Loading...
The URL can be used to link to this page
Your browser does not support the video tag.
338 JEFFERSON AVE - BUILDING INSPECTION
The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of !, Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept Building Permit Application To Construe r, Renovate Or Demolish a One-or Two-F roily Dive ling This Se ion For Offici Use Only Building Permit Nu r. to lied: Signature: �� Aq Building Commission / Spector dQuildings Date SECTION A: AMITE INFORMATION 1.1 Pre�tT A dr s : 1.2 Assessors Map& Parcel Numbers L l a Is this an cepted street?yes no Map Number Parcel Number 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 Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWN NRSHIPt 2. wnert f ord C11Z 2 p Name(Print) Aress for Ser e: C/.f77 ( --/ 6 V Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ No er of Uni Cher ❑ Speci �/1 Bn f Description of Propos Work': p7— SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials f,� 1. Building Permit Fee: $ Indicate how fee is determined: I. Building $nj�j 2. Electrical g Z�, ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ Z,y60." 2. Other Fees: $ 4. Mechanical (HVAC) $1' — List: 5. Mechanical (Fire S Suppression) Total All Fees- $ _ �'''' /��, p� Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ _1I 'Z Oc' ❑paid in Full ❑Outstanding Balance Due: }�a fv� e LOwr, P�— SECTION 5: CONSTRUCTION SERVICES I Lic tsed Cons ucti Supe visor(CSL) L/ �J 27 License Number ` / Expiration Date "e o CSL-_ Q er List CSL Type(see below) _ Description ` A so U Unrestricted u to 35.000 Cu. Ft.) S' R Restricted 1&2 FamilyDwelling e / M Mason Only 6 �7 RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition fteredpr m t C ntractor(HIC) C� (1 rJ of YA, IR nt a Registration Number I_ ^,o- ( D �7` ` �6nj / Expiration Date Telephone SECTIO 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 .........AT—� 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 to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNEWRIA AUTHORIZED AGENT DECLARATION 1 ,as Owner or Authorized Agent hereby declare t the qtat0entJ#nd inf r 'o opn the foregoing application are true and accurate,to the best of my knowledge and h © t� l Z� Print me c � � D X zg � (l Sign u e of Owner or Aut ized A t Date Si a under the ains an enalti s f er'u 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 HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS, respectively. 2. When substantial work is planned, provide the information below: Total Floors area(Sq. Ft.) (including garage, finished basement/anics,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" ACORD,P CERTIFICATE OF LIABILITY INSURANCE 10/30/20 s' PRODUCER (978)774-8040 FAX (978)774-3581 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Tarpey Insurance Group Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 491 Maple St (Rt 62)-Suite 304 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 183 Danvers, MA 0192 3-03 8 3 INSURERS AFFORDING COVERAGE NAIC# INSURED 7, P. Remodeling & Construction, Inc. INSURERA. Safety Insurance Co 39454 220 Yankee Division Highway INSURERS: Travelers Indemnity Company 25658 Danvers, MA 01923 - INsuRERc: INSURER D: INSURER E: 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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. INSR DD' TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS LTR WMIDDNYI GENERAL LIABILITY 6P00003110 11/05/2008 11/05/2009 EACH OCCURRENCE $ 1,000,00 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 PREMI.qr.q(Pa CLAIMS MADE [�] OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 1,000,00C GENERAL AGGREGATE S 2,000,000 GEML AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 X POLICY PRO LOD PRO- AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accitlenl) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC S AUTO ONLY: AGG $ E%C ESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR ❑ CLAIMS MADE AGGREGATE S $ DEDUCTIBLE $ RETENTION $ Is WORKERS COMPENSATION AND 6KUB0915C31508-AR 09/30/2008 09/30/2009 X WC STATU- OTH- EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 1Q0,000 OFFICER/MEMSER EXCLUDED? E.L.DISEASE EA EMPLOYEE 4 ZOO,OO If yes,describe untler SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 OTHER DESCRIPTION OF OPERATIONS/LOCATIONS VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS eneral Carpentry CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE James Tare , CIC, V Pres ACORD 25 (2001108) ©ACORD CORPORATION 1988 I CITY OF SALEM PUBLIC PROPRERTY DEPAJI JNIENT III o'g-'l;. r.,; construction Debris Disposal .affidavit (re\Iuired for all demolition :uld rcno\ation \\'ork) In accordance \\ill, the sixth edition of the Stale Building Code, 7So Ch1R section 1 1 1.5 DcbI is, and the pro\ istons oI MGL c 40, S 54; Building Permit if is issued with the condition that the debris resulting from uperly licensed waste disposal I'acility as defined by MGL c this work shall be disposed of in a pr 111, S 150A. The debris will be transported y: SSA lna nic of hauler) he debris will be disposed of in ollinc ul ljollty) u taddre�.u(lacihlvl .renatwc of 1) n it .y'Pii n t. CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT M sst xl IIC W,%%tu.\G ION SIaLL I • SM1%4,MANS vi.nt it 1 Is007C 1 I,I. '073-.':sY959301:%x 974-74t 1.446 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers t ylicaiit Infonnrtion iv Please Print Le ih t 14il lnt: l Bu`we%v1)r;pm rafinNlndlvdua0: : ddlcss: 22-0 1 City,Srale,Rip Pit Phone ,.: .%re iuu einployerl Check the appropriate box: I*)PC of project (required): 4. ❑ I am a general coutractor and 1 I :un a cmplu)cr with G. ❑ New construction e nl,lo ees full and/or art-time).' have hired the sub-contractors 1 ) ( p 7. ❑ RcfnoJeling 2.❑ 1 1111 a sole proprietor or partner- These listed on the ntract r sheet. ,hip and have no employees These subcontractor have K. Demolition %vorkrrs' co working Ilr me in any capacity. mp. insurance. 1). ❑ pudding addition No workers' comp. insurance 5. ❑ We arc a corporation and its 10.0 Electrical repairs or additions I required] officers have exercised their right of exent tion per MGL 11.❑ Plumbing repairs or additions 3.❑ 1 ani a homeowner doing all work c y152, s l 4),Pmd w have no myself. LNo workers' comp. s ( 12.❑ OtheRour repairs insurance required.] r anployecs. nc workers' 13.0 Other comp. insurance required) •4ny.,glbcaul that chucks boo it[ muss alau lilt oul the w,Iian lwluw,ltowiny,hCu wurkui cumponu ion pulicy udlrrntatiun. ' I tom.a,wrwrs who stdmtil this affidavit indicating they am doing all%work wW then him outside corur:ietors must auhmil a new afGdavil indicting Awh. -(-,mtmu^That Owck this box msutt mbchcd an addaiun4I Axvt showing the amnia of the sub.ontrxtun and then%when'comp.po icy mformancen. /roll an eurpluyer that ix pro vidinr wur Hers'c•uinnvat it it Insarnnee jar my rurp/uyrcc Belory is rho pu/icy and jub site i„jonnatiun. Imurancc Company Naine: .. Itolicv a or Self-ins. Lie. ft, I _ �. __— EApirallon Date: Job Site Address: s City-Slate/Zlp: Attuch is copy of lire worki:44 compeniation policy dedarAtIll page (showing the policy number and expiration date). I�ailurc to secure coverage as required under Section 25A ul'\IGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 and/or une-year imprisonment,as well as civil penalties in the tuirre of a STOP WORK ORDER and a fine of up to S250.00;1 d.ty .lgainst the violator. Fie advised that a copy of ilia statement may be forwarded to the 011ice ul In%c,ngau,rns ul the DIA :or usuuaCcc c,,scruge %cri6caUon. /du her%•n t rtijv ,der the p it u,t tenet jperjury that the iajurinallon provided above is true!correct. U/Jici toe only. Do not n•rite in this area, tube eumpelered by city ur to,vn al icia/. ('ilv or fawn: __ Put init/License 0, I%%uing.%uihurily (circle one): 1. Ilr,ard of Ilc:dlh 2. Iluildin. Depart ovell .1. Citi.1uwn Clerk 4. Electrical luipec(or 5. plumbing Inspector 6. Other Cwuacl VVrsull: .. .. Phone 0: Information and Instructions Massachusetts Gcncral Laws chapter I i2 requires all employers to provide workers' compensation for their employees. Punu;tnl to this statute, an emphgee is defined as"....every person in the service of another under any contract of hire, c%press or Implied, oral or wrinen-" An employer is defined as "an individual, partnership, assoclanou,.corporation or other legal entity, or any two or more 01 the t rcwing engaged in ajomt enterprise, and including the legal representatives of deceased cmplu)er,or the receiver or trustee of.rm individual, pwincnhip,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or it,. the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." .IGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal ofa license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." additionally, NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any euntract for the performance ul'puhlic work until acceptable evidence otcunnpliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificates)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confimtation of insurance coverage. Also be sure to sigu and dale the affidavit. The affidavit should be rctumed to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit fur you to fill out in the event the Office of Investigations has to contact you regarding the applicant. 11I.ase be sure to fill in the pennitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple pennitAicensc applications in any given year,need only submit one affidavit indicating current policy iutormation of necessary) and under"Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I h t)I tlec of Investigations would line to think )'no in advance fur your cooperation and should you hove :my questions, please do not hesitate to give us a call. The Dcparunctu's address, telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents OfAce of Invest1gatlons 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 www.mass.gov/dia ,SS\ Board of Building Regulations a;id- �10� lugHOME IMPROVEMENT CONTRACTOR Registr wn, 115467 Expiraton 1/30/2610 TrI 2�,2310 ,1 I EType PI'ivate, o-porati_on -k 'J.P. REMODELING`ANq CONSTRUCTION INC _ JOHN POLIZZOTTI�" f220 YANKEE DIV DANVERS.MA 01923 :rrassacnuser u - ucp:uur'cm u, �_ . . .. BB;u'd of Building Rc� uunc �;rrcn Construct1O n Supervisor ulations :lird Standards ' License: C8 �529 License Restricted to: 00 22 OHN S POLIZZOTTI ANKEE DIV HGWylIi DANVERS, MA 01923 �{ rw ('un,mixxi„unr Expiration: 10/31/2010 rr#: 4784