13 HOLLY ST - BUILDING INSPECTION a
The Commonwealth of Massachusetts
� Town of
Board of Budding Regulations and Standards �w
?� Massachusclis Slate Building Code, 780 CNIR. Ta edition Building Dept
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One. or rn o-Funuh'Dtr elling
This ScctlgWf als,017liclAd Use Onl
Building Permit Num r• at lied:
Signature:
Budding Commnvonsrt Inspector of Buildings Date
SECTION 1:!XITE INFORMATION
1.1 Propert Address: 1.2 Assessors Map& Parcel Numbers
�7 I-I.OL1.Y ST Parcel Number
M
I.t a Is this an aeee led street''yea no &PNumber
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Arco(sq R) Frontage 1 fl)
13 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided '
I.f Woter Supply:(M.G.L c.a0,aSe) 1.7 Flood lone lafot7rsatloa: 1.8 Sewage Dbposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if
SECTION 2: PROPERTY OWNERSHIP'
i.l Owoer'ofRecord: /3 4ou-Y ST% SALCm i✓Ipl-_ 01170
,R I S A• kAO Al Add"for Service:
Name(Print)
�l7rp- 7Y`�-(o9a.-o
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek oil that apply)
New Conswction O E:tistin8 Building O Owner-Occupied O 1 Repairs(s) O Alteration(s) i2'l Addition O
Demolition O Accessory BldS.O Number of Units_ Other O Speedy:
Brief Description of Pro posedWork': Afriob6 of EYi577a6 Ko'2j�fa oivE &kTg A ovL i/a-8
/} N6id KA�IkBBm AND �q.Wn/+�0.Y 7-3 f pwa RE.PCA_"CL' SiY NiN Dart/S
i+ Nr watt. d P D i cA-L �
SECTION d: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building f 1. Building Permil Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)a multiplier a
J Plumbing S 2. Other Fecs: f
4. .Mechanical (HVAC) S List:
s Mechanical tfire S Total All Fees: f
Su ec'man
Check Yo. _Check Amount: Cash Amount:_
h Total Project Cost S 6
tJ �� 0 Psid in Full 0 Outstanding Balance Due
C r
SECTION !: CONSTRUCTIIOcNSER 'JCES
S.I Licensed Construction Supervisor ✓ /y(CSL) rf g
License Number Evpn.mon Date
' �/ronl i
� J£rQ
Niror"I CSL Hplda List CSL r
�� SU/d Sfa'r P(> Si�NEWAm M41.021d17 rile(x'r hcluw)
I
A JJrcas/) Tw pir Descriptton
U Unrestricted u w J3.000.000 Cu. Ft.
R I Restricted IA2 Family Dwellin
StanUWe
w17-�r 9r'/l thaw Only
9- RC Resrdental Roofin Covering
Telephone %S Residential Window and Siding
SF IResidential Solid Fuel Burning Appliame Installation
D 1 Residential Demolition
SJ Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6/WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.I. e. ISL/ ISC(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? Yn.......... 0— No...........O
SECTION 78:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
DPDA
a"m
as.�ar of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Q;a�, )/, a010
Signature of. to
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, AiV70A11O VFTR4nl0 , as Owner or Authorized Agent hereby declare
that the statements and information on the are foregoing application a We and accurate, to the best of my knowledge and
behalf.
AWMIVIO V&f_AAAID
Print Num
Sjgnatute of Owner or Authorized Agent Date
Si ned under the pains and penalties ofperjury)
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program).will gg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 IO.R6 and 1 IO.R5. respectively.
