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110 JEFFERSON AVE - BUILDING INSPECTION cfc 3 S 3 Z .v y The Commonwealth of Massachusetts RECEIVED Y OF j Board of Building Regulations and Standar fbSpECTIONAL S RVIVLEM Massachusetts State Building Code, 780 CAW Revised Mar 2011 Building Permit Application To Construct,Repair, Renovatefr,.Q¢�oA a % 38 One-or Two-Family Dwelling 1'�► �� This Section For Official Use Only Building Permit Number: Date Applied: 4 Building Official(Print Name) Signature D to SECTION 1:SITE INFORMATION 1.1 Property Ad ass: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(It) 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 Zone?Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 wner of Recor �n)(1 /I lys MR 61970 Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) IJT-I Alteration(s) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify Brief Dcs ption of Proposed Work': 0 1 &L4Z2bAA p'y7 ,/tO i SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ I. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ t 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ n� Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ b ❑Paid in Full ❑Outstanding Balance Due: '."xJIVf10 V13J3fl c A�!OlT�3gZ! I 8F ;P q - �lij GtuS SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ^n 9�D �,rt (J f-e.e License Number 9 Expiration Date Name of CS/LHollldder / R0, List CSL Type(see below)_ __ l'P J No.and Street Type Description ) /) /� 0 1 q ( �/t U Unrestricted(Buildings u to 35,000 cu.ft. _dCl 1T Cl I V R Restricted 1&2 Family Dwelling City/Town,State,Zl Masonry C Roofing Covering WS Window and Sidin SF Solid Fuel Burning Appliances 7 1 Insulation Telephone Email address D Demolition 5.2 Registered Rome Improvement Contractor(HIC) 17 , A- !JP I` HIC Registration Number Exp Lion Date HIC Company=ristran N e N .and S�et Email address �lti)lp�.� YYl (� bl 4(o g g7��i7�i-7y2� City/Towne,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 to act on my behalf,in all matters relative t work autho 'zed by this building permit application. Ct G ,(- q gi oCi ,n S t Print Owner's Name(EI ctronic ignature) Date SECTION 7b:OWNEW 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. F-r� e I ,� _ Print Owner's or onzed AgeFA Name(Electronic Signature) Date NOTES: I. 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 BIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dos 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"maybe substituted for"Total Project Cost" � Q 4 N G� cn fQp l.t L. u I rj ❑ ri niL1 tl r O.: w CJI �� u.. •�•' � �; L+I I I��I'IIIII�II@hlllll.�;r' �:� i:.v� �� } a �� III�( �' � •M� i CI1Y OF SALE., NU SSACHUSETI'S ' BuE DLNG DEPART SMNT 130 WASHNGTON STREET,3'FLOOR ` TEL (978)745-9595 FAX(978) 740-9846 KIJIBERLEY DRISCOLL NfAYOR THomAs ST.PIEttRE DIRECTOR OF PUBLIC PROPERTY/BU DING CO%L%=IONER Construction Debris Disposal 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 c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: �i e.I�ee,IRoz�t�(name of(name of hauler) The debris will be disposed of in : (name of facility) ��ilJ��. (add ss of facility) �l signature of permit applicant r i ate dcbrisaffdm The Commonwealth of Massachusetts Department oflndusd3el Accidents OfJlce oflnvestigations 600 Washington Street Boston,MA 02111 wwwmass gov/dia Workers'Compensation Insurance Affidavit:Bmlders/Con#aetots/Electriciaus/Piumbers Applicant Information Please Print Legibly Name(BusincojorsonbetinNrndividual): ' ILLI (V Address: 6170 t �Pl p c 1� IL d �t City/StatelLip: nl Jl 4 h,t N 561 Phone 9 79-y 79- 7 N Z 0 Are you an employer?Cheek the appropriate box Type of project(rMtdteft L am a emp1oyer with_ -Z�: 4. ❑1 am a general contractor mid 1 6. ❑New construction employees(full and/or parvmne)" have hied the sum-contactors 2.0 I am a sole proprietor or t par - listed on the attached sheet.1 7. ❑Remodelingship and have no employees These subcontractors have S: ❑Demolition working for not in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'twulp.insurance 5. ❑We are a corporation and its required) officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right ofaxemption perMGL 11.0 Plumbing repairs or additions myself.