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15 LAURENT RD - BUILDING INSPECTION (2) a� The Cunununwralth Of Alassachusetls ----1 V` t\ BOard Of Building Regulations and Slandaids F( )It �II �I( II' \I III tilassarhuselts St:to Building ('Ode. 7ti(1 ('t1R. 7 rJi(iun ll, Building Pet ,Application To Construct. Repair. Renovate Or Denioli.h a R, i o,d hom.i, t Onr- or Tito-l-tunih lhrrllin,q -',It - 1 this Section For Official Use Only - 1 Building Permit N� cr Dote Applied: 6 /O Z±--_--__-- ----- - HuJdmg ('ununn .p"lor ul But Wines !Jute SECTION 1: SITE INFORMATION — — -- 1 1.1 Properly address: 1.2 .\ssessors Map & Parcel 'Numbers f.la ! ti s i i uc, to i _m. rt" src+ ru 91 n Numher P:ue \ inhr• . I t.i ;! i r u:af.n,t' i 1Y.rprt v toocas. o %s: ..,. Zoning District Proposed Use Lot 3na Isy..•U FFuntaec (It) 1.5 Building Setbacks (ft) j Front Yard Side Yards Rear Yard ! Requited Provided ReyuueJ Provided RCyuimJ Pru,iJCJ �I F ly: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal S)stem: Zone: _ Outside Fltlud Zone? Nlunici aI ❑ On .ne disposal s ,icm ❑ ate❑ Check if yes❑ P I }� SECTION 2: PROPERTY OWNERSHIP' ecord: t, 9a_� Address for Service: I j Sign.wre Telephone SECTION 3: DESCRIPTION OF PROPOSED `.'.%ORK2 (check all that apply) New Construetiun Sting Buiiding ❑ Owner-Occupied ❑ Reu:urslsl ❑ Alteration(s) ❑ 1JJinun� w - - ---- - --=-- � De.nuii:ion ❑ .Accessory BIJg ❑ Number of Units Other ❑ Speedy. - 8:icl Descriptiunuf Proposed Wurk'': _ --- ------ �------ - 17 -- - I � ��(/11.__.. .Lf��l`G�ZCOI�' rSECTION J: ESTIMATED CONSTRUCTION COSTS ItemHatfmated Cults: Official Use Only yJl (Labor and Ma(erials) _ F2. uilding $ I. Building Permit Fee: $ Indicate how fee is deicnnuted: -F-" ❑ Standard CitylTuwn Application Fee I $lectriw ❑Total Pmject Chat (ttem 6) z multiplier xumbing '� 2. Other Fees:echanical (HV:\C) List:echanical (Fire ,� -- Total All Fees: $ suppression) I �— Check No. ?,eck Amount: -1�(�ash :\muunc b fowl Pr(/Je'l'l COSI�S�rp,,./l�J) ,.� ,,VP id in Full 0 Ouutanding Bal:mce Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supersisor (CSI.) D `7 3375 Lrcnse N'umher F.spu.Iliou U.1w Namc of ('SL Molder Lot CSh T%pr Ise, hcluw 1 ____ -- p F re Ihzcn )uon \JJrrs> l fit estl Iced I up to 35.(H)O Cu 1:1 1 — ('I )- 6 ' o"�—� ��Q''J R Re,tomed 1@2 FamlhS11,11at..I, Dw ellinc RC ResiJrnual Roohnc(lncnne helephone \1'S ResiJ.'niial \\'i ndu„ .u:d SiJine Sh ResiJenu.Il .Solid I icl Burlunc \pl,h.m.: Im(.ill.ni,a, I G179- -Y) t4 ' 3/7 D ResiJcnu.Il Unnoluwn --_ 5.2 Registered Ilorne Improvement Contractor (IIIC) to � � HIC Conyru 'ame or fIIC Re (rant Nte Reglsrauon Nunlhe�__ J 7of9 Addre,�Zf/�Jl��n �f -+ F;a{n raiwn U;ue Signature elephone SECTION 6: WORKERS' CONI NSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C•(6)) Workers Compensation Insurance affidavit must be completed :md submitted with this upphcation. Fatlure to pn,vde this affidavit will result in the denial of(he 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 as Owner of the subject property hereby authorize to act on my behalf. in all m:Itiers relative to work authorized by this building permit application.. Si nature of Owner Date SECTION 7b: OWNER, OR AUTHORIZED AGENT DECLARATION 1• , as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Pant Name Signature of Owner or Authorized .Agent Date (Signed under the pains and penalties of er u ) NOTES: I. An Owner who obtains at building permit to do his/her own work, or:In owner who hires an unregistered contraclnr (nut registered in the Hume Improvement Contractor(HIC) Program), will not haee access to tre at hin ation program or guaranty fund under M.G.L. c. 142A. Other important infoimation,m the [I IC Pmer:un and Construction Supervisor Licensing (CSL) can be t0LInd in 780 CNIR Regulations I l0.R6 and 110.R5. respectocly ' When substantial work is planned, provide the information below: Total floors area (Sy. Ft.) (including garage. finished basement/atncs, decks or porch, Gross living area ISy. Ft.) Habitable room count Number of fireplaces Number of hedronms Number of h.uhnuans _ Number of Imit/haihs -hope of hearing system - Number nt decks/ pr.rchcs _-_-- Type of cooling system li nc Inset —___ Opcn 2 'Tolal Project Square Footage- may be ♦tlbstltuied for Fatal Project Cost- J� ST��EA)s Tyefp o G,ZedN Doozs f�JaECri�°AD CITY OF SALEM PUBLIC PROPRERTY v, DEPARTMENT ,. ,. . \\.\iIII]\�.i`N%1141 rT ♦ S.%IIM, \I.\Ii.V :.. I I -I'I.1: '1,'8-'ii`)j9i ♦ 1'\S: 974.174-.9/ 46 Construction Debris Disposal Affidavit (ra.luired lbr all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 Cb1R section 111.5 Dcbris, and the provisions of MGL c 40, S 54; Building Permit ik is issued with the condition that the debris resulting front di this work shall be sposed of in a properly licensed waste disposal facility as defined by MGL c l 11. S 150A. The debris will be transported by: (name of hauler) I Ire debris will be disposed of in (name of facility) (address of tacilitvl MN vn' m'c of permit applicant date - --. CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT :,I.nf:Bi.I:Y i)K IsC,n.l. A st to 12C WASHING I ONSI`Ren)' • SAI.L'S4,M.\SSACIn Sc I-is G197C 978-745-9595 • 1':vx:978.?41^.')846 Workers' Compensation Insurance Affidavit- Builders/Contractors/Electricians/Plumbers Print Le :%u )licant Information Valne (Bucincs5 Orgeiblv anization Indyu//real): yn s Address: Cilyistatei/sip: © / 2�3 Phone r': 0179--7- L 3333 Are you an employer! Check the Appropriate box: Type of project(required): i ❑ New construction 4. ❑ 1 am a general contractor and I I.g 1 ant a employer with CI III (full am.Vur purl-time).` have hired the sub-contractors 7t. . El Remodeling ).❑ I :mn a sole proprietor or partner- listed on the attached uhcec t ship and have no em ployees These sub-contractors have 8. ❑ Demolition working me in any capacity. Workers' comp. insurance. 9_ ❑ Building addition ❑j. We are a corporation and its [No workers' comp. insurance. officers have exercised their 10.❑ Electrical repairs or additions required.) I I. Plumbing repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per ry ❑ S P' myself. [No workers' ctnnp. C. 152, §1(4),and we have no 12.❑ Ruufrepairs ees cin t ploy . LNo workers' - 13. insurance required.] ❑ Other comp. insurance required.] -any.ggilicant that checks box ill must also rill um the secli.it Wow showing their works cumpensation policy inlinmalion. t I rumeuwners who submit this affidavit indicating they are doing all work and then him outside contmetors mint submit a new air'.'avin indicating such. that chuck this lox must attxhcd an additional sheet showing the none of tire Sub<onrroctors and their worker'comp.policy informntiun. 1 nmr con employer that is providing workers'compensation hr.curance for my employees. Below is the pulley and job site itrfonnurion. Insurance Company Name: ( fh7 C,,-- ud I'olicv 4 or Self ins. Ltc t:: A vl EU Z -� _— Expiration Datz: Job Site Address; j� -� �t7 _,A+— City;Stateizip: —J 4;1 1 An ' Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). huilure to secure coverage as required under Section 25A of.%IGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one-year imprisonment, as well as civil penalties in the Toren of a STOP WORK ORDER and a fine Of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Iaveatigarious of Lhc DIA for insurance covcra'c verification. l do hereby certify under the pains and penalties of perjury that the imfonnation provided above is true alai correct. Datc Pht'oc I official use wily. Do nor vo-he is this area,to be completed by city or town offiriui City or Town: Permit/License X__._.. Issuing :\uthority (circle one): 1. 11,ard of llc:dth 2. IAtildin; Deparuncut .i.City/town Clerk 4. Electrical Inspector 5. plumbing Inspector 6.Other ---- - Contact Pcrsou: ---- - __.__ Phone tl: � r j Information and Instructions ;Massachusetts Gencras Laws chapter 152 requires all employers to provide workers' compensation fix their employees. Pursuaint to this statute, an einpluree is defined as"...every person in (lie service of another under any contact of hire, express or implied, oral or written." An em r/oyer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more Of the tJreLoing engaged tit Joint enterprise,and including the legal representatives of a deceased employer,or the receive�,r or trustee of: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 rl�ne grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." NIGL 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, 'vlGL 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 GII out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if necessary, supply sub-contractors) nanme(s), addresses) and phone number(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 employ I ees,apolicyis required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confimnation of insurance coverage. Also be sure to sign and date the affidavit. The aff idavit 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 tine. City or'rown Officials Please b 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. l'Icase be sure to till in the pennittlicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current policy it If'ormation(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 todie - applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Wlierc a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. it doig license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Oitil u tit lovestigations would like to thank you in advance for your cooperation and should you have:my questions, please du not hesitate to give us a call The Depaknncnt'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-NIASSAFE advised S-�G-us Fax # 617-727-7749 www.mass.gov/dia .4CORD_ CERTIFICATE OF LIABILITY INSURANCE 14 D 5/27/08 HFOP ID C DATE ( 27 OB O • PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Thomas Gregory Associates Inc. HOLDER. THIS CERTIFICATE DOES NOT.AMEND, EXTEND OR 601 Edgewater'brive S235 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Wakefield MA 01880 Phone: 761-914-1000 rax:781-246-2601 INSURERS AFFORDING COVERAGE NAIC0 INSUMD INSURERA: Arbella Protection Ins. (A) INSURER 8 HB' Murphy Plumbing a Heating, INSURER C: Inc 6Hrowns Kitchen 6 Bath Inc 72 Holten Street INsuRERD: Danvers MA 02923 INSURERE: 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. LTR NS TYPE OF INSURANCE POLICY NUMBER DATE MMID DATE MMIDD LIMITS GENERAL LIABILITY E ACHOCCURRENCE $ SO OOOOO A X COMMERCIAL GENERAL LIABILITY 6500025389 06/01/08 06/01/09 soa:vrence) s 300000 CLAIMS MADE X❑OCCUR Y ore Pam) $ 5000 AOVINJURY $ 1000000GREGATE s2000000GENL AGGREGATE LIMIT APPLIES PER: COMP/OP AGO S2000O00POucv JJECD} Loc n. 1000000 AUTOMOBILE UAIMLITY COMBINED SINGLE LIMIT $ 1,OOO,OOO VXOCCLJtMFZTB ura 99770400002 06/01/08 06/01/09 (Es ecadeM) WNED AUTOS BODILY INJURY s (Per person) DU.EOAUTOS AUTOS BODILY INJURY S (Per ecadeN) OWTIED PUfOS PROPERTY DAMAGE S (Per ecadet) LIABILITY AUTO ONLY EA ACCIDENT $ AUTO OTHER TITIAN EA ACC $ AUTO ONLY: AGG s IFBRELLA LIABILITY EACH OCCURRENCE s10000 00 UR cLAIMSMADE 4600025390 06/01/08 06/01/09AGGREGATE s 1000000 UCTIBLE' 10" 510000 s WORKERS COMPENSATION AND X TORY LIMBS ER A EMPLCYERS•LIABILITY 9095020607 06/01/08 06/01/09 E.L EACH ACCIDENT $500000 ANY PROPRIETOWFARTNEWEXEOnIVE OFFI(IERNEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE 1500000 II Yes,describe under E.L.DISEASE-POLICY LIMIT $5 0 0 0 0 0 SPECIAL PROVISIONS be. OTHER DESCRIPTION OF OPERATIONS I LOCATIONS 1 VEHICLES 1 E%CLUSIONS ADDED BY ENDORSEMENT 1 SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION OOOOOOO SHOULD ANY OF THE ABOVE OESCWBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MILL DAYS WRITTEN NOTCE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL To Whom it May Concern IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER ITS AGENTS OR REPRESENTATNES. AUTHOWIBD SEMA ACORD 25(2001I08) - - 0 ACORD CORPORATION 1988