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BUILDING E (35,37,39,41) LEE FORT TERRACE - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or De One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: � � ck I Building O�(Print e) Si ature Da e SECTION 1:SITE INF IO 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers Building E(35.37.39,41)Lee Fart Terrace L I a Is this an accepted street?yes no Map Number Parcel Number a 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 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® 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 Replacement of Entry New vinyl Soffit Wrapping existingfasciaexisting fascia SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ l9(ram 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: $ 1 ct 2-te 4 0 Paid in Full 0 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 List CSL Type(see below) 9 Epping Ave No.and Street Type "Description U Unrestricted uildin su to 35,000 cu.ft. f Hampton, NH 03842 R Restricted 1&2 Family Dwelling Cityrrown,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 10Hazel 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.`752.¢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 Ow er 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. Pri er's Name(Electronic Signature r- SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATIOR By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in thi applicati n is true a accurate to the best of my knowledge and understanding. Print Owner's or Au orized Agent' M ame(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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/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" 1 i CITY OF &U� ENi, NULSSACHUSETTS • BUILDING DEPARTMENT • ' 120 WASHINGTON S7REEr.r FLOOR TEL (978) 745-9595 FAX(978)740-98" KINIB RU EY DRISCOLL MAYOR Tlloaus ST.P13axR& DIRECTOR OF PUBLIC PROPERTY/BUI DLNG COMMISSIONER Workers' Compensation insurance Affidavit: Builders/Contractom/Electricians/Plumbers Applicant Information Please Print Legibly Name leusinc OrganizatiordlndividualyEnvironmental 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 or project(required): 1.FXI 1 am a employer with 75 4. 0 I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.0 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. 0 Demolition working for me in any capacity, workers'comp.insurance. 9, itdi 0 Bu ng addition workers comp,insurance S. We are a corporation and its required.] ffi 10.0 Electrical repairs or additions required:) Officers;have exercised their 3.0 1 am a homeowner doing all work right of exemption per MGL I 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 camp. insurance required.) ;Any appacant tluu a ux*s box#1 most also fill out the section below showing their workers'compensation policy infumutian. r 1 bsneuwrers whir submit this affidavit indicating they ate doing an work and then hire outside contractors mum submit a new affidavit indicating such. =Cormuctors that chLsk this box must aaachad an additionai Awt showing the name of ax sub conuamnn and their workers'twmp,policy jor am ion. !am an employer that it providing warhers'compen ration lnrurance for my employees. Below is the polley and Job site information. Insurance Company Name:_Commerce & Industry Ins. co Policy 4 or Self-ins.Lic,#:WC003603167 Expiration Date:8/1/12 Job Site Address:Lee Fort Terrace City/statcaim Salem, MA 01970 ,mach 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 I,500.00 and/or one-year imprisonment.as welt 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 or the DIA for insurance coverage verification. !do hereby certify under, pal and penal r of perjury that the information provided above Is true and correct. %Lnalttre' ,AAA Date 11-4-11 Phone#: 603-329-6101 OJjeial use only. Do not write in this area,to be completed by city or lawn ogklai City or Town: Pirmit/Lfcense# Issuing Authority(circle one): I. Board of Ilealth 2.Building Department 3.Cilyfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person• Phone#: �1 OP ID:TF ACORO' DAT iMMIDDNYYY) CERTIFICATE OF LIABILITY INSURANCE OEe108111 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. NPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If 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 endorsemen s . PRODUCER 781-935-8480 CONTACT DeSanctislnsurance Agcy,inc. 781-933-5645 NAME:PHONE PAX 36 Cummings Park E-MAIL uc Ne Woburn,MA 01801 ADDaESS: aSTOMERCUSMER .ENVIR-2 INSURERS AFFORDING COVERAGE NAIC a INSURED Environmental Restorations Inc INSURERA:Everest Indemnity Insurance 10 Hazel Drive INSURERS:Harleysville Insurance Hampstead, NH 03841 INsuRER c:Commerce& Industry Ins.Co. 19410 NsuRERD: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, ILTRNSR TYPE OF INSURANCE ADD[ UB POLICY NUMBER MMIDD//YEYY MMI DY YY LIMITS GENERAL UABILITY EACH OCCURRENCE $ 1,000,00 A X COMMERCIAL GENERAL LIABILITY EF4ML01532111 06/01/11 06101112 PREMISE aD(Ea E 60,00 CIAIMS-MADE ® OCCUR MED EXP(My one person) $ 5,00 X Inc.P011utionLiab I Asbestos/Lead PERSONAL S ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,D00,00 POLICY X PRO- LOD $ -AUTOMOBILE DABNTY COMBINED SINGLE LIMIT $ 1,000,00 ANY AUTO - (Eeacaidenl) ALL OWNED AUTOS BODILY INJURY(Per person) $ B X SCHEDULED AUTOS BA00000064339E 04112111 04112M2 BODILY INJURY(Per accident) $ X HIRED AUTOS PROPERTY DAMAGE $ (Peraccidenn X NON-OWNED AUTOS $ UMBREa EXCESS LA S X OCCUR EACH OCCURRENCE $ 5,000,00 EXCESS LIAa I A CLAIMS-MADE EF4C000090111 06/01111 06/01/12 AGGREGATE $ 5,000,00 DEDUCTIBLE X RETENTION 10 000 _ WORKERS COMPENSATION WC STATU- AND EMPLOYER5 LUIBIUTY X O7H- C ANY PROPRIETORIPARTNER/EXECUTIVE YIN C003603167 08)01111 06/01112 OFFICERAIEMSER EXCLUDED? ❑ NIA E.L.EACH ACCIDENT $ 1,000,00 (Llantlatoryln NH) MA,NH,RI,NY E.L.DISEASE-EA EMPLOYE $ 1,000,OO N yes,deaait,e urwer DESCRIPTION OF OPERATIONS W. E.L.DISEASE-PO4CY LIMIT $ 1,000,00 p Equipment CIM026607813 04/23/11 04/23/12 Scheduled D Stored Materials 152,78 CIM025607813 04/23111 04l23N2 Stored. 50,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES ( ILLUSTRATION OF COVERAGE. Attach ACORD 101,Addltlonal Remarks Schedule,If mom rpu specs Is lmd) 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 RE VE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD Office LIM HOME IMPROVEMENT CONTRACTOR 1 Registration: 117430 Type: Expiration: � 012 - Private Corporation ONMENT _ INC CHARLES MINIS 10 HAZEL DR J HAMPSTEAD, NH 0�4`fi�=� Undersecretary r i i I I a.csachusctis - Dc pit rtrn ell t of Public Safeh Board of Building RC'nlations and Standards Construction Supervisor License License: CS 71077 CHARLES J MINASALLI 9 EPPING AVE HAMPTON,-NH 03842 Expiration: 7/25/2013 ('mm�iissiuner Tr#: 998