BUILDING A (46,48,50,52,54,56,58,60) LEE FORT TERRACE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
\� Building Permit Application To Construct, Repair,Renovate r Demolish Revised Mar 2011
One or Two-Family Dwelling
1 This Section For Official Use Onl
Building Permit Number: - Date Applied:
to c�
'Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATIOfi
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Building A(46A8,5e,52,54,56,58,80)Lee Fort Te"m
1.1 a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Salem Housinq Authoritv Salem, MA 01970
Name(Print) City,State,ZIP
27 Charter Street 978-744-4431 dtucker@salemha.org
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building M Owner-Occupied M Repairs(s) ❑ I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
Replacement of Entry doors New vinyl Soffit Wrapping of existing fascia
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ ;0 FjZ00 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
O Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: '$
4.Mechanical (ITVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ Ou ❑
r Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
CS 71077 7/25/2013
Charles J. Minasalli License Number Expiration Date
Name of CSL Holder
9 Epping Ave List CSL Type(see below)
No.and Street Type Description
U_ Unrestricted up to
Hampton, NH 03842 R Restricted 1&2 Family(Buildings
Dwellin5,000 cu.ft.
Cityfrown,State,ZIP M Masonry _
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
603-234-9213 Cminasalli@gmail.com I I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) 117430 10-3-2012
Environmental Restorations, Inc./Charles Minasalli HIC Registration Number Expiration Date
HIC Company Name or MC Registrant Name
10 Hazel Drive. Cminasalli@gmail.com
No.and Street Email address
Hampstead, NH 03841 603-329-6101
City/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..........M No...........❑
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize Environmental Restorations, Inc.
to act o my behalf,in all matters relative to work authorized by this building permit application.
er's Name(Electronic Signature�C
SECTION 7b:OWNEW OR AUTHORIZED AGENT DEC RATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this pplication is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. 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"
CITY OF SM.E.N1, 2AXSSACHUSETTS
• BUILDING DEPARTatENT
120 WASHINGTON STREET,310 FLOOR
TEL (978) 74S-9S9S
FAX(978)740-9846
KIMBERt EY DRISCOLL
TMAYOR THOMAS ST.PIF.RRE
DIRECTOR OF PUBLIC PROPERTY/BL'QDLNG CO%5GSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name IBusimn Orsanirationilndividuatl:Environmental Restorations, Inc.
Address:10 Hazel Drive
City/State/Zip:Hampstead, NH 03841 Phone#:603-329-6101
Are you an employer?Check the appropriate box: Type or project(required):
1.® I am a elnploycr with 75 4. [1 1 am a general contractor and 1 6. ❑New construction
employees(fidl and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.: 7- ®Remodeling
ship and have no employees These sub-contractors have & ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. []Building addition
f No workers'comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs"additions
3.0 1 am a homeowms doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.i 1(4),and we have no 12.0 Roof repairs
insurance required.)f employeca.[No workers' 13.0 Other
comp.insurance required.]
'Any appliCM 00 choke box Of must ako till not the raetiea below showing their works,'comymation policy information.
I 1 hsneowoera who submit this aaitbvit indicating they ate doing an work and then hire amide contrumn must suhma a new affidavit indkving sU&
:Conttaaon that dick this box must avwhed an additional dmwt showing the nano of tha orb-eonuo3om and their woduve'comp.policy infommum.
Ian an employer that lr providing workers'compensation hasurnace for my employers. Below is the policy and job rite
information.
Insurance Company dame:Commerce 8, Industry Ins. co
Policy#or Self-ins.Lic.#:WC003603167 Expiration Date:8/1/12
Job Site Address: Lee Fort Terrace City/Statellip: Salem, MA 01970
Anub a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/tu one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerr ffy under thgpala�� penalf fperjury that the information provide]above is true and correct.
Sitpautre: (//!/i/J s pate 11-4-11
Phone#: 603-329-6101
OJJiciat use only. Do not write in this area,to be completed by city or town oJJklaL
City or Town: PermidLicense I
Issuing Authority(circle one):
I.Board of health 2.Building Department J.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person:— Phone#:
OP ID:TIC
Al R OATE(MMND/YYYY)
CERTIFICATE OF LIABILITY INSURANCE 08/08/11
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.
adPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WANED,subject to
the terns 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 endorsements .
PRODUCER 781-935-WO CONTACT
DeSanctislnsurance Agcy,lnc. NAME:
781-933-5645 PHONENo FAx
36 Cummings Park E-MAIL we Np:
Woburn,MA 01801 AooREss:
RIMER ,.ENVIR-2
INSURERS AFFORDING COVERAGE NAICN
INSURED Environmental Restorations Inc INSURER A:Everest Indemnity Insurance
10 Hazel Drive INSURER B:Harle sville Insurance
Hampstead, NH 03841 INSURERC-Commerce&Inclusby Ins.Co. 19410
INSURER D:Acadia Insurance Company
NSURER 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.
ILTRN-RR TYPE OF INSURANCE DL B POLICY NUMBER MM/DCYDI'%YYY M D Y/VYVY UNITS
GENERAL LIABILITY
EACH OCCURRENCE $ 11,000,0110
A X COMMERCIAL GENERAL LIABILITY EF4ML01532111 06/01111 06/01112 Fvl pREMISEs aocwrte E 60,00
CLAIMS-MADE OCCUR MED EXP(My orreperson) $ 5,00
X Inc.PollutlonLiab
PERSONAL&ADV INJURY $ 1,000,00
ASbeetOSlLead GENERAL AGGREGATE $ 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP ADD E 2,000,00
POLICY X PRO- LOC E
' AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000,00
ANY AUTO Wa acc oenp
ALLOWNEDAUTOS BODILY INJURY(Per person) $
B X SCHEDULED AUTOS BA00000064339E 04/12/11 04/12/12 BODILY INJURY(Per accident) $
X HIRED AUTOS PROPERTY DAMAGE $
(Perercident)
X NON-OWNED AUTOS $
UMBRELLA IJAB X OCCUR EACH OCCURRENCE $ 5,000,00
EXCESS LA CLAIMS-MADE
A 6EF4CUO0090111 D6/01111 06IOtNY ncGRECATE s 5,000,00JEquipment
DUCTIBLEETENTION E 10 000ERS COMPENSATIONWG STATU- OTHPLOYERS'IMSILIW XIQBx I WILE FIR
OPRIETORrPARTNER/EXECUTIVE YIN 67 Ott/01111 08/01112RAIEMSER EXCLUDED? ❑ NIA EL EACH ACCIDENT $ 1000toryln NH) Y E.L.DISEASE-EA EMPLOYEE E 1,000,00 eambe antler
IPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT E 1,000,00
ent CIM026607813 04/23/11 04/23112 Scheduled 152,78
Materials - CIM025607813 - 04/23/11 04/23/12 Stored.
50,00
DESCiL1PTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional RemarMs Schedule,If more epees la required)
ILLUSTRATION OF COVERAGE.
CERTIFICATE HOLDER CANCELLATION
TO WHOM
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
TO WHOM IT MAY CONCERN THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
/ AUTHORIZED FIT VE
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD
7
- <L\l 0fficcA. �'f>f����es �p i
HOME IMPROVEMENT CONTRACTOR r ;
Registration: ,y 1117430 Type:
Ezpiratiorr.. <<UaNO'12 Private Corporation
ONMENT R ��}$INC
= I CHARLES MINISks �
10 HAZEL DR
I HAMPSTEAD, NH 03
�'4,y=,6—._r•,' Undersecretary
9
b..
j
i
i
iN9ussachusetts - Dep.uYment of Public SafrtN
Board of Building Re-ulatiuns and StanU.u-ds
Construction Supervisor License
License: CS 71077
CHARLES J MINASALLI
- 9 EPPING AVE
HAMPTON, NH 03842
Expiration: 7I25/2013
('nnmtissiuner Tr#: 998