336 JEFFERSON AVE - BUILDING INSPECTION \') - g --- I he CoI11111oI1N'eallh 111 bl:usaihuseus
)�/ s LOMMil
Bo,lyd ul'lluilding Regulations and Standards CI I'Y OF
Massachusetts State Building Coda. 7SB CNIR SALEM
Udr YA �Permil Application Tn C'onstruct, Repair. Renovate Or Demolish afate-ur rnv-Funtill• Dn'elling
Phis Section Fur❑Ilicial Use OnlUer: Date Ap lied:Marc) Sigrtature
SECTION I:SITE INFORMATION
1.1 Property AJdren: 1.2 Assessors blsp& Parcel Numbers
I.la Is this an accepted street? es Vo Ship Numher Purcel Number
I.! Zoning Information: 1.4 Property Dimensions:
Luning District Propowd Use Lot Area(sy It) 1'mnlagc(11)
1.5 Bulidin`Setbaclu(R)
Front Yard Side Yards !Ma
Rear Yard
Required Provided Reyuirod Proviequired Provided
1.6 \Voter Supply:(M.G.I.e. JU. §Ja) 1.7 Flood Zone InformationwaQe Disposal System:
Potb1lc O Prh air❑ Ame: _ Outside Flood'Lu
Check If es❑ pal❑ On site disposal s)stem ❑
SECTION7: PROPERTYOW
1.1 Oxnerl of Recprd:
7' , , vts9(uy.Slalc,l.IPand Street telphoneEmail AddressSECTION J: DESCRIPTION OF PROPOSED Wll that apply)New Construction ❑ E.cisting Building Owner-Occupied RAlterntlonls) Addition ❑
Demolition ❑ Accessory Bldg, ❑ Nuntberof Units__ Other O Speriry:
Brief Description of Proposed 1Vork':
SECTION a: ESTM ATED CONSTRUCTION COSTS
I1V111 Eitinmtrd Cosn:
1Lahur and\lalrriab) Ofllclal Use Only
I, Building S PO I. Building Permit Fee: S Indicate how lac is determined:
'. Flectrical S ❑Standard City Tostn Application Fee
❑Tulal Pra tot('ust't Ilent O a muhi leer
_. Usher Fees: S
J. \(eehenical ill\ %C) S List:
\Iechuniial tFve _-----_—.—.-
'Itillive,sioni S rotal \II Fces: S__- _ --
1'nlal s I roicct Cn+t: i Check Vu. ( hceA :\nunun:
n _. .__ l'.nh \nu nun:
❑ P.lid in Full ❑Oalstanding ll.11,mce Due:
SF.('I'IONS: ('ONSI'RI1('TIONSERVICFS
5.1 C'msstructium Supcni.rur I.iceose(C'SI.)
I iccnse .Nunlhcr J F\pirdlinn Date
\.rue III t'SI I I,dJcr 1 Ist t'Si. I')IV 11ce helomI__. -- —
I')pe I)cicripliun
No. .uel Street 1hlrestridcJ lihuldin"li to it,IIllU tu. IL1
— Q � ��rn-_��,—_�� 7�_ Ii Reslricl.J Lt_' f.unil Drrcllin
Cityi I'oltni.—Slue.LIP .11 Roolin
I(C RI,Idin Gus Grin
K'S N'illatm .wd Sidio '
SF Soil d F l Burning:lppliances
9,� �/7 �4� / G �. rj 1 Insulution
I'elc hone fnulila Jnss D Demolition
4.2 Registered Ilome Improvement Contractor(111C) /?
S+� � ? �a fi`/! Y- Y' f.__ III 1Reyisl lWr F\Iliruliun Wig
I IIC'Company Nook nr I II 'It.yutrunt Name
�AQnn
No. wd Wee limail uJJrtss
Ci !Town, Slate ZIP 'Tale hone
SECTION M WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M,G,L e. I52. 28CM)
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 O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED 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 matter lot -to wo Is authorized by this building permit Opp Ication.
r7
Date
Print mid s w le I -lectrunic Sig al re
SECTION 7b: WNERt OR AUT110RIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in thi ppiicatioll
i is true and ace ate to est of my knowledge and understanding.
9
I'ri l ncr'e ur:\uthluiicJ,\ynu's N; w 11!leclronic Siyna
Dulc
NOTES:
1. .1n Owner svho obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
lout registered in the Hume Improvement Contractur iHIC1 Program),will rw have access to the arbitration
program or guarwuy fund under M.G.L. c. 142.A. Other important information on the HIC Program can be found at
,I,s,s nLr•. ��I , 1 Infonnaliun on the Construction Supenisor License can be round at2. „`t`t ❑I•t" 'o:'t 'lit`
\1 hen substantial work is planned,provide the information below:
rotal dour area tiq. Il.l . __—_.._1 including gauge, imishcd basement attics. decks or porch I
habitable room count .-
Gross lis my area l sq. ll,l . .. Nuother of hctIl
\umherofiircplaces .. _. _ .. --- \ulnberot'halt'hal
\timherol'hadtromns _
I pe,rt'heotulgit,teal \umherolJccki porches
I pe nl :oollny .�aeni
I'nclascd ..ltpen
1 ..I'otol Ilroiect \,Illare I'00f-We III,, he •IlhHlltltcd II,r l olal Ill t 1,C
Q'I'YUF5'UE.m, Nass.1CHUSE"ITS
' 1)LILDI,NG DEPARTMENT
_O 1 W.ISHLVGTO+ N $TtEET, 30 FLOUR
_ w
F.k-'r(97,9) 710.9844
!:1>IaEU-EY DR)SCOLL
NUYOR �IOSL\3 ST.PtERRB
• DIRHCTUR OF PL'OLIC PROPERTY/RL•fiDiNG COSLMISSIONER
Workers' Compensation Insurance Affidavit: Uuilderi/Contractors/Electricians/Plumbers
\nnlleant fnformatlnn Please Prilat U ihty
.NJIIIC Illueiik.0 Orgamrationlmlividudll: ��J� Gii7�7�i.�—j L,Q
Address: J 3 lTe P,, �Gn
City/Sratc/Zip: Slelfea j 2' 42/147p PhonaH 97� 3/ 7
Arty') n n employer'?Cheek the appropriate bate
Type of project(reyulred):
1. un a employer with _ A J, ❑ I am a general contractoJLK
mnpinycea(fLll and/or part-lime).• have hired the sudcamr • ❑New cunstrruliana Bola proprietorur purtncr• listed on the wnehed.+he • ❑Remodeling,hip and have no employees These sub•contractars ha Q Demolitionworking for main any capacity, workers'comp, insuranc(: o workers'com insurance 3. ❑ Building additionV p. ❑ We are a corporation andrequired.) officers have exercised th •❑Electrical repairs or additionsJ.Q 1mn a homeowner doing all work right u!uxamptiun per M .❑Plumbing repairs or udditlonsmyself.(No workers'comp. c. IJ2, )I(d),anJ we havQ Roof ropairs
insurance required.) 1 empluyecs. (No workers'
❑Other%ny Wtilh:un dW rhuulls boa of mwt,iw fill um iM s ,,w bulawt,howingIhvir"lists•romrrnudan puryine+rmmlan•
'l livnuuA M"whe"I'Mit this 4111davit indieanng ihey ur doing all,wre,nd that lain w4idg canlnatae mmr n'hmO t new alTrdavit indtain
t',:mnrWnthnt ch,<4lhis box mwUeouhd in.u4htlunal h.1 Oluwing the nwna him t"J"Co rtrWns""Ut 1rwalivn'wm g�aK
P paltry in(umunaq.
/urn un rurpluyrr that/r pruviJlnX Ivarkerl'rumpoural/art lnsorunee�ar my emp/uyrrx Below le the policy und/ub slis
inlormallon, /
Irt.urance Company Name: kr b G/y- _�d�f 1✓=.� r�r �' � �'����O3 z
y --
Policy 9 or Solf-iim Lie. n: /
�,/� Eapiralian Date:- `�la.p/
tub Sita Addfess: .336 (Te-fiel C//a tl-r' (:ilyi Slate12:ip; �C1®�
\ �y/
inch copy of the worlts r camponutlon policy declaration page(showing the policy number and expiration data),
h'.liluru to
secure cuvars,a as rcyuired under Section M%of MCL c. 152 can Icad to the imposilian of criminal penalties of a
rinc up to 11,50.00 indlur ane•yeir iinpri.ronmcn4 as wolf as civil penalties in the 1•arm of a STOP WORK ORDER and a tine
ai.ip to 52A.00 a Jay r,ainsl the violator. Ile advieed that a copy ni Ihit nutcment foxy Fw iur.•ardc'J to dta 011ica of
I.Ivr,uymun+of the MA Grr insurance uoverage Ycritie.rtiun.
1 du hereby cnn%y rnlJrr rho puim a tJ pen older,r/ vrjury that llro infiururudmt pruviJaJ ubuv,r�it truo•rnJ contra
r7//irial rue,ndy. /7,i.roI ivrire in this rmr, ru.5e rumpludJ 5y city ur to,a
(:;ty Ir Ilnva;
to parity (eircla nae): . . ._
i. ;:uafd nl Ileollh !, If nildln Ucp.trl mrul I, ('fly;1 ut+n Clark I. (•:laetrir.tl I;t+ t
.i. Uthcr Pcrtnr �. I LI�uDnq httpta,v
I�ial.t.f Pr ntn;
i • i
,- CITY QF S.tt.E,Ni, AkSS.ICHC'SETTS
dLLLDLNG DEv.sRT.%tE`t
I .0 W-Wi NGTON sruxr, 1iO Each
� ItL. �918) 14S-7S9!
1C1JBF_R1 fiY DItLSCO[l.
RVc(973) 74&9844
.�UYolt MOAU ST.PMXAS
0laWrOtt Of Pt.sue 0ROPRATY/at:M"4c co-nuurov EA
Construction Debris DISPOS31 AdIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition Oahe State Building Code, 190 OR section 111.S
Debris, and the provisions of,WGL o 40, S 54;
Building permit 4 is issued with the condition that the debris resulting from
INS work shale be disposed of in it properly licensed waste disposal facility as defined by&IGL c
111, S 110A.
The debris will be transported by:
(n+ma act'hauler)
The debris wi 11 be disposed of in
(name of tZlily)
(r ddrrer
yn�mrs of perm,f ippht�nt
07/09/2012 09:47 9786833147 PAGE 01/01
DATE(MMIDDIYW1)
Aco� CERTIFICATE OF LIABILITY INSURANCE
7/s/2o12
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIFIMATIVELY 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 aaNRcate holder Is an ADDITIONAL INSURED,the Pelidy(lea) must W endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions Of the policy,Certain policies may reguilm an endorsement A statendni,on this celtlRoete does not confer rl9hb-to the
GemRCale holtler In lieu of such endomement(s).
PRODUCER NgME'
M P Roberts insurance Agency Inc PHDNE . 978-683-8073 A�cNo:978-�683-3147
No
1060 09g0001 Street ADDRE9S'.
_ North Andovar Ma 01.845 INSUaEsl91 AFFORDINd CWBMOE NAICA
INSURER A:ATLANTIC CASUALTY INSURANCE
INSURED STEVf.N HAOLEY INSURERB:Merehant8 Insurance
INSURER C'Liberty Mutual insurance
239 JEF)FERSON AVENUE INSURER O:
,$ALMI, MA 01970 INSURER E',
INSURER F
COVERAGES CERTIFICATE NUMBER' REVISION NUMBER:
THIS IS TO CERTIFI'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 3E 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.
TYPE OF INSURANCE R rrvo POLICY NUMBER MM/OD/YYY M IDD LIMf76
LTR EACH OCCURRENCE s 1 000 000
LE
LWBILIT/
X COMMERCIAL GENERAL LIABILITY PREMISES E.occunsnce $ 100 D00
CLAIMS-NAOE OOCCUR MED EXP(Any one person) $ .FJ 000
A L143002666 07/09/12 07/08/13 PERSONAL&ADVINJURY s 1,000,000
GENERAL AGGREGATE s 2,000,000
OEM%AGGREGATE LIMIT APPLIES PER; PRODUCTS-COMPlOP AGG s 2,OOO,000
POLICY PRO- LOC $
AUTOMOBILE LIABILITY a eCGdeni B ULL LIMIT 300,000
00/000
ANYAUTO 10/26/11 10/28/12 BODILY INJURY(Pgr pgroen) $
ALL OWNED SCHEDULED MCA7014084 BODILY INJURY(Per RcGdenU 5
$ AUTOS X AUTOS
ON-OWNHIRED AUTD9 8 AUT09 SED Pa accident S
X
UMBRELLA LIAB OCCUR EACH OCCURRENCE S
ExCE39 LIA9I I CLAIMS-MADE AGGREGATE If
DEO RETENTIONS s
WORKERS COMPENSATION W"TArdlT9 DTI
AND EMPLOYERS'LIABILITY O7/OB(12 O7/OS/13
YIN WC531S329064032 El.EAGHACDIDGNr a 5 �O004NY PROPRIETOWFnRTNERIEYECUT1VEONIA
C OFNCERIMEMaER EaCLUCE09 E.L.DISEASE-EA EMPLOYE $ 5(Myyandp"In NHIDESCRI�ON FIbe BOPERATIONS MI" li DISEASE-POLICY L@4R s 5
DESCRIPRON OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD I In.AdditimAl Remarks SGredulg,it mom apace le required)
F-978-740-9846i,l
RE: 336 JEFFERSON AVENUE SALEM, MA
CERTIFICATE HOLDER CANCELLATION
CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES SE CANCELLED BEFORE
120 WASHINCTON STREET THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
SAL-24, MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORIZED REPRESENTA
1988-2010 ACORDCORPORAT1IONN. All JjrightS resented.
ACORD25(2010/05) The ACORD name and logo are registered marks of ACORD
1
I