26 HOWARD ST - BUILDING INSPECTION (2) V�
The Comnionwcallh of Massachusetts
/) Board of Building Regulations and Standards Tom
�J) t� Massachusetts State Building Cade. 780 CMR. T"edition Building Dept
Budding Permit Application To Construct, Reciair, R oval r Demolish a fk�
Ti One- or Aso-Famil D rl in
This Sao For Q ul nl
Building Permit Numbir . ied:
Signature:
Its ding C issioner/Inspector of E n Date
SECTION h JtT INFORMATION
1.1 Pr pe y Addreu: 1.2 Asasasors Map& Parcel Numbers
1ki,`a ,.n Sr
I.1 a Is this an aece led street''yes no Map Number Parcel Number
1.3 Zoning Information: 1.� Property Dimensions:
Zoning District Proposed Use La Arca(sq R) Fronuge(R)
1.5 Building Setbacks IN
From Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,S54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if es0
SECTION 2: PROPERTY OWNERSHIP'
2.1—Owner'of Record*y- C C.T
AIK Name(Print) Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O 1 Alteration(s) O Addition O
Demolition O 1 Accessory Bldg.O Number of Units_ Other O Specify'
Brief Description of Proposed Work': Gt/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Coss: OOlelal Use Only
(tern Labor and Materials
1. Building f I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S O Total Project Cost'(Item 6)it multiplier x
7 Plumbing f Z. Other Fea: f /'
a. Mechanical IHVAC) f List: 1 f 6b
t Mechanical (Fire S Total All Fees: f
Su resswn
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S 0 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
51 Li sed Construction Supersisor(CSL) V O�G
i JL,cerise Numhr F;P—.r—J11A Date
.Nyae of CSL 1 I/y,/I�rr �d,� List CSL T
a h�f�4CC✓� 7i �Y rl YpelxY below)
Type I
Address /s Description
U Unrestricted u to 35,000 Cu. ft.
R Restricted IA2 Family Diacilinst
Signature G .M %fawnry Only
RC Residential Rooting Coverm
Telephone WS Residential Window and Sidin
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Reldstered Home Improvement Contractor(HIC) 1 ?l��
r U 1�
HIC Co any erne or HIC Registr1a/nt N��] C \ RR ptII-tuber
Address r''��1 /(WVA'�� 3 '
E tpiri io Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 132.S 2SC(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 ARtlavit Attached? Yes.......... No........... O
SECTION 7a:OWNER AVTHORIZATI0NsT0 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 behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
� �SECTI,OOIN 77bb:OWNER' OR AUTHORIZED AGENT DECLARATION
1, l�`fC,n ( ) ( �1a17��fi/ ,as Owner or Authorized Agent hereby declare
that—the state—ments and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. S�,IIAJ QrQWu�
Print Name in La
Signature of Owner or Authorized Agent Date
Signed under the gains and penalties ofperjury)
NOTES:
1. 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 dg have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I 10 R!. 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 half baths
Tv pe of heating system Number of decks, porches
Tspeofcoolingsystem Enclosed Open
1 'Total Project Square Footage"may he suh.uluted for 'Total Project Cost"
CITY OF S.1LEM. NLksSACHL:SETTS
BL•aDLNG DEPART%[&'%T
120 WASHLNGTON STREW, 3'FLOOR
T L (978) 745-9595
F.,Lx(978) 7404846
KI.(gEgIEY DRISCOLL
MAYOR THOMAS ST.MULS
DIRECTOR OF PLBLIC PROPERTY/BL'QDLNG CONLNBSSIONER
Workers' Compensation Insurance AITldavit: Builders/Contractors/Electricions/Plumbers
aptlicant Information L Please Print Legibly
ev Naine Iousin Ortaaatzzatiomindavldual): Li1��J Xi4kXc, aa�4 \ rev/ (-h( Srr
Address:_
City/State/Zip: -�( Z(44,-- Phone 0-
Are you to employer?Cheek the appropriate boa: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time)." have hired the sub.-contractors 6. ❑New nrcdtw
2.❑ 1 am a sole proprietor or paancr- listed on the attached sheet : �• ❑Remodelielig
ship and have no employees These subcontractors have V. ❑ Demolition
•working for me in any capacity. worker'comp.insurance. 9. Q Building addition
[No workers comp. insurance S. We are a corporation and its
officers have exercised their 10.Q Electrical repairs or additions
required.[
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.0 Otha
comp. insurance required.]
'Any applicant that chocks has e1 must also rill out the secoen below showing their waken'an eontpatttfGm policy infuntutlots.
