (978) 922-6600 ^X N,,(9Te1 922-Taco
306 Cabot Street ��^I: .IsT.orlinq-insuxanoeBverizon.n.t
F.O. Sox 493 IN5URER9 AFFORDING COVERAGE NAICO
Beverly, MA 01915- INSURDRA:Commerce Insurance Co. CCM
INSURED William M. Walsh Carpentry INSURER d:
William Walsh D13A INSURER C:
15 Lakemans Lane INSURER D:
INSURER 0:
Ipswich MA 01938— INSURER P•
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 TYPE OF INSURANCE p ICYN MMA POLLEN N PDUGYEXP LIMIT8
A GENCMLLIADUTY C)COyX 5/01/201905/01/2014 EACH Or.C11RRFNCF S 300,0()0
X COMMERCIAL GENERAL LIABILITY / / / / $ 100,000
CLAIMS-MADE FxIOCCUR / / / / MED r.XP(An,an° n° a S,OOD
PERSONAL S ADV INJURY a 300,000
GCNCML AGGREGATE a 600,000
GEN'L ACGRECA1e LIMIT APPLIES PER / / / / PRODUCTO-COMPIOP AGG a 600,000
17 I'•UUtr PRt} LOC / / / / PO S
ALITOMOHILF,iILRILITY
COMBINED SINGLE LIMIr—
(FDqucisminn
ANY AUTO / / / / DODn.Y INJURY(r.r W..) a
A1.I OWNED SCHEDULED / / / / BODILY INJURY(Per ed9Men0 a
ADIOS 171 AUTOS / / / / PROPERTY 0 Mace
1 unED AUTOS NAUTOS DO a
UMURELLA LIAe OCCUR / / / / EACH OCCURRENCE $
PXCE99 LIAe CLAIMS-MADE / / / / AGGREGATE $
WORKER'S COMPENSATION WGRTATU- TH-
AND EMPLOYERS'LIABILITY
ANY PROPRIETOR/PARTNERIBXFCUTIVE YIN / / / / E.L.EACH ACCIDENT I
OPI'ICI:RIMFMRPR F-ct.UDEDT ❑ NIA
IMendemry in NHl / / / / E.L.DISEa8E-EA EMPLOYE $
R Ole d11,91 unrlxr
01:$C IIIPI ION OF OPERATIONS DAb / / / / E.L.DISEASE-POLICY LIMB $
PROP CXpyX 5/01/2013 05/01/2014 SpC
DESCRIPTION OF OPERATIONS LOCATIONS VEHICLES (Anach ACORD 101,An4Rl°n.l Romorh.6clwdul.,N mm°apse I.r.qulmd)
CERTIFICATE HOLDER CANCELLATION
(978) 740-9846 ( )Fax SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 9E CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCM WITH THI!POLICY PROVISIONS.
City of Salem
Building Inspectors Office AUTHORITEO REPREBENTATIVE
City Hall n ,
Salem MA 01970- 4-1AL,�/^\
ACORD 25(2010105) 01958.2010 ACORD COR TION. All rights msorved.
INS026;z010051 01 The ACORD name and logo are registered marks of ACORD
;. CITY OF S,V.ENI` .
- � , t.r1;155:\CHLSETTS
.?\};�.�� �` QL'tLD4YGDEP.1RTJtEVT
110 CV.4iJi6VGTOV STRE&T, }'�Ft.00R
` ~{ TEL (978) 145-9595
<IMLMILEY DRISCOLL FLC(978) 7.10-9344
;,L�YOR I}ro�c�Sr.Pt�ftns
DCtEGTOR OF pl:OLfC PROPER7y/g(;�p�r,COJOff58lONER
Construction Debris Disposal AftIduvit
(required for all demolition and renovation work)
In accordance with the sixth edition of ilia State Building Coda, 730 Cib I.S
Debris, and the provisions of UGL a 40, S 54; tR section l l
Building
shall Uedisposed permit i#
this wo is issued with the condition that this debris resulting from
l l 1, S I SOA. of in a properly licensed waste disposal facility as defined by,LIGL e
The
debris will
be transported by;
U C)
(namo efhaular)
The debris will be disposed of in
I
(narno of ticthly)
--_--"I'll",oft,",
V
:ignatttrp of xnit.ipplicanr
.r
�e�Oorrviuo�ruue�n�P/L�1a4:1rre�uaelGt
Office of Consulnfr Affajr&&Business Regulation
OM
E IMPROVEMENT CONTRACTOR
egistration .j28323 Type:
Expiration 3/24/2015i DBA
i�lPURM
WILLIAM WALSH CARPENTRY
I r;
WILLIAM WALSH
15 LAKEMANS LN. '
IPSWICH, MA 01938
Undersecretary
19
Massachusetts Department of Public Safety
4 Board of Building Regulations and Standards
Construction Supem sor
License CS-058383
1 1 t s OF
• W1LId4,M M
15LAKEMAUSLN
Ipswich MA�19
' i neer e.� Expiration
.. - „ Commissw 3 .-r.�,.- T......,.+....e1^. .