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BUILDING C (14,16,18,20,22,24,26,28) LEE FORT TERRACE - BUILDING INSPECTION _& The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF IMassachusetts State Building� Code,780 CMR S LLEM ised Mar 011 - I Building Permit Application To Construct,Repair,Renovate Or emolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers Building C(14,16,18,20,22,24,26,28)Lee Fort Te m 1.1 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 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 Housing Authority 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 WORK2(check all that apply) New Construction❑TExisting Building® Owner-Occupied El Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ 1 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: Labor and Materials Official Use Only 1.Building $ L;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: $ 3 ez,�,b 0 Paid in Full 0 Outstanding Balance Due: t SECTION 5: CONSTRUCTION SERVICES - 5.1 Construction Supervisor License(CSL) CS 71077 7/25I2013 Charles J. Minasalli License Number Expiration Date Name of CSL Holder 9 Epping Ave List CSL Type(see below) No.and Street Type Descnption' U Unrestricted(Buildings up to 35,000 cu.ft. Hampton, NH 03842 R Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Sidin 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 I,as Owner of the subject property,hereby authorize Environmental Restorations, Inc. to act on y behalf,in all matters relative to work authorized by this building permit application. wner's Name(Electronic Signature) SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATIO By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained'in thisaapppplic tion is true and accurate to the best of my knowledge and understanding. I I ./// - //- /0- a 11 Print Own s or Authorize ent'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. ove /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 Cosf' , CITY OF S.UZN1, .1.XSSACHLSETTS • BCBDING DEPAKMIUNT • 120 WASHINGTON STREET,3m FLOOR TEL. (978)74S-9595 FAX(978)740-9846 Kl%,BERLEY DRISCOLL Ib1AYOR T Homm ST.PiERB6 DIRECTOR OF PUBLIC PROPERTY/Bt:IIDING COMMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers AnDlicant Information Please Print Leeibiv Name (eusim-ssrOrganizationrtndividual):Environmental Restorations, Inc. Address:10 Hazel Drive City/State/Zip:Hampstead,NH 03841 Phone #:603-329-6101 Are you as employer?Check the appropriate box: Type of project(required: 1.® I am a employer with 75 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ i am a sole proprietor or partner- listed on the attached sheet.t 7. ®Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any Capacity, workers' comp.insurance. 9. ❑Building addition (No workers'comp.insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ t am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.(No workers'comp. c, 152, g I(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' 13.❑00ner comp. insurance required.) 'Any a"licunl that dtedw box 81 most alw rill out the sectim below showing their wodten'compensation policy infum nioa. f homeowners who submit this affidavit indicating they are doing all work and then him mid,contrantns must suhmk a+ affidavit indicting suciL =ComrsKon that ciutk this brat moat attached an additional shot showing tha same of the subeontmclon and their wo+kem'romp,policy inrommrion. l am an employer that is providing workers'compensation hunrance for my employees. Below Is rile policy and fah site informatlon. 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 polity number and expiration date). Failure to=ore coverage as required under Section 25A of MGL C. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations ur the DIA for insurance coverage verification. l do hereby certify ander the pains and penaties of perJary that the informadon provided above is true and come, Sienature• Date 11-4-11 Phone x: 603-329-6101 Official use only. Do"Of write In this array,to be completed by city or town officla[ City or Town- Permit/License# Issuing Authority(circle one): 1. Beard of health 2.Building Department 3.Cityf'own Clerk 4,Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: OP ID:TF CERTIFICATE OF LIABILITY INSURANCE °AT 08108/1 ""' 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 INSURERS), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. ,MPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) 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 endorsemen s . PRODUCER 781-935-8480 CONTACT DeSanctis Insurance nce Agcy,Inc. 781-933-5645 PHONE e FAX 36 Cummings Park EMAIL Arc No): Woburn,MA 01801 ADDRESS: RRoOu ER I .ENVIR-2 INSURERS AFFORDING COVERAGE NAICp INSURED Environmental Restorations Inc INSURER A:Everest Indemnity Insurance 10 Hazel Drive wsuaERe: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, ILTR NSR TYPE OF INSURANCE AOD B POLICY NUMBER MMIOD/YYYY MMMD E%P YYYV UNITS GENERALUABILITY --' EACH OCCURRENCE $ 1,000,00 A #Xc,OMMERCIALGENERALLIABILITY EF4ML01532111 06/01111 06/01112 pREMI 's Eaoc n ce $ 50,00CLAIMS-MADE ® OCCUR MED EXP(My one person) $ 5.00c.PollutionLiab PERSONAL 8 ADV INJURY $ 1,000,00 Asbestos/Lead GENERAL AGGREGATE $ 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 S 1,000,00 1 ANY AUTO (Ea accident) p BODILY INJURY(Per person) $ p ALL OWNED AUTOS E X SCHEDULED AUTOS BA00000064339E 04112111 04/12112 BODILY INJURY(Per accitlent) $ X HIRED AUTOS PROPERTY DAMAGE $ (Perercldent) X NON-0WNED AUTOS $ S UMBRELLA LLIB X OCCUR ;E1,EACH CURRENCE $ 5,000,00 E%CE33 UAB CLAIMS-MADE $ 5,000.00 A EF4C000090111 06/01111 061D1/12 ATE DEDUCTIBLE $ X RETENTION. 10 000 $ WORKERS COMPENSATION STATU- OTH- ANO EMPLOYERS LIASIUTY C ANY PROPRIETOWARTNER/EXECUTIVE YIN C003603167 OB/01111 08/01112 OFFICER,MEMBER EXCLU05DI ❑ NIA ACCIDENT $ 1,000,00(Mandatory In NH) MA,NH,RI,NY yascriea rower ASE-EA EMPLOYE $ 1,000,0D DESCRIPTION OF OPERATIONS below E.L.DIBEASE-POLICY LIMIT $ 1.000.00 p Equipment CIM025607813 04f23111 04/23112 Scheduled 152,76 D Stored Materials CIM025607813 04/23111 04/23112 Stored. 50,00 DESCRIPTION OF OPERATIONS I LOCATONS/VEHICLES (Attach ACORD 101,Additional Remand Schedule,ll more space Is 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. I AUTHORIZED R 'E VE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Office`6fOot. rBfi�L.,, HOME IMPROVEMENT CONTRACTOR (1a ' Registration: 117430 Type: Expiration: _ jlRCl_N0tp Private Corporation ONMENTAy� —� INC i CHARLES MINIS 10 HAZEL DR _ " •+ t HAMPSTEAD, NH 05 — Undersecretary y, i M1'lus,;rchosct[s - Deportment of Public Satoh Board of Buildin- Re'ulations and Standards Construction Supervisor License License: CS 71077 CHARLES J MINASALLI 9 EPPING AVE HAMPTON, NH 03842 Expiration: 7/252073 (' mmisiunrr Tr#: 998