2. When substantial work is planned. provide the informalion below
Total floors area(Sq. Ft ) (including garage. finished basemenUanics.decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type ofhoting system Number of decks/porches
rs pe of cooling system Enclosed Open
1 "Total Project S4uare Fuotage"may he suhstituied for 'Total Project Cost"
' CITY OF S.U.E.`t, ,Less kai :sET-rs
Bl 11DLNG DEPARTIL+NT
1'_O W.oiiHQIGTON STREiM Ya FLOOR
TEL (978) 745-9595
FAX(978) 740-95"
KI,BERIEY DIlISCOIL
MAYOR T)iamu ST.PMRRs
DIRECTOR of Pt BLIC PROPERTY/el'ILMNIG COSOBSSIONER
Wurkers' Compensation Insurance AlMdavit: Builders/Contractors/ElectrlcianslPlumbers
lnnllcant Information Please Print Le iblo
Vaind(8urino&0rymrahotilnd4v,duaa): — VETR4n1O C.0n15T9AJ( Z10/J `CA�
Address: 5- S(4NSsrT AD
city/StateiZip: 5T0Ne4A-m . MA-, Qllki) PhoneM.. 780-665-6733
troy* as employer!Check the appropriate boa:
Type or project(regtslrted):
1. 1 am a employer with_� 4. Q 1 am a general contractor and 1
employees(full and/or past-time).• have hired the subcaaracior 6. ❑New canawcrion
2.Q I am a sole proprietor ou partner-
listed on the attached sheet, : 7. Q'*emt deling
:hip and have no employees Then sub-contractors have s. Q Demolition
working rot me in any capacity. worker'comp.insurance, 9. Q Building addition
[No worker'comp insurance S. Q We an a corporation and is I O.Q Electrical repairs are additions
requited.l oft=have exercised their
J.Q I am a homeowner doing all work right of eaanption par MOL 11.Q Plumbing repair or additions
myself.(No worker'comp. c. 152.91(4).and we have no 12.❑Roof repairs
insurance required.] t employee.LNo worhma' t3.❑Other
comp insurance required.)
-Any applicant the clwcaa hat rat man ale fill mil Ilrr rcum bohm aA, &tho4 eorkma-oorttpattatdw policy inflnnadoo, .
'I hatrtrwta who Yukon this aeirvit indicating racy m doing an work am the him weir esurapara ntnar ruAnY a now alRrvil indicants mtr
(•.mtro�Yora shot chock this hot mud admire an addtiwmt dow thawing do,tree of ale uto4voineho r d tlwir sumom .tartar.poky woon."oe,
I era as rarp/oyer that It priovid/nE worker'coaapetsredan/nsuranerjir my asp/ayaas. ea/ow/a/ka
informalba PWI97 as/fmh sGr
InwranceCompany.Name: TLJW Ct7`( 9r, TNSoioZ4&/(P
Policy r or Self-ice. Lio. p: Expiration Date:
Job Sim Addrusn: /3 /-JOLLIe S T 5-AiRM City/Sta1WZip: 5,4tf V_, MI{. O 1 R70
Amach a copy of the worker'compensation pogey declaration pap(showing ohs policy number and expiration dab)6
Failure to secure coverap as required under Section 25A of MOL e. 152 can lead to the imposition of criminal penalties of a
fine up to 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 S250.00 i day against the violator. Ile adviswl chats copy of this slatemcnl may ba furwurded to the O171ce of
I nvcamgariuna olllia DIA for insurance coverage vwitication.
