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112 LEACH ST - BUILDING INSPECTION -* l < � S � �0-1z) The Commonwealth of Massachusetts CITY OF A Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR Revised:Liar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Officia se Only Building PermitNumber: lbate pplied: Building Official(Print.N:une),- - - Signature( Date SECTION fiSITE INFORANIATION 1.1 Propert Address: L2 Assessors Map& Parcel Numbers _ri.2 x�C S7— I.la 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(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if yes[] Municipal❑ On site disposal system ❑ SECTION2; PROPERTY OWNERSHIP' 2.1 wnert of Record: �L 04?rt /Ww z C.O/r elle m (Print) City,State,ZIP 4/ ST �r 70p— 9-29 —e &g& No.and Street Telephone Email Address 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. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work': L 37 1✓iiG /�e�/.yu�ro..../ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs:Labor and Materials) Official Use Only I. Building S Q�`'�/' 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x d. Plumbing S 3. Other Fees: S 4. Mechanical (FIVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees: $ Check No. - Check Amount: Cash Amount 6. Total Project Cost: $ ❑Paid in Full 11 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /��-�—� � �07 Pz „ /�/y License Number Expiration Date Name of CSL Holder L"t 9r List CSype(see below) / CC No. and Street Type Description ` U Unrestricted Buildin s u to 35,000 cu. ft.) &iel✓ R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Ivlasonry RC Roofing Covering WS Window and Siding - C SF Solid Fuel Burning Appliances 1 I Insulation Telephone Email address D I Demolition 5.2 14tgiste'redd Home Improvement Contractor(HIC) f xV Olp�eer C- 8�-1/`7 1-I1C Registration Number Expiration Date HIC Cun, Name or HIC Regislm�Name f 6 (doz=. S'� � No. and Street Email address /� - ,. ,, a,rz1 97"F-2;SK o�rf fit /Town, State,ZIP 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 PERNIIT` 1, as Owner of the subject property,hereby authorize t4 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED.AGENT DECLARATION- By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Prim Owner's or i torized A yen ' mne(Electronic Signature) Date 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. I42A. Other important information on the HIC Program can be found at www.massj_ov'oca Information on the Construction Supervisor License can be found at www.11lass.go0d0s 12. When substantial work is planned,provide the information below: Total floor 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:1IY-M. lLASSACHI SETTS ©L'ILDLNG DEPART\I);NT 120 WASHLNGTON STREET, 3'a FLOOR �3Mta T EL (978)745-9595 F.+x(978) 740.98.46 KI.\fBERtRYDRISCOLL THo,% SST.PlERRz MAYOR DIRECTOR OF PUBLIC PROPERTY/BCIIDL`IG CONL\IfSS[ONER Workers' Cotnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers �hlilicant (n(ormatton Please Print Legibly Nalnc(0suinss,Organization/Individual):4J/9l2#o��rrcc. (_• ���s Address: S-Z C�9-�Z Si City/Statc/Zip:g04 ve,-A✓ Phones l: Are you on employer?Check the appropriate box: Type of project(required): I.❑ 1 am a employer with 4. ❑ I am a general contractor and f 6. ❑Now construction ntployees(full and/or part-time)' • have hind the subcontractors 2.Xam a solo proprietor or partm r- listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These subcontractors have 8. ❑ Demolition working,fur me in an capacity. workers'comp.insurance. 9 y p ry. ❑Building addition (No workers'comp.insurance 5.0 We are a corporation and its . requircti.) officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MOIL 11.❑Plumbing repairs or additions myself(No workers'cump. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t employees.[No workers, Il.