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452 LAFAYETTE ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY 1 Massachusetts State Building Code, 780 CMR, 7'"edition OFSALEM Revised January 1 Building Permit Application To Construct,Repair, Renovate Or Demolish a I, 2008 One-or Two-Family Dwelling This Section For Official U Only Building Permit Number: Signature: �IMYr� Building Commissioner/Inspector of B ' d Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers / 1.1 Is 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 ft) Frontage(11) 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 OWNERSHIP' 2.1 Owner'of Record: (Print) Address for Service: rgnature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: Brief Description ofProposcd Work': S'(z) eta , -Yt lo,-1l'nie. �Pe SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials L Building $ 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: �c�� 5.Mechanical (Fire $ Supression Total All Fees:$ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ 7qzX> JJ 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) g 3 r/S i 3 / :]GA n,1 �'����� License Number Expiration Date Name of CSL-Holder List CSL Type(see below) C� SZ Address /� T Description �l U Unrestricted u to Cu.Ft.,:: �— R Res[ric[edl&2Familily Dwelling Si tore M Masonry Only �T7IC 3G'7�Go RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) d 3,/ Registration/ HIC Company Name or HIC egistram Name umber r:1 P6e./,A<d Sf S Ie /kA. t7%Gt'7D ��7/�/ Address !, Expiration Date 4irnature 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, �Qy(/ T (,, M'j��(�1,►2 as Owner of the subject property hereby authorize -Z5-6Z 4/�/t� to act on my behalf,in all matters rela ' e work authorized by this building permit application. 7/12./,1 Signature of Owner Date SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application aze a and accurate,to the best of my knowledge and behalf. Print am 7 �t ZA Signature of Owner or Authorized Agent Date(Signed under the pains and penalties of perjury) 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 I I O.R6 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementiattics,decks or porch) Gross living area(Sq. Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths 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" VDAC Liberty ISSUING OFFICE 181 tviutual. Workers Compemation and INFORMATION PAGE Employers Liability Policy ACCOUNT NO. SUB ACCr NO, Liberty Mutual Insurance Group/Boston 1-378103 0000 LIBERTY X11+1T.AL INSUPANC'E C9 1-619 POLICY NO. TIml) SALFS OFl i('L COUI: SALES CODIi N I R WCl-31S378103.011 XX X WEST ON 102 REPRESEN"I'A'11VH 3t100 2 Yk AR ASSIGNED 2010 Item 1.Name of CHARLENE TOBEY DBA THE CHIMNEY COMPANY Insured FF.IN 27-2771208 Address 52 ORCHARD ST RISK ID 160395 SAL EM,MA 019711 Status Ol - INDIVIDUAL Other workplaces not shown above: SEE ITEM 4 Mo.Day Year Me.Dry Ye.v Item 2. Policy Period: From 06-05.2011 w 06-05-2012 12:01 AM standard time at the address of the insured as stated herein, Item 3.Coverage A. Workers Compemalion Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liabilily Insurance: Pan Two of the policy applies to work in each state listed in itern 3.A.The limits of our liability under Part Two are: Bodily Injury by Accident 1,000,000 each accident Bodily Injury by Disease 1,000,iN10 policy limit Bodily Injury by Disease 1,000,000 each employee C. Other States Insurance: Part 'Three of the policy applies to the states. if any, listed here: SEE EN D WC 20 03 06A D. This policy includes these endorsements and schedules: SEE. EXTENSION OF INFORMATION PAGE Item 4. Premium - The premium for this policy will be determined by our Manuals of Rules Classifications Rates and Rating Plans. All information required below is sub ecl to verification and change by audit. Ptmnium Baei, Rues LINE110 Per$100 r?atimamd ('ode &stiuuted ut Rr,• Annual Clacdhcaoons Vp. 'ro[al Annual Premiums o.nomtinn Prcmiuna SEF- EXTENSION OF INFORMATION PALL! Minimum Premium 5 SW ( MA ) Twat Estimated Annual Premium S 1,543 Interim adjustment of premium shall be made: ANNUAL This polity,including all endorsements issued therewith, is hereby countersigned by Amho,{xed R.om e,uodlw Date 06-15-11 Lx:Code Term. Dper. Audit nuais I Periodi:l4rymvru Haung n..,ix PM.11.6. 1 flume sma Dividend RENEWAL OF: 06-15.11 I N, I MA WCI-3113 378103-010 GPo 41131) RI Copyright 1987 National Council on Compensation Insurance WC!rl 00 rq A Broke,Copy OP ID: SS CERTIFICATE OF LIABILITY INSURANCE DATEIM 07/19/1YYV) 9/11 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(ies) 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(s). PRODUCER 978-688-7000 CONTACT Durso 8:Jankowski Ins Agcy LLC PHONE FAX 198 Massachusetts Avenue 978-688-7001 A/C No Ezt: A/C No: North Andover,MA 01845 ADDRESS: Durso&Jankowski Ins.Agcy. PRODUCER CHIMN-1 CUSTOMER ID 0: INSURER(S)AFFORDING COVERAGE NAIC 0 INSURED The Chimney Company INSURER A:Travelers Ins. Co. 19038 DBA Charlene Tobey 52 Orchard Street INSURER B: Salem, MA 01970 INSURER C: INSURER D: INSURER E: 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. 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE POLICY EFF POLICY EXP LTR POLICY NUMBER MMIDD/YYYY MMIODIYYYY LIMITS GENERALLIABILITY EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY 16802773R556ACJ11 06104/11 06/04112 PREMISES Ea occurrence $ 300,000 CLAIMS-MADE OCCUR MED EXP(Any one person) $ PERSONAL B ADV INJURY It 1,000,00 GENERAL AGGREGATE It 2,000,00 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,00 POLICY F1 JECT PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS BODILY INJURY(Per accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC A STATU- OTH- AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY PROPRIETORRARTNER/EXECUTIVE❑ NIA E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED9 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION BIDDIN1 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE BiddingPurposes THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN P oses ACCORDANCE WITH THE POLICY PROVISIONS. 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