'I I,w+eawnws who submit this affidavit indicting IIIey an doing all work and then him outside con achot nwM submit s now aslldevil indicting suck
:',,honors thin cheek this has mutt anwhed an 3"liondsI sheaf showing den none of the subeosascters and their workers'ramp.policy infosmmien.
I um an employer that Is provid/nir workers'contpensadon fnsarronce for my esapltyees. Below/s the pellay and Job sits
informalion.
Insurance Company Name: ZM aAw 6
Policy N or Self-ins. Lie. N:_.SZl J,e Expiration Date:
Job Site Address: e;ZK ffJQ1( 11 City/State/Zip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and eapirsdoa slate).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of■
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 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Invcsngmiomt of the DIA for insurance coverage verification.
l do hereby certify mtddar/tthhey pains and pentrllles of per/ury that the informadam provided ab4vc if true and carreet
ioff,eial use amdy. no not write in this area,to be,ompleted by city or town oJflrisd [
City or Tuwn: PermitfUcense
hsuing.%uthoray (circle one):
I. Ilourd of lieallh L Buildlnt; Deparlmcnt J. C'itylrown Clerk 4. Flectrical Inspector 5. Plumbing Inspector
6. Other
Cuatacl Person: _ __. __ Phone N'
ACORq CERTIFICATE OF LIABILITY INSURANCE 10/1 2009»05/
PRODUCER (781)449-6786 FAX (781)449-4269 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
BOYNTON INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
72 RIVER PARK STREET ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
NEEDHAM, NA 02494
INSURERS AFFORDING COVERAGE NAIC 3
INSURED Kyron Inc INSURERA: Max Specialty
DBA Preserve Services INSURERS: Hartford Insurance
203 Washington Street,8256 1"$URERC:
Salem,MA 01970 NBURER D:
INSURER
COVERAGES
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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTp TYPE OF INSURANCE POLICY NUMBER PATE LUD fi LIMITS
GENERAL LIABILITY MAX01310000308 05/23/2009 OS/23/2010 EACH OCCURRENCE S 1,000,00(
X COMMERCUIL GENERAL LIABILITY PRENNSE3 emIT" S SD DD
CLAIMS MADE a OCCUR MED EXP(Any"PM,CA) S 5 00
A PERSONAL S ADV INJURY S 1,000
GENERALAGGREGATE S 2,000,000
GEHL AGGREGATE LIMIT APPLIES PER PROOUCTS-COMPIOPAGG f 2.000,00
I X POLICY JEST LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMB
ANY AUTO (ER PxlEent) S
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Fw Pq ) S
HIRED AUTOS BODILY
NON-OWNED AUTOS S
PROPERTY DAMAGE S
(Per xWstl)
GARAGE LIABILITY AUTO ONLY-EAACCIDENT S
ANY AUTO OTHER THAN EA ACC S
AUTO ONLY. AGO I
EXCESSIUMBREII UAINJTY EACH OCCURRENCE 6
OCCUR CLNMS MAN: AGGREGATE S
S
DEDUCTIBLE S
RETENTION S S
WORKERS COYPEYIsATION 014314392 05/20/2009 05/20/2010 X TORV UMITs AND EMPLOYERS'LLABILRY YIN
B ANY0 I=FEWEERREERCUDED7 CUTIVEI� E.L EACH ACCIDENT E 100,
Ow
Imyond.wory in NH) u YES E.L.DISEASE-EA EMPLOYE S 100,00
SPEC'AL PR�OIRSIONSNeIow E.L.DISEASE-POLICY LIMIT S 500 00
OTHER
MSCNPTION OF OPEMTHMS I LOrATTONS I VEWCLES IEXCLIJSMS ADDED RY ENDORSEMENT I SPECUIL PR5;tms
1.000 Bodily Injury and /or Property Damage Deductible
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO NAIL 10 DAYSMTUTTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO TH!LEFT.BUT FAILURE TO DO SO SH LLL
IMPOSE NO OBLIGATI OR UABIYTY OF ANY KIND UPON TH!INSURER.ITS AGENTS OR
Eric Husgen REPRESENT
14 Conant St. AVTHORRED A7TVE
Marblehead, MA
ACORD 26)200=1) ®1 2008 ACORD CORPORATION. All Fights reserved.
The ACORD name and logo are registered marks of ACORD
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
,Ill i:. PI h.l !BI„ �'41 '
•SAI r%I,
'fEt:978-.'43--7;95 • I %8:978.740-9846
Construction Debris Disposal Affidavit
(required fur,all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR 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
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I1I. S 150A.
The debris will be transported by:
jjaJKnAI
(name ut hauler)
The debris will be disposed of in
(name ut aci ity)
(address ul'Iacility) -
,ignatur�e of permit applicant
J C/
da e