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62 JEFFERSON AVE - BUILDING INSPECTION (10) The Commonwealth of Massachusetts Board of Building Regulations and StandRE4E I V E D CITY OF Massachusetts State Building CoQie,gn0GMAL SERVICES SA Revised M Marar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelllik5 OCT —2 A q 31 ` This Section For Official Use Only Building Permit Number: I Date A lied: Z.J�► AV q�r tr- Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION ` 1.1 Property Address: /� � ��� �J 1.2 Assessors Map&Parcel Numbers L l a Is this an accepted street?yes no Map Number Parcel Number 1 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) 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: Public Private❑ Zone: _ Outside Flood Zyne? MunicipaleOn site disposal system ❑ Check if yes SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownert of g�tecord /' of f t C %I'.�eclr/,1/ Name(Print) City,State,ZII' 33 Sdd' ,VW&0 o?3-?1041* No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing BuildingA lteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work : f 6ER Aex � 10 ,me Aof' uArwrl-A>c-✓ -Al F/rA,Pt�s, SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application F 2.Electrical $ ❑Total Project Cost'(Itemf6)-x'multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: Cl' 5.Mechanical (Fire $Suppression) Total All Fees: $ ` Check No. Check Amount: Sash Atno 6.Total Project Cost: $ �500 ❑Paid in Full ❑ Outstanding Balance Due: }Y�rat -VO Cot\ST- LO [9 SECTION 5- CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) L55 L t7lVo 6 6-ad.`/ 5 License Number Expiration Date P l 1�0 Name of CSL Holder List CSL Type(see below) ' No.and and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/'rown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding ��o,.�d�t SF Solid Fuel Burning Appliances 9 }$/lj�r/1' rA 1P&(Vv oNf�7� �,t 1 insulation Telephone --� email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ?,AS•_/F /555�7( 5+z ltiC� �d S k�/ HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name jl LCtvcrso - #70ef, -Ca No.and Street Email address �[ouC I? c� t nt A- 01 y 3 a q�b_dSC--L y .1 . City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.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 .......... — No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize C A.P'e R-&ff-j' _C�-C Ccrk,%Mv of T^ e to act on my behalf,in all matters relative to work authorized by this building permit application. Gt'1 16 r Print Owner's Name(Electronic Signt&e) Date 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. -cw.+ Print Owne 's or Authorized Agent's Name 1 nic Signat&c) Date 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 10 Park Plaza ,Suite 5170 �@s Boston, Massachusetts 02116 Home Improvement Contractor Registration �-- - ==— Registration: 158671 // Type: DBA tF �= Expiration: 225/2016 Tr# 249949 x S. POLISKEY & SONS - STEPHEN POLISKEY 26 EMERSON AVE #2 - � GLOUCESTER, MA01930 ' '," <_ pdate Address and return card.Mark reason for change. Address Renewal D Employment Lost Card SCA 1 O 20MQMIl 5 Office of Consumer Atfairs&Business Regulation License or registration valid for individul use only before the expiration date. If found return to: ME IMPROVEMENT CONTRACTOR Wegistration: 158671 Type: _ Office of Consumer Affairs and Business Regulation im8on: 2252016 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 - S.POLISKEY&SONS - STEPHEN POLISKEY 26 EMERSON AVE#2 g . GLOUCESTER,MA 01930 --' Undersecretary of valid without sighdture Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialty License: CS$L-099900 atilt. 4 Stephen Poliskey 26 Emerson Ave Gloucester MA 01930 r J..G..� 8 10 Expiration Commissioner 06/22/2016 CO d CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDOMM 10/01/2015 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 po5cy(1es)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 certificate does not confer rights to the. certificate holder In lieu of such endorsement a. PRODUCER 978-283-7711 978-281-3895 e" Palazzola Insurance Agency Palazzola Insurance Agency PNONE 978-283-7711 F NO): 1 Main Street Unit#9 WILss• h Ills. alazzola ahoo.com Gloucester, MA 01930 INsu AFFORDING COVERAGE NAIC0 INSURERA:The Providence Mutual Fire Insurance Co. INSURED INSURER 6: Cape Ann Copper Company Inc. WSURERC: 26 Emerson Avenue waUREIRD: Gloucester, MA 01930 meURERE: 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. NOTWTHSTANDING 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. MSR CY EFF PO LTR TYPE OF INSURANCE POLICY NUMBER Mill (MMkMI UNITS j COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1000000 A CAIMS•MADE ©OCCUR PREMISE t 50 000 MED EXP we ) E 5 000 BOP 0086600 00 3/5/2015 3/5/2016 PERSONAL BADV INJURY s2.000.000 GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE E2000000 POLICY❑JECT 7 LOC PRODUCTS-COMP/CPAGG s2,000,000 OTHER S AUTOMOBILE UABWTY MGI�EDSI t ANY AUTO BODILY INJURY(Par pamon) S ALL OVVNEO F SCHEDULED BODILY INJURY(PwwddonQ S AUTOS NON10"CO P eOPERTY DA AOE f HIREDAUTOS AUTOS t UMBRELLA LING OCCUR FACHOCCURREN'CE E EXCESS LIAR CLAIMSIEADE AGGREGATE E DEO I I RETENTIONS t WORKERS COMPENSATION STAM AND EMPLOYERS UABILMY ANY PROPRIETOR/PARTNERIEXECUTIVE Y❑ NfA E.L.EACH ACCIDENT f OFFICER/MSMSER EXCLUDED] (Mandarery In NH) E.L.DSEASE-EA EMPLOYE t f yBB 063Ci Un DESCRIPTION OF OPERATIONS balmEL.dSEASE-POLICY LIMR S OESCRIP710NOFOPERATIONS/LOCATIONSIVEHICLES IACOROiN.Adr➢nenal Remarks Sehedub,r WaeaehedVmomspacebmuked) CERTIFICATE HOLDER CANCELLATION City of Salem SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Building Department ACCORDANCE WITH THE POLICY PROVISIONS. 120 Washington Street Salem, MA 01970 AUTHORMED REPRESENTATIVE B 1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD I MAP 24 LOT 89 ASSESSOR'S MAP 24 LOT 97 RUSCIO NOMINEE ASSESSOR'S MAP 24 LOT 96 REALTY TRUST KURT C. & AUDREY WELLING NORMAN J. & MARION E. BLANCHETTE 62 JEFUSC'OFERSON AVE. 17 BERTUCGO AVENUE 15 BERNCCIO AVENUE MAP 24 LOT 88 SALEM HOSPITAL _ 2'* 108 JEFFERSON AVENUE 116.21' 173 W ASSESSOR'S MAP 24 LOT 89 PARCEL TO BE CONVEYED -AREA- _ _ 9683t S.F. 14900 - ASSESSOR'S o 1T6-04 _ MAP 24 LOT 88 3 14 KqE °E SALEM HOSPITAL o JEFFERSO 108 JEFFERSON AVENUE v ASSESSO DETAIL INCLUDING BOTH EXISTING LOTS & LOT TO BE CONVEYED mo MAP 24 SCALE: 1" = 150' - v JAMES A n 60 JEFFE A 0A,± F _ 2 1 STORY COMMERCIAL omim vac 7g I BUILDING PROPOSED CONVEYANCE OF LAND FROM SALEM HOSPITAL TO RUSCIO 8 �- WITH THE INTENTION OF USING FOR I 6 #62 ADDITIONAL PARKING SPACES. 3 4 5 t5't 8 PARKING SPACES SHOWN, 2 9' WIDE X 20' DEEP, TYPICAL _ OVER —_°—'¢="�—— 77.25' 6 t 1.4'} V 1 m 82 EFFERS�N AVENUE PLOT PLAN OF LANC IF 62 JEFFERSON AVENUE SALEM V xa PREPARED FOR . BOB RUSCIO� SCALE 1" = 20' SEPTEMBER 16, 20 c NORTH SHORE SURVEY CORPORAL 14 BROWN ST. — SALEM, MA ZONING DISTRICT IS RI RESIDENTIAL ONE FAMILY. QTY OF SALEA MASSACHL SEM BuaDING DEPARnrNy 120 WA9ffNGTCNS7WT,rR OOR UL(978)745-9595. FAX(978)740-9846 RINIBERL,EY DRISQ'�LL MAYOR I}i�STAEM DIRECTOR CFPURUCPR0PERTy/AtnDmocmffssiomR Construction Debris Disposa/Affidavit (required for 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 c40, S 54; Building Permit# q is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: C 4 ft t4 kA l Coe`p-e r CC�d� C- (name of hauler) The debris will be disposed of in: 1.1W (name of facility) C'-_(cAAc.ti S h— \C (address of facility) Sigl ature of applicant �o — S Date