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51 LARCHMONT RD - BUILDING INSPECTION (3) nce Commonwealth of Massachusetts 3 Board ol'Building Regulations and Standards CITY g u OF SALEM Massachusetts State Building Code, 780 C'MR, 7 edition ReviseJJunmr!r Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Num r. 4 1 Dale Applied: !' Signature: 7 4L .12 Buildi g t"GinmissItyV In for of Buildings I}ute SECTION 1:SITE INFORMATION 1.1 Pro a ddress:frof7g1.2 AssessorsMap& Parcel Numbers \ Pus PN / I A a Is this an accepted street?yes no Map Number Parcel Number IJ Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(11) 1.5 Building Setbacks(R) 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: 1.3 Sewage Disposal System: Public❑ Private O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: S L Gif �A/ y X Q� ,W .e b 5.st77=yy�I /rI.¢ ��/ O Name(Print) A dress for Service: CrANZl Nu 6Tr FV �'79 / 1007 Signal T lephone SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ 1 Owner-Occupied Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify: Brief Description of Proposed Work': _ 1 . / SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Omclal Use Only Labor and Materials 1. Building S 1. Building Permit Fee:f Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 1. Plumbing S 2. Other Fees: S 4. Mechanical (IIVACI S List: 5. Mechanical (Fire S Su ression Total All Fees:S Check No. Check A Count: Cash Amount: 6. Total Project Cost: S 9�� ❑Paid in Full ❑Outstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) pE � I� l.icense Numbs I:.vpirutiun Dale f� �1A Name ul'C�1 •I IulJer tor-Zl9,q List l'SL f)pe(see below) `'�/ ✓�/ ay �rOg /Y" f Deuri ion Address t% U Unrestricted u to 35.000 Cu.Ft. Restricted 132 FamilyDwellin Signa re ns� �/. 9. M masorwy(MI RC Residential Rooling Covering 1'deph ne WS Residential Window and Sidin SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition S.2 Registered Home Improvement Contractor(HIC) l IIC Company Name ur)IIC Re slrant Name Registration Number bill P Address es t ©r�o y . ) 97g imo7 Expiration iration Date Signature releptione 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. f 2SC(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 ..........O No...........O 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. - Si mature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 1 ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application arc true and accurate,to the best of my knowledge and behalf. Print Name Signature of(honer or Authorized Agent Dale (Siwwd under the pains and penalties of '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 W have access to the arbitration program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 IO.R6 and 1 IO.RS,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch) Gross living area(Sq.Ff.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half7baths 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" 'y COUTO PAINTING & CARPENTRY 4 Hudson st, Apt #1 Lynn, MA — 01904 (978) 979-1007 www.coutofinest.com coutopainting@yahoo.com ESTIMATE Gary Barrett 51 Larchmont rd Salem, MA 01970 Deck Demolition and removal of the old porch. Install 7 new footings, 3 under the center beam, and 4 on the outside rim. The footings will be 4 feet deep, and concrete poured into 10 inch sonotubes. The framing for the deck will be W joists, and a triple 2x10 beam. All joists will have joist hangers. The apron joist will be lagged into the house using 5 inch lags 32" on center. The flashing will be copper. The decking will be l x4 fir, the railings will be fir 4x4 posts with 2x4 fir rails and 2x2 Fir balusters spaced approxamatly 4 inches on center. Lattice will be installed around the outside edges of the deck with 1 x4 trim on the bottom and corners, and 1 x8 trim just under the decking. There will be an access door next to the bulkhead, and stairs to the driveway just after the door. The stairs will have railings. All materials will be pressure treated wood, unless noted Repair siding and soffit trim as needed. Total Price $ 8410,00 rti Back door removal and installation of new door and storm door is $ 500.00 The doors are to be supplied by owner. Couto Painting will provide all other materials If you have any questions, please give us a call. TOTAL: $ 8,910.00 Payment terms will be $ 4000.00 at the start of the job and the balance upon completion. al „o Reslrr 4 on h � l cenec .t/ r� / Q^'gR J"inR�j�l/� l cJLVt ; Cg 10, ° A7 2374,1/ SA@/iya ADFM/ .r/�Uor;.3 533 R@V @R ' Mg 0 SAO 9PTQ9q G Y RF3;'t'q FR iA(o J^giv ue/ ln: VFRF / q OzjV J r49 g r.,,n,gi.vigq,� T i2/i �� 1 01 8S0 12 ,acoRo® CERTIFICATE OF LIABILITY INSURANCE ��8�2010 , PRODUCER (9:78) 532-5445 FAX: (978) 532-2217 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION B.K. McCarthy Insurance Agency, Znc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 10 Centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Entrance Peabody MA 01960 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Sentinel Ins Co LTD 13000 MOISES COUTO DBA COUTO PAINTING INSURER B:Hartford Casualty Ins Co 1911 4 HUDSON STREET APARTMENT #1 INSURER C' INSURER D: LYNN MA 01904 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 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD'L POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION MMIDDMYYI LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000 t 000 DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES(Ea occurrence)_ A CLAIMS MADE 1z OCCUR 08SBAZP9095 5/27/2010 5/27/2011 MED EXP(Any one person) $ 10,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000 X POLICY PRO LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY A (Ea accident) $ UTO ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident $ PROPERTY DAMAGE $ (Per accident AGE LIABILITY AUTO ONLY EA ACCIDENT $ 7R ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ E%CEBB I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ B WORKERS COMPENSATION 7WC V IMIU- OTH-I FIR AND EMPLOYERS'LIABILITY YIN ANY PROPRIETOR/PARTNER/EXECUTIVE❑ E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED? - (Mandatory in NH) OBWECLF5357 5/27/2010 8/16/2010 E.L.DISEASE-EA EMPLOYE $ 100,000 If yes,describe under E.L.DISEASE-POLICY LIMIT $ 500 000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS f V EHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Refer to policy for exclusionary endorsements and special provisions. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OFTHEABOVE DESCRIBED POLICIES BECANCELLED BEFORE THE EXPIRATION Maurice Martineau DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN 29 Harbor Street NOTICE TOTHE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL Salem, MA 01970 IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE '�/_` /> n Sohn McCarthy/LG4 ,�i ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. INS025(200901) The ACORD name and logo are registered marks of ACORD IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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). DISCLAIMER This Certificate of Insurance does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2009/01) INS025(200901) CITY OF SALEM PUBLIC PROPRERTY y . .�tt• ;II�I �. its, DEPARTMENT '..I4It;RI I:Y DRI"Ct LL x-lart'R 12C.WnsHI.\i.10,N SIRELT 0 SALEM,MASSACIII SE I IS01970 rta.:978-745-9595 • pax:978.740.9840 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers 3 licant Information Please Print Leeiblv Ni tric tl3ucilxss/OrB3nizatioNlndividuap /+W� : ✓ ° � Address: Y2�A 50ti At- :;O I City'Srarei%ip: GYNti ,/V A- I Phone Are you an employer'.' Check the appropriate box: 'I'ype of project(required): I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 G. ❑ New construction employees full and/or art-time).` have hired the sub-contractors l Y ( P' 7. ❑ Remodeling 2 I am a sole proprietor or partner- listed on the attached sheet. -19 ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity, workers' comp. insurance. 9, ❑ Building addition To workers'comp. insurance 5. ❑ We are a corporation and its � 10.❑ Electrical repairs or additions required.] officers have exercised their right ofexem exemption a MOL 11.❑ Plumbing repairs or additions 3.❑ I um a homeowner doing all work S P P' myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t cmployces. (No workers' 13.0 Other comp. insurance required.] -Airy;yplicant that chucks box dl must also till out the ection hYow showing(heir wurkur cumpensatiuo policy information. ' I lomcuw'm:rs who submit this affidavit indicating they are doing all work and then him uutside contrneton mutt euhmit a new al'fdavil indiuling such. �Conoti tors that check this box must attwhed an additional sheet showing the name of ttat subcontractors and their wurkam'comp.policy infurmariun. I ant an employer that is pro viding workers'compensation insurance for toy employees. Below is the pulicy and job site information. I nsurance Company Name:-- 2T. . ..C= ,,4-��---t ----�y�'� � Policy 4 or Self-ins. Lic. In: ___,.----- Expiration Dade: Job Site Address: City/Stateizip: Attach it copy of the workers' compensation policy declaration page(showing the policy number and expiration date). pailuro to secure coverage as required under Section 25A of`1GL 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 S250.00 It day against the violator. Be adviscd that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and perrahics of perjury that the imfarinution provided above is true and correct. Sic•rtlnrc. l 1)-is', flume?: Official use ditty. Do not sprite in this area, to be completed by city or town dffic•iaL City or Town: _ Permit/I.iccnse X_____ Issuing Authority (circle one): 1. Board of llcalth 2. Building Department 3. Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Peron: --_ _ - ---- Phone tl: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pnf]Uatrt to this statute,an einplgvee is defined as"...every person in the service of another Under any contract of hire, express or implied,oral or written.- An einploxer is defined as".an individual,partnership,association,corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee uf:n individual, partnership, 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 on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or renewal of a 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 contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please Fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary,supply sub-contractor(s) namc(s), address(es)and phone nuniber(s)along with their certificate(s)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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned 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 for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Plcase be sure to fill in the pennitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple pennitllicense applications in any given year,need only submit one affidavit indicating current policy information(if 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 tilled 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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. Thu Oliice of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number - The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM r PUBLIC PROPRERTY DEPARTMENT \I11` l rl 'G8-N9 9;;)5 • I AN:77S"74:"9846 Construction Debris Disposal At'tidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CN1R section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit i1 . -" is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: C K I name of hauler) I'lie debris will be disposed of in ILJOa�f�_Sr A (name /ull facility) (adtfress of facility) " signature of permit applicant Cr7 2 0 date --- Jrhn.�tl do.