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BUILDING F (19,21,23,25,27,29,31,33) 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 D;,x6j a 1 L{1 One-or Two-Family Dwelling vj/11 This Section For Official Use Only Building Permit Number, Date Applied: �tct.L�.tn.1..� Luv�izz�ILu vg ' O/ Building Official(Print Name) SignattuF ate SECTION 1:SITE INFORNrATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers Building F(19.21,23.25.27.29.31.33)Lee Fort Ta w 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?Check if yes❑ Municipal❑ On site disposal system ❑ 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® Owner-Occupied M 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 Estimated Costs: Item Official Use Only Labor and Materials 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard Cityffown 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: $ 301 S2ig 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 List CSL Type(see below) 9 Epping Ave No.and Street Type 'Description U _ Unrestricted(Buildings up to 35,000 cu.ft. Hampton, NH 03842 R Restricted 1&2 Family Dwellin CityfFown,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./Chades 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 f as O 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. \\NO A) -ELuwOwner's Name(Electronic Signa Datel 0 SECTION 7b:OWNER'OR AUTHORIZED GENT DECLARA40N �- By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained�Ijt��l' ation is true and accurate to the best of my knowledge and understanding. Print ner's or Authorize gent'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.eov/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 Sm EN4 1NL-ksS.ICHUSETTS I'� • BL'ILDLNG DEPARTMENT ` 120 WASHINGTON STREET,3'a FLOOR TEL (978)745-9595 Fax(978)740-9846 KLN BERLEY DRISCOLL MAYOR THOMAs ST.PIERRa DIRECTOR OF PUBLIC PROPERTY/8UUDL'dG CONL%aSSIONER Workers' Compensation Insurance Affldavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name lBusim-WOrganizatiotvindividualyEnvironmental Restorations, Inc. Address110 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.® 1 am a employer with 75 4. 0 t am a general contractor and 1 6. ❑New construction employees(full aad/orpsrt-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 R. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. [1 Building addition f No workers'comp.insurance S. 0 we are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 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,¢1(4),and we have no 12.0 Roof repairs insurance required.)t employees. [No workers' 13.©Orbs comp.insurance required.) •Any appacam 1hW d uA*s bM 91 must also Ill out 1he section below shawing thair aorke s'compensation policy infemtatioa '1 kaneowners who subma'his afrtdavb iMiening they arc doing ail work and then hire outside mntmmtws must mhmh a new affidavit indio ing•„eh Controvtms thW cheek this bait mhtW mtached m a"tio al sheet showing the mme of Om rub•oo,a rem sad their workem-comy,pnliey h,fomatiaa l am an employer that it providing workers'compensadan insurance for my employees. Below is the policy andJob site informaion. Insurance Company Name:Commerce& Indust Ins. co Policