12 LAURENT RD - BUILDING INSPECTION lU Z, The Commonwealth of Massachusetts
L Board of Building Regulations and Standards CITY
n O Massachusetts State Building Code, 780 CMR, T"edition OF SALEM
/t •V{�I �s� RevisedJannwv
II Building Permit Application To Construct, Repair, Renovate Or Demolish a /, 2008
One-or Two-Family Dwelling
This S on For Official Use Only
Building Permit Num Dale Applied: t r
Signature: + GtLc7
Building Commission r/Flasislictor of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.I 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 11) 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? Municipal❑ On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record•
Name(Print) Address for Service:
147u 7`(t{ G Io-1
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units_ Other ❑ Specify:
v Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official U Only
Labor and Materials a Use n
y
I, Building S Go 1p,00 1. Building Permit Fee:S Indicate how fee is determined:
2.Electrical S ❑Standard City/Town Application Fee
o,r7.� ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S aJ 2. Other Fees: S
• q. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S g860.O� ❑Paid in Full ❑Outstanding Balance Due:
C -Q e ewe
� r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL C5 I
(j ;`\r"CA L � � ,r License Number li.ptrat un Uate
Name ol'CSL•Ilul r v 1 1 d3&3 List C'SL"Type(see below)
[l7 Lc s q JYl J� 1CG�L� N�Y .r Description
✓ 'Y
nrestricted u to 35,000 Cu.Ft.
I re s U/ Restricted I&2 Family Dwelling
Signature V, M Masonry Only
(O; --77 oZ ' C(.370 RC Residential Roofing Covering
Telephone WS Residential Window and Sidin
Cc l( 4 C0o3-7 70-5y g$tf SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5 2 Registered Home Impprovement Contractor(HIC) 3 O�t(
h > 5 lbu(T C ric{ d-Curla�'R
IiiC Company Name or 111C Registrant Name Registration Number
I - er o3s 33 moo/O
A R
It (pg--77A-g37d Expiration Date
Signature r 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..........O No...........❑
SECTION 79: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: OWNERI OR AUTHORIZED AGENT DECLARATION
Qh,u -j d ,as Owner or Authorized Agent hereby declare
that the statements and info nation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print N
Signature of Owner or Authorized Agent Date
(Sianed under the pains and penalties ofperjury)
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 no 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 780 CMR Regulations 110.116 and 110.115, 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. 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"
1 �
CITY OF S.0 E.N[9 ANWSACHUSETTS
KI DLNG DEPutn(ENT
120 WASHINGTON STREET, r FLOOR
h+L (978) 1{5-9595
F.ut(978) 1i498M
KISIBcat FY DRISCOLL
HAYO)t INOMU ST•PIERM
DIRECTOR Of PL OLIC PROPERTY/RL'QDNG CONMOSSMER
Workers' Compensation Insurance Allldavit: Ouilderi/Contractor*E)ectrlclantiPlumbers
knnlieant Information Please Print Les ibir
VOtnd ltlurtnnaOrtarsuarienlrwhvldual►: �,��.�ncc>.�c�. .�w�`�c✓� �csr� S� �-�c..f�7e✓��I('/
Address:
City/Statdzip: C?<L td_ 1y if 03 933 Phono N: (�,cn,3— 7 7a — a 370
Are you as empisysr!Check the appropriate boa: I
Type of Project(requira W
1.[ja-1 am a cmplw with 1 4. ❑ 1 am a general contractor asd 1 R ❑New construction
ful dlor pan-time).• aa
have hired the arbcontreere
2.Q 1 am a sole pmprieta or partners listed an the anselW shcea.: '. a Re rricdeling
;hip and have no cmployem Theca sub-contraeten have L Q Demolition
working for rise in any capacity. workaa'comp insurance. 9. Q Building addition
I No workers'comp insurance S. Q We are a corporation and its I0.❑Elet trip)repairs a additions
rt*F NLI offmn have exercised their
).Q I am a homeowner doing ail work rigla ofexemprioa par MOL 1 l.Q Plumbing repain or additions
myself.[Na waken'comp a 152,f 1(41 and we haw no 12.Q Roof mpsirs
insurance required.l► employees.LNG workers, IS.QOthv
camp insurance requinAl
.Any applicant ihr dtedr W It mar MM ere and th.rrerim blow rkowiq rbdr vorkate'cornpwmWM policy inawetrlea
r t Lwwu.naa who submit ails onlewb ilVlcod"thcy an doing der work ad due him souids e'aa mono i mar whus a now a inch it idbriA/ru k
:r',mtrswrn Ihr cheek Aio lnn nogg anarlW aw alditwnd stew stewing an twtN d'rkr wdheearraeyte W thole wwrkwa'COMP.policy isawrtraaa
MEMO
I Mae ere larpleyN fhaY b pnv/dGrR WII/awl r rM�elUelf/le/MM/t1ea1 fN Ir)r/Playlli Qehw/s rM pl&p ew/Jo1 r/lr
inforNom iota
Imsurance Company Name: A C E ✓ISM+-� tC,e-
Policy M or Self-ins, Lie.M: Expiration Date:
Job Sire Address: City/statetzip:
.%track a copy of the workers'componsanon poYey deeteratlse pap(showing the polka lumbar and aaplratbaa dteb)6
h'ailurs to secure coverage is required under.Sectice 25A of MGL a 132 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties is the form are STOP WORK ORDER and a floe
of up to S210.00 a day ayainse the violates. Ito advivad that a copy of this statement maybe furwurdod to the oalce or
Iowcsoyatiuns of the DIA for insurance covcrags vcriticativa
I /a hereby certify under the-pains and pen./Net o/y1►/aq Cher the infbrworlee provided above is true and toned
"ruiec Data:
P.".one 4,
O/JlCul w1 anly. era nee wr;t1 in this Yrce, to b1.urwplited ey wiry err fawn alpriot
City or fawn:
hsuing Aulhorily (circle time):
I. Ituard of Ilrallh I. Ruildlnu Department J.Ciy/town Clerk t. Electrical Impcclor S. Plumbing Impactor
6. Other
l..,ntact Pcrton: _ __ Phone M•
'S CITY OF SALEM
• PUBLIC PROPRERTY
�• DEPARTMENT
I'.11: MII1 '•M Iv 'l l
\I W:T O$.%II M.MAN"
141:'L78•7439395 01:%X:9111J4'Is46
construction Debris Disposal Affidavit
(required 1'ur 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 q _ 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:
mc-u) P1SPil-moC3
puma of halklerl
The debris will be disposed of in
(nrrnt ul aci tty .
laddreme of facility)
Signature of lxrn t applicant
date
massachusctts - Dcpalrtmcnt of Public Sjdets'
Board of Building Regulations and Standards
Construction Supervisor License
License: Cs 69481
Restricted to: 00 •,
I
RICHARD L JALBERT I k
10 LANGDON AVE
EXETER, NH 03833
Expiration: 1/10/2011
(',nnmissi,mrr Trtt; 9156
,p� �/ee V/09)NSNYl1lL�Ba[l/{ o�✓�ladda��e�ide(ld
�\ Board of Building Regulations and Standards
-i HOME IMPROVEMENT CONTRACTOR
= Registration:,, 130643
Expiration:-4!5/2010 Trig 268450
,;,.,. ....M1Tm: DBK
RICHARD JALSERTCONSiR:B�CARPENTRY
RICHARD JALBERT`,, 31..
10 LANGDON AVE ;:'•ate
EXETER,NH 03833 "-' Administrator
s
04/06/2010 11:36 FAX 603 772 3246 FOY INSURANCE EXETER _ Q 001
ACORDN CERTIFICATE OF LIABILITY INSURANCE DATE(MMIOD)YYYY)
PRODUCER 603.772.4781 FAX 603.772.3246 04/06/2010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Foy Insurance Group - Exeter ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
64 Portsmouth Ave HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
PO BOX 1030 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Exeter, NH 03833 INSURERS AFFORDING COVERAGE NAIC#
INSURED RTchar Ja bert INSURERA: Concord General Mutual Ins Co 20672
10 Langdon Avenue INSURERS: ACE Property & Casualty Insuranc
Exeter, NH 03833 NSURER C:
INSURER D'.
INSURER E:
COVERAGE
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' TYPEOFINSURANCE POLICYNUMBER POLICY EFFECTIVE POLICY EXPIRATION
uM rs
GENERAL LIABILITY E629044-2 07/15/2009 07/18/2010 EACHOCCURRENCE $
X COMMERCIAL GENERAL LIABILITY SOO,O
DAMAGE TO RENTED 50,0
A CLAIMS MADE OOCCUq MEDEXP(Any-re Person) $ S,OO
PERSONAL&ADV INJURY S SOO,OO I
GENERALAGGREGATE $ 1,000 O
GENT AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG $ 1,000,000
POLICY JEOT LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT
ANY AUTO (Ea accident $
ALL OWNED AUTOS
SCHEDULED AUTOS BODILY INJURY
(Pw Person) $
MIRED AUTOS
NON-OWNEDAUTOS BODILY INJURY $
(Pwa Ic nt)
PROPERTY DAMAGE S
(Pwacddenl)
GARAGEUABIU
TO A
ANY AUTO
AUTO ONLY-EA ACCIDENT $
OTHER THAN EA ACC $
AUTO ONLY: AGG S
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE S
OCCUR ❑CLAIMS MADE AGGREGATE $
DEDUCTIBLE
RETENTION $ $
WORKERS COMPENSATION AND NWCC45827239 08/31/2009 09/31/2010 X WCSTA'D- OTH-
EMPLOYERS'LIABIL[TYANY ; STATE: NEW HAMPSHIRE EL.EACH ACCIDENT S ZOOO
B EXCLUDED?OFFICERIIMREIMBERED E
EXC UDED: RICHARD JALBERT
If yea,d.imbe under E.L DISEASE-EA EMPLOYE $ 100 OO
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT I S S00,00
OTHER
DESCRIPTION OF OPERA ONS)LOCATIONSIVEHICLESI EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
Aerations usual and customary for a Carpenter
E: Project at Mrs Jalbert's Residence
CETIFICATE HOLDER ELL
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL
Salem Mass Building Department 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,
Attn: Thomas St Pierre BUT FAILURE TO MAIL SUCH NOTICE$HALL IMPOSE NO OBLIGATION OR LIABILITY
120 Washington Street OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Salem, MA 01950 AUTHORIZED REPRESENTATIVE
Gar Rohr CIC/ENANCY
ACORD 26(2001108) FAX: 111,740,1146 OACORD CORPORATION 1998
04/06/2010 11:37 FAX 603 772 3246 FOY INSURANCE EXETER Z 002
r
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
The Certificate of Insurance on the reverse side of this form 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.
r
ACORD 25(2001108)