(No workers'comp. a 152,§1(4),and we have no M(]Roof repairs insurance required')t employees.(No workers 13.❑Other coop.insurance required-] 'Airyapptieaotthucheebboxal mumsi ®1ootthesection[doe showing dedr worima'eompmmdonpoucy bdbnnad= t Hummwnnswho submit this aidwit Inficaling nay=doing aU wat and urea hheomtidecomtactaa m wAmita new affidavit mwh 'Conaacmrs that check this box mum-ruched®aMdno IAM Mwwmg drct ofihcsub and their wakm'mop,polky m6rmwoa lam an emplgyar thatlSP7owding wFken'eompmmvdojs uw mceforotj'OlWIVe S Below is dwpol/ef mnf joh Site Infarnmtion. I ` _ Iasormcc Company Naate:a-(\)i(N)e i\. Policy#or Self4ns.Lic. D- Expiration Date: 1L Job Site Address: I I y �l a S o A Q J V cty/Stimamp: Ea o n2 rn c) ( g Attach a copy of the workers'compensation policy dedaretiou page(showlog the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine 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 staternnu may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do.yereby arvder eke-Pfifts dMOVenables ofper,jury that the hrlornrm+on provuhvl ahowe is tore and eorrea Sttmatrue• Jt�(' \/ Date 4-il Phone#: g"-�-� —� (4 7 Z) .0fe rd ire only. Do not wi ite in this area,to be completed by city orimm offiefat City or Town' Permtt/Lkense# Issuing Authority(drele one): I.Board of Health 2.Bolding Department 3.Cilyfrown Clerk 4.Electrical Inspector 5.PlumEbnn�pector 6.Other Contact Person: Phone#: CERTIFICATE OF LIABILITY INSURANCE DATE(MIDI Yi)14 ,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(ids) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policx certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsenen PRODUCER CONTACT NAME: Circle Business Ins. Agcy, Inc PHONE I FAX N 247 Newbury Street MP ADDRESS: Danvers, NA 01923 INSURE SAFFORDIN3 COVERAGE NAIC# INSURERA:Safety Indemnit INSURED INSURERS:Seneca Insurance Eric A. Teel Roofing, LLC I INSURER C:Continental Indemnity Co an Po Box 46 INSURER O: Rowley, HA 01969 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES 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 HEREN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS ANDCONDITIONS OF SUCH POLICIES.LNIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS. INSR AML SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MRIDIV MTNDDIYYYY LIMITS B GENERAL LIABILITY BAG-1018051-1 12/20/13 12/20/14 EACHOCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABIUTV DAMAGE TO RENTED $ ZOO OOO CLAIMLSlMADEOCCUR MED E(P(Ary one Pawn) $ 5,000 PERSONAL&ADV INJURY $ 11000,000 GENERAL AGGREGATE $ 2,000,000 GEJ'LAGGREDATE LIMIT APPUES PER PRODUCTS-OOMIPX)P AGG $ 2,000,000 ilPOLICY FX1TOT- LOC $ A AUTOMOBILE LIABIUTY 6219821 9/10/13 9/10/14 COMBWI)Eaacci� NGLELIM $ 1 OOO OOO ANYAUTO BODILY INJURY(Per person) $ ALLOWNED X SCHEDULED BODILY INJURY(Per accident)AUTOS AUTOS (P h $ X X NON-OWNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS er acWem UMBREUALIAB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTION$ $ L. WORKERS COMPENSATION 46-819686-02-04 11/19/13 11/19/14 WCSrATU- X OTH- ANDEMPLOYERS'LIABILITV YIN ANYPROPRIEIORIPARTNERIEXECUTIVE OFEOERIAEMBER EXCLUDED? N� NIA E.L.EACH ACO DEM 8 SOO OOO (Mandatory in NH) EL.DISEASE-EA EMPLOYEE $ 500,000 If yes descrilhe under OF OF OPERATIONS Mlrw EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACach ACORD till,Additional Remarks Schedule,if mom space is requ red) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N Bouchard S Sons ACCORDANCE WITH THE POLICY PROVISIONS. 110 Jefferson Ave Salem, MA 01970 AUTHORIZED REPRESENTATIVE Paula Halas ©1988.2010 ACORD CORPORATION. All rights reserved. . ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: �G Gjc� 6e, 0 a deSfV's fo Stork C./? j pe'rove. S �� k