❑Other comp:insurance rcquirtid.) •Any applicant that chtsks box e1 must also fill out the scaluo below showing their waken'compensation policy information. '1 ri"downem who submit this adobe t indicating they an doing all work and that him outside contractors most submit a new affidavit tndiasing such. :Cammeton that chwit ibis box most arachod an additiunul+hest showing the name of the nbrvmractors and their workers'comp.policy information. l urn am entployea'that It pravldbig workers'c omptwsadon htsurance for my employees Below/s the poiley attd fob site inforarullon. n� l� �y!1 C- insurance Company Name: ��7y a P Nolicy 4 or Sclf•itu. Lic. 0: / W 7d26.2/apD/.ZO!•f Expiration Date: 4:5 2�U�—I�y Job Site Address; //Z �cix� ST City/State/zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration slate). Failuru to sccuro coverage as required under Section 2JA of 4IOL c. 152 can lead to the imposition ofcriminal penalties of s tine up to SI,500.00 und/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and aline of up to S2210.00 a day against the violator. Ile advlscd that a copy of this statement may be forwarded to the Oflied of Invesligutiuuv ul'thc DIA for insurance covcmge veriticatiurL l do hdreby ctrrlfy raider ilte pulrtt and penal/lds o perjury that the hrfarawallon provided above is true and carreca � Dato: �— -7 Sianunrc• a � Phone 4• / 7,` !r7�rI' d J r/ . UJ/icia!use only. Oa not write in this area,to be completed by city or towns ajfle(uL I City orTuwn: Issuing,%ulhurity(circle one): I. Board of licailh 2, fluildinq Deparhnunt 3.Cityi rown Clerk 4. Electrical lmpectur i. Plumbing In.tpeetor 6.Other Contact Peevua: Phpnoth ( CITY OF SAL.EM. TNLkSSACHUSETTS BUiMLNG DEPARTMENT a• 120 WASHNGTON STREET,3° FLOOR TEL (978) 745-9595 FAx(978) 740-9846 KI,.%tBER >=Y DRISCOLL T MAYOR DIRECTOR ST.PiEitRns DIRECTOR OF PUBLIC PROPERTY/BLILDNG COSLUISSIONER Construction Debris Disposal Affidavit (required for 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# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of h uler) The debris will be disposed of in : (name of facility) (address of facility) c! signature of permit applicant date ams�+r.d.w HIC N 126-356 ®[D �utonp �itilDerg, �Jt�c. 13 SEWALL STREET r PEABODY, MA 01960 OFFICE: 978.922-6120 SPECIFICATION SHEET _ Home Phone; ,� `g Ou nets Nane /'/'�A'/�ems!.! ~. . . . . . , . , . . . Rork Phone: . . , . . . . . . 1 . 1 City . . . . . . _ . . . . . Slate . . . . . . . . . Za'p . . . . . . . . . Job Address .'. �. Z,,. . . .'�.'-:-x!r! . . . . . .:, . . . . . . . . . . . . . . SIDING 1.Siding Type. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . Wdrh . .. . . . . . . . . . Color, . . . . . , . . . . . . . . . 2.Area to be dose. Main House. . . . . . . . . . . . . Breezeway. . . . . . . . . . . . . Garage. . . . . . . . . . . . . Additions . . . . . . . . . . . . . . Dormers Other .. . . . . . . . . . . . . . . .. . . . . .. . 3.Insulation. . .. . . . . . .' . . . . . . . . . . . . . . . . .. . . . .. . .. . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . . . . . . . . . 4.Trim cover ❑Yes O No Color.. . . . .. . .. .. . . . . . . . . Trion to be done: Sous.... . . . .. . . . Fascia. . .. . . . . . . . . . . Rakes.. .. . . . . . .. . . . . . . . . . . . . Ceilings. .. . . .. . . . . . . . . . . . . . . . . .... , . . . .. . .. . . . . . .. . . . . . . . . . . . . . . .. . . . . . . . S. Window and Door Frames . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . .. . . .. .. . . . . . .. . . . . . . . .. . . . . . . . 6. Gutters and spoors O Yes ❑No Use heavy gauge seamless. . . . . . . . . . . . . . . .. . . . . . . . .. . . . . Color. . . . . . . . . . . . . . . . 7.Shutters 0 Yes O No . . . . . . . . . . . . .y/y . . .. . . . ' 8. Wrndows rind Doors . . . . .CZ..G'. ���7Z^t' 33. c..-�..�,.-G.vr. . � Z1p �'w� ��ROOF/NG ��%.�/`�'ff,W' F�� «-�-1/�'i �t� r✓ [/ate. MaterialType . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . .. . Color . . . . . . , . . . . . . . . . . . . . . . . . Areasto be done. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . .. . . . . . . . . . . . .. . . . . . . . . .. . . . . . . Remove existing shingles O Yes O No 15 lb.felt. . . . . . . . . . . . .. . . . .. . . . . Metal Edging . , . . . . . . . . . . . . .. . . . . . . . . . . Chirnnevand vents, etc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . NOTES. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . .. . . . . . . . . . . . .. . . . . . '. . . . . . .... . . . . . . . . . . . . . . . , . . . . :. . . . . . . . . . . . . . .. . ... . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . , . , , . , , . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . .. . . . . ... . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,`,. . . . . . . Deposit Material all labor to cost $. . .�l1..�. . . . r. 1 . . . . .payable as follows: St. . r777 . .1st Instaihnent DO NOT SIGN THIS DOCUMENT IF THERE ARE ANY BLANK SPACES. $. . (}7/�y,rd Instaihnent $. .��(�l.:C/. .6alalce on completion Contractor will do all said work hr a good wnrkmanshlp manner. You may cancel this agreemenz if ithas been eorrammared by aparty thereto at a place other than all address-of file seller, which may he his muhh office or branch thereof,provided ivsa nntifi-the seller in wrlNng at his main offh'a or branch ifs•onlinun•nail polled.by telegram,sent or by delhuns not(aler dam eoithtfght of the third bminess dal foAmvbhg life signbig of tills agreement. IN IYITNESSIrHEREOF, fire ltitr'es hove heremmn signed their manes this. . . . . ( day . . . . . . . . r . . . . . . . . . . . . . . . 2u. signe .Arrpte . . . . . . . . .(.'.�. .dD [op t erg, Inc. Signed. . . . . . . . . . . . . . Owner / ner . . . . . . . . . . . . . . . . . . . O Per. . . . . . . . . . . . . . . . . . . . . . . Representati e Authori:.ed Rep. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 91 ikeh.labor dApnres, owletnemt w edther or material supplier delacs resulting in work uappaye am betnnd the unarol r f the rompanv. rvC1% 1 IrmVm 1 G Vr ii-imm LI 1 1 1 0612112013 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(les) 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 Phone:978-777-9394 CONTACT Dan Hurley Dan Hurley Insurance Agency -PH NAME, FAX Chestnut Green,Suite 24 Fax:9T8.7TT-3306 we No Exl;978-T77-9394 ac NOV.978-777-3306 Seven Federal Street E-MAII den hurls insurance.com Danvers,MA 01923-3620 ADDRESS: Daniel J Hurley INSURERS AFFORDING COVERAGE NAIC 0 INSURERA:AIM Mutual Ins.CO. INSURED Kiley Brothers Construction INSURER 8:Preferred Mutual 15024 Bartholomew Kiley DBA I INSURER C: 56 Conant Street Danvers,MA 01923 INSURER D: INSURE E: INSURERR 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 D POLICY NUMBER MMIDDIYTYY MM FXP LTR /LICY EFF POLICY D/YYYY LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 300,00 B X COMMERCIAL GENERAL LIABILITY CPP0100564252 10H6/2012 10/16/2013 PREMISES Ea occurrence $ 100,00 CLAWS-MADE XO OCCUR MED EXP(Any ors,person) $ 5,00 PERSONAL S ADV INJURY $ 300,00 GENERAL AGGREGATE $ 600,00 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGO $ 600,00 POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accident) $ AUTOS AUTOS NON-OWNED PROPERTYOANIAGE $ HIRED AUTOS AUTOS Per accident $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ CEO RETENTION$ $ WORKERS COMPENSATION X WC STATU- OTH- AND EMPLOYERS'LIABILITY Y I A ANY PROPRIETOR/PARTNERIEXECUTIVE YIN NIA AWC7026218012012 06/20/2013 06/20/2014 E.L.EACH ACCIDENT $ 100,00 (Mandatory In NH) SEE SEE NOTES E.L.DISEASE-EA EMPLOYEE $ 100,00 (MandaOFFICEtory EF If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OFOPERATIONSILOCATIONSIVEHICLES (ABaah ACORD 101,Additional Remarks Schedule,if more space is required) Window 6 Siding installation. Bart Kiley is exempted from workers compensation policy. CERTIFICATE HOLDER CANCELLATION FORINF SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ©1988.2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD