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BUILDING D (2,4,6,8,10,12) LEE FORT TERRACE - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF WMassachusetts State Building Code, 780 CMR SALEM 1 Revised Mar 2011 \�(tl Building Permit Application To Construct, Repair,Renovate Or olish One-or Two-Family Dwelling This Section For Official Use O y Building Permit Number: ' Date Applie . LTTZ2 O uilding Official(Print Name) _ _ S' afore Dale SECTION 1: SITE I FORMA 1.1 Property Address: 1.2 rs MW&Parcel Numbers Building 0(2,4,8,8,10,12)Lae Foil Tert m 1.1a 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(it) Front Yard Side Yards Rear Yard Required Provided Requued Provided Required Provided 1.6 Water Supply:(M.G.L c.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 ❑ 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 WORK (check all that apply) New Construction❑ Existing Building M Owner-Occupied ® Repairs(s) ❑ 1 Alteration(s) ❑ 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: ff Official Use Only Labor and Materials 1.Building $ 2191 ,696 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 $ x. Suppression) Total All Fees:$ Check.No. Check Amount: Cash Amount: 6.Total Project Cost: $ �ci(P 0 Paid in Full 13 Outstanding Balance Due: ,r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS 71077 7l25/2013 Charles J. Minasalli License Number I xx—p anon Date Name of CSL Holder List CSL Type(see below) 9 Epping Ave No.and Street Type Description Hampton, NH 03842 R R e tict d 1&2 Family dings wellingp to cu.ft. sd City/Town,State,ZIP 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...........IM 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. t act kn my behalf,in all matters relative to work authorized by this building permit application. -Wffit Owner's Name(Electronic Signature '.SECTION 7ht OWNEW OR AUTHORIZED AGENT DECLAIU TION ' By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contain this app I' ano n 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 i w mass goy/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 .N1, N'L-kSSACHUSETTS • BUILDING DEPARTNCEINT • ' 120 W ASHINGTON STREET,Vo FLOOR TEL (978) 745-9595 Fax(978)740-9846 igS[BFRi EY DRISCOLL MAYOR Trlomm ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUI DLNG COSEWSSIONER Workers' Compensation insurance AMdavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly Name (Busine—WOrganizationtlndividw):Environmental Restorations, Inc. Address:10 Hazel Drive City/State/Zip:Hampstead, NH 03841 Phone#:603-329-6101 Are you to employer?Check the appropriate box: Type of project(required): 1411 am a employer with 75 4. ❑ 1 am a general contractor and 1 b. New constrttctiom employees(filll and/or part-time).* have hired the sub-contactors 2.❑ 1 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 workingfor me in an capacity. workers'comp.insurance. Y P tY• 9. (]Building addition required.] workers'comp. insurance S. ❑ We are a corhave exercised and its 10.©Electrical repairs or additions required.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions myself.(No workers'comp. C. 152.§](4),and we have no 12.❑Roof repairs insurance required.)t employees.LNo workers' 13.C)Other comp_insurance required.] ;Any appaeaw that c1[M*.two#1 must also Cal snit the seclim Wow showing Chair wmken'compensation policy infurmation. t I t,vneuwnets who submit this affidavit indicating they ate doing all work and thco hire outside cantnccros must submit anew affidavit indicting such :Conuacton ChM check that box must anached an additional naet showing the mmnae of the sub.eoatrMom and thetr work='comp,policy inrw nation. l am an employer that is providing workers'compensation Ltsurance for my employees. Below is the policy and fob site information. Insurance Company Name:Commerce& Industry Ins. co Policy#or Self-ins.Lie.#:WC003603167 Expiration Date:8/1/12 Job Site Address:Lee Fort Terrace City/Stale/Zip: Salem, MA 01970 ,Utacb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonmeM 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 or the DIA for insurance coverage verification. I do hereby cerr fy un rrAe pa as and aides of perfury that the informadon previded above is true and correct li enature�"_c Date. 114-11 Phone#,603-329-6101 OBicial use only. Do not write in this urea,to he completed by city or town offa'iaL City or Town- PermittLieense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#• i OP ID:TF CERTIFICATE OF LIABILITY INSURANCE OATE 8108D/YYYY) 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. "dPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. H SUBROGATION IS WAIVED,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 781-935-8480 CONTACT NAME: DeSanctis Insurance Agcy,Inc. 781-933-5645 PHONE FAX 36 Cummings Park EMAIL E ArC No)- Woburn,MA 01801 ADDRESS: `IJEOMERI MENVIR-2 INSURERIS1 AFFORDING COVERAGE NAICIf INSURED Environmental Restorations Inc INSURER A:Everest Indemnity Insurance 10 Hazel Drive - IN e:Harleysville Insurance Hampstead,NH 03841 INSURER C:Commerce&Indus Ins.Co. 19410 INSURER D: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 ADOL UB PDUCY NUMBER MMIDD/YYEYY MWDDDY UNITS GENERAL LIABIDTY EACH OCCURRENCE $ 11,0130,000 A X COMMERCIAL GENERAL LIABILITY EF4ML01532111 06/01/11 06/01112 PREMISES EaOccurre $ 60,00 CLAIMS-MADE ®OCCUR MED EXP(My one person) $ 6,00 X Inc.PollutlonLiab PERSONAL 8 ADV INJURY $ 1,000,00 Asbestos/Lead GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGO $ 2,000,00 POLICY X PRO LOC $ AUTOMOBILEUABIUTY COMBINE SSINGLE LIMIT $ 1,000,00 ANYAUTO (E33cdtlem) ALL OWNED AUTOS BODILY INJURY parson) $ B X SCHEDULED AUTOS BA00000064339E 04/12/11 04/12/12 BODILY INJURY(Pe,I..dsm) $ X HIRED AUTOS PROPERTY DAMAGE $ (Per occident) X NONLOMED AUTOS S E UMBRELLA LIAR X OCCUR EACH OCCURRENCE $ 5,000,00 EXCESS UAB (,LAIMS-MADE A EF4C000090111 - 06/01111 06101/12 AGGREGATE $ 5,000.00 DEDUCTIBLE X RETENTION $ 10000 $ WORKERS COMPENSATION WCSTATU- OTH- AND EMPLOYER5LIASIUTY X C ANY PROPRIETORIPARTNER/EXECUTIVE YIN C003603167 08/01111 08/01112 E.L.EACH ACCIDENT $ 1,000,00 OFFICERAIEMBER EXCLUDED? ❑ N I A (Mamlatory In NH) MA,NH,RI,NY E.L.DISEASE-EA EMPLOYE S 1,000,00 Ryyee deeCnCe uMer DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ 1,000,00 p Equipment CIM025607813 04/23/11 04/23112 Scheduled 152,76 p Stored Materials CIM025607813 - 04/23/11 04/23/12 Stored. 50,00 DESCRIPTION OF OPERATIONS/LOCATIONS I VEHICLES (Attach ACORO 101.Additional Remerb S ILLUSTRATION OF COVERAGE. cheOule,It mom space Is required) 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 R 'E VE 01988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD Office`6{�odi�0 rATrAlf'PiV'$tl�jh ¢� �e HOME IMPROVEMENT CONTRACTOR Registration: 117430 Type: Expiration: 012 Private Corporation ONMENTP,t� _ INC 9 CHARLES MINIS — -3 C ' 10 HAZEL DR �- = i HAMPSTEAD, NH 0 4� - /'I 4 Undersccretar Y b.. I . 6'1a.csachusctts - Dcp:uYmcnt of Public S:dch Board of Buildin, Rc�ulutions and Standards Construction Supervisor License License: CS 71077 CHARLES J MINASALLI - 9 EPPING AVE HAMPTON, NH 03842 Expiration: 7/2512013 ('u nu»ixsianrr Tr#: 998