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BUILDING B (30,32,34,36,38,40,42,44) LEE FORT TERRACE - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF r� Massachusetts State Building Code,780 CMR SALEM r 1 Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolis a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Da a ppli Building Official(Print Name) Sigimt6fe Da e SECTION 1:SITE INFO ION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers Building a)30,32,34,36,38,40,42,44)Lee FM Tartars 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 yesO 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 III Repairs(s) ❑ 1 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 $ S2 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier `, x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 16)GZ,b 0Paid 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 Hampton, NH 03842 U Unrestricted(Buildings u to 35,000 cu.ft. Ciampi Stale,ZIP R Restricted 1&2 FamilyDwelling M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 603-234-9213 Cminasalli@gmail.com I Insulation Telephone Email address D 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 HIC 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 1,as Owner of the subject property,hereby authorize Environmental Restorations, Inc. to a o my behalf,in all matters relative to work authorized by this building permit application. wner's Name(Electronic SignamrAat :SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARA Iq 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 t e 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 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 S.1L.E1N1, NLkSSACHL'SETTS • BUILDING DEPARTNIENT ' 120 WASHINGTON STREET,3'°FLOOR T EL (978) 745-9595 FAx(978)740-9846 KINIBFRr RRY DRISCOLL MAYOR TrloaiAs ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BlUI DLNG COSI.MOSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbera Applicant Information Please Print Legibly Name iBusim-ssiOrganirationtimtividuap:Environmental Restorations, Inc. Address:10 Hazel Drive City/State/Zip:Hampstead, NH 03841 Phone#:603-329-6101 Are you an employer?Check the appropriate boa: Type orpro]ect(required): 1.50 1 am a employer with 75 4. ❑ I am a general cotarector and 1 6. New construction employees(fuil apd/orpart-time).' have hired the sub-eantracmts 2-❑ 1 am a sole proprietor or parmer- listed on the attached sheet.: 7. Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ©Building addition [No workers'comp,insurance S. ❑ We are a corporation and its 10❑Electrical repairs or additions required.] officers;have exercised their 3.111 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions myself.[No workers'comp. c.152, 91(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.0 Other comp.insurance required.[ Any appacam that chculin box ri matt also fill put the section below showing their wmk=1 compensation policy infumtatiom t 1 rnmeowrwa who submit this affidavit indicating theY an:doing all work and Ilion hire otmide commcton most submit a new affidavit indicating such. Contmcton that check ibis boa must anached on additional ahml showing the come of the sub eontrectors and their worben'comp,pal icy infwmadon, I um an employer that is providing workers'compensation insurance for my employees. Below is she policy and Jab site ittjormation. Insurance Company Name:Commerce& Industry Ins. co Policy#or Self-ins.Lic.#:WC003603167 Expiration Date:8/1/12 Job Site Address:Lee Fort Terrace City/State/Zip: Salem, MA 01970 Attach 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 1,300,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to$250.00 a day against the violator- Be advised that a copy of this statement may be forwarded to the Offee of Investigations or the DIA for insurance coverage verification. I do hereby certify under th ain penalties jperjury that the injormadon provided above is true and correct sienalure. Date: 11-4-11 Phone x: 603-329-6101 Oflurial use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): I. Board of health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person• - Phone#' i OP ID:TF ACORO' DAT (MUDDIYYYY) `..� CERTIFICATE OF LIABILITY INSURANCE OEs108/11 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. dPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. It 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 CONNAME:TACT DeSanctis Insurance Agcy,Inc. 781-933-5645 PHONE o FAx 36 Cummings Park fthIL Woburn,MA 01801 ADDRESS: c1!=NERI P,ENVIR-2 INSURERS AFFORDING COVERADE NAIC p INSURED Environmental Restorations Inc INSURER A;Everest Indemnl Insurance 10 Hazel Drive INSURERS:Harleysville Insurance Hampstead, NH 03841 INSURERC:Commerce& Industry Ins.Co. 19410 INSURERD:Acadia Insurance Company INSURER 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. I1211 NSR ADDITYPE OF INSURANCE .... B POLICY NUMBER MMIpCO� MwDOY UNITS GENERAL LIABILITY EACH OCCURRENCE S 1.000,0 A X COMMERCIAL GENERAL LIABILITY EF4ML01532111 06/01/11 06101/12 PREMISES fEa occurrence) b 50,00 CLAIMS-MADE ® ROCCUR MED EXP("ops person) $ - 5,00 X Inc.PollutionLiab t Asbestos/Lead PERSONAL a AOV INJURY $ 1,000,00 GENERAL AGGREGATE E 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO 8 2,000,00 POLICY X PRO LOC $ 'AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 1,000.00 ANY AUTO IEe accitlem) ALL OWNED AUTOS BODILY INJURY(Per person) $ B X SCHEDULED AUTOS BA00000064339E 04112/11 04/12/12 BODILY INJURY(Per accident) $ X HIRED AUTOS PROPERTY DAMAGE $ (Par acoid.m) X NON-OWNED AUTOS $ $ UMBRELLA LIMB X OCCUR EACH OCCURRENCE E 51000,00 A DEDUC LLE CLAIMS-MADE EF4C000090111 06/01111 06/01112 AGGREGATE $ 5,000.00 DEDUCTIBLE X RETENTION $ 10,000 1OFFICERUMEMBER RKERS COMPENSATION $ D EMPLOYERS LIABILITY X WC STATU- OTH- Y PROPRIETORIPARTNER.EXECUTIVE YIN CD03603167 08/01111 08/01112 EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $ 1,000,00ntlatorylo.ndII NH) MA,NH,RI,NYEL.DISEASE-EA EMPLOYE $ 1,000,00 s etD,he enterSCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 ipment CIM026607813 04l23111 04l23112 Scheduled 152,76red Materials - CIM025607613 04/23/11 04/23H2 Stored. 50,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Ad,Iltlonal Remarlra Schedule,I1 mom.Pace Ie r"red) 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. 1 AUTNORU:EO RT tVE Of 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD Offccq&o��+ � es _ HOME IMPROVEMENT CONTRACTOR Registration: 117430 s Type: Expiration: , N_ O12 Private Corporation W06NIMENT F _ — $INC CHARLES MINIS,, 10 HAZEL DR I HAMPSTEAD, NH 0 Undersecretar I Massachusetts - Dep;u-tnunt of Public Safrh Bnenl of Buildin", Regulations and Standanls Construction Supervisor License License: CS 71077 CHARLES J MINASALLI 9 EPPING AVE HAMPTON, NH 03842 c Expiration: 7/25t2013 (' mmissinner Trkl: 998