/de hereby certify us-Oder the pei�n prna/t/es ojprr/ury that the brjorwadoa provided ubaver is true and rurrrd
'Z1_17.uurr_
Phme d �i7- 7�981 � -
D/flcia/ear aniy. Da nor write is this areas ti be.utnpietd by ciy or ranvn u/f,.ia[
City or ruwn: _ ecronit/i.lccnse
tasuing.\uihurily lcircle une):
I. Ituard of lltalih 2. Ruilding Department J. caytrown Clerk 4. Electrical lnspector S. Plumbing Impactor
6. Other
l.nrtact Person:__ _. Phone e:
,S CITY OF SALEM
PUBLIC PROPRERTY
a Y' DEPARTMENT
1 C W.%4111\(.:oV SIKLCT .S.0 I\I,
I'rl, )73.143 516 . F.\s:978.7149846
Construction Debris Disposal Affidavit
(required I'ur all demolition and 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 . - is issued with the condition that the debris resulting from
ff
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
D311 w�Ustramc o f taErf
The debris will be disposed of in
(nameol ?"Malty)
(address of lacility)
Nignuure of permit applicant
/— 11—to
due
Jan 11 2010 15:39:09 -> 9787409046 The Hartford Fax Page 003
ACQRD,,, CERTIFICATE OF LIABILITY INSURANCE U022 01-1i 2G10
AWDh OR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PAYCHEX AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
210705 P: () — F: (888) 443-6112 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
PO BOX 33015
SAN ANTONIO TX 78265 NSURERS AFFORDING COVERAGE
INSURED INSURER A:Twin City Fire Ins Co
INSURER B:
VETRANO CONSTRUCTION INC. INSURER C:
5 SUNSET RD. NsuRER O:
STONEHAM MA 02180 NSURERS:
COVERAGES
THE POLICIES OF INSUR BEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.ND7WI17T37AFIDTRU--
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Mw POUCYEPPECT w POL/CYE RRATMN
LM T NOf INSL11M P Po[YCV NIMOR[R M"MM OAT!MM YV L/M/TS
GSAYRAL LLAR&lTV EACH OCCURRENCE 0
COMMERCIAL GENERAL LIABILITY FIRE DAMAGE(Any one Sre) 0
CLAIMS MADE L7 OCCUR MED"P(Any one pcsml e
PERSONAL&AOV INJURY e
GENERAL AOOREGATE 0
GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS COMP)OP AGG e
PRO 71 L
JEO OC.
POLICY
AUMMORH!UANUTV
COMccldw 1NGLf LIMIT 0
ANY AUTO Ee eCCldenS)
ALL OWNED AUTOS
BODILY INJURY y
SCHEDULED AUTOS (Per person)
HIRED AUTOS
BODILY INJURY 0
NO&OWNED AUTOS Pm eccld,n0
PROPERTY DAMAGE y
IPer eooideml
GARAOR LMRH/TV AUTOONLY EAACCIDENT 0
ANY AUTO OTHER THAN EA ACC 0
AUTO ONLY: AGG 0
RXCLSSLMB 0Y EACH OCCURRENCE 0
OCCUR J CLAIMS MADE AGGREGATE e
0
DEDUCTIBLE 0
RETENTION 0 e
WOR SCOUMMArXWAW X WC ETATLI OTH-
A EMPLOYERR'LKOB?V 76 WEG LTH3367 04/19/09 04/19/10 E.L.EACH ACCIDENT $500 000
E.L.DISEASE-EA EMPLOYEE 0500, 000
f.L.09EASE-POLICY LIMIT 1 0500 000
OTMR
OEBORLPTR]N OF OPERAT/ONO/LOCATRIABNEfRC{F8/EXCLU&ONB AO�O 9Y EiWOROEMENT/OPLC[AL PROVI8LON8
Those usual to the Insured' s Operations. Job Site Address: 13 Holly St.
CERTIFICATE HOLDER I ADWMNAL INSURED;LWSUMMaTTERr CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
City of Salem 30 DAYS WRITTEN NOTICE 00 DAYS FOR NON-PAYMENT)TO THE CERTIFICATE
Building Dept . HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO
120 WASHINGTON ST REPRESENTATIVES.OBLIGATION ORLIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
SALEM, MA 01970
AUTNo RESENTAn
ACORD 26-S (7/97) ®ACORD CORPORATION 1 BEE
DURABLE POWER OF ATTORNEY
KNOW ALL PERSONS BY THESE PRESENTS, that I, IRIS A. KAMON, of Salem, Essex
County, Massachusetts, do hereby constitute and appoint MARILYN COSTA of Salem,
Massachusetts, as my lawful attorney, to act for me and in my name, as follows:
1. To demand, collect, recover, sue for, receive and give receipt and due discharge for any money,
debts, dividends, interest or other property of any sort, real or personal, now or hereafter due or
becoming due to me or to which I may be or hereafter become entitled.
2. To sell, assign, transfer and convey any stocks, bonds, securities or other property, real or
personal, owned by me or to which I am now or may hereafter become entitled, to improve,
repair and maintain the same and to grant options and enter into purchase and sale agreements
relative to the same.
3. To invest and reinvest in any stocks,bonds or other securities or property, real or personal.
4. To borrow money and as security therefor to pledge, mortgage or hypothecate any securities or
other property, real or personal.
5. To endorse for transfer all certificates of stock, bonds or other securities and to execute, sign,
acknowledge and deliver in my name any deeds,bills of sale or other instruments of transfer or
conveyance or any other instruments, under seal or not under seal.
6. To represent me and vote in my name at any and all corporate or other meetings and to give to
any person or persons general or special proxies, discretionary or not discretionary, to vote in
my name at such meetings.
7. To conduct or participate in any lawful business in my name.
8. To form, incorporate, reorganize, merge, recapitalize, sell, liquidate or dissolve any business in
which I may have any interest.
9. To enter into and/or carry out the provisions of any agreement for the sale of any business
interest or the stock therein, upon such terms and conditions, including the making of such
representations, warranties and indemnities, as my attorney shall deem proper.
10. To compromise or adjust any matter involving my interests.
11. To endorse and negotiate for any and all purposes all promissory notes, bills of exchange,
checks, drafts or other negotiable or non-negotiable papers payable to me or to my order.
12. To deposit funds or property with any banking institution and to withdraw any part or all of
said deposits.
13. To make and sign checks or drafts upon any deposits in my name in any banking institution.
14. To employ agents and attorneys for any purpose and to pay the compensation of said agents or
attorneys.
15. To go to any safe deposit box to which I have access and to place in or take from it any
property or papers.
16. To appear for me and represent me before the United States Treasury Department, the Internal
Revenue Service or any other taxing authority in connection with any matter involving taxes in
which I am a party.
17. To prepare and execute any tax returns for me.
18. To execute any claims for refund, protests, applications for abatement and consents to and
waivers of determination and assessment of taxes, agreeing to a later determination and
assessment of taxes than is provided by any statute of limitations.
19. To receive and endorse and collect any checks in settlement of any refund of taxes.
20. To examine and to request and receive copies of any tax returns, reports and other information
from the United States Treasury Department or any other taking authority in connection with
any of the foregoing matters.
21. To transfer funds or property of mine to any trust established by me, whether before or after the
date of this instrument.
22. To consent to surgery or any other medical procedure or treatment, or the withholding of the
same, on my behalf.
23. To reform estate planning documents (other than wills) if they prove to be defective.
24. And to do all things necessary to carry out the intent hereof as fully as I might do if I were
personally present, whether such actions shall take place in the Commonwealth of
Massachusetts or elsewhere.
My said attorney is authorized to delegate any powers hereunder to a third party, from time to time, to
revoke any such delegation, to pay himself reasonable compensation for services rendered by him
hereunder from any property owned by me or to which I am now or may hereafter become entitled and
to deal with himself or with any other concern in which he may be interested, as freely and effectively
as if dealing with a stranger.
I nominate and appoint MARILYN COSTA of Salem, Massachusetts, as my conservator, guardian of
my estate, and/or guardian of my person, if the need for the appointment of such a fiduciary should
arise at any time in the future.
This power of attorney shall not be affected by my subsequent disability or incapacity.
2
This power of attorney is given as a Durable Power of Attorney pursuant to Massachusetts General
Laws Chapter 201 B.
My death shall not revoke or terminate this power of attorney if my attorney, without actual knowledge
of my death, acts in good faith hereunder. No person dealing with my attorney hereunder shall be
responsible for the application of any money or property paid or transferred to him.
Wherever the context so requires, the singular shall include the plural, and vice-versa and the feminine
shall include the masculine and neuter, and vice-versa.
IN WITNESS WHEREOF, I have hereunto set my hand and seal this day of
2006.
y —
IRIS A. KAMON
Commonwealth of Massachusetts
Essex, ss.
On this � day of (YOUG�(.. 2006, be ore me, a undersigned no public,
s vi ence o e tification,
personally appeared IRIS A. KAMON, proved to me thrlug-i s�t �
i.e., a Massachusetts driver's license, to be the person(s) whose name(s) is/are signed on the preceding
or attached document, and acknowledged to me that he/she/they each signed it voluntarily for its stated
purpose.
botaryubli n
My commission expires: �� / Q
WENDY S.DOUGLAS
Notary Public
COMMON@&of Massachusetts
My Commission Expires
November 1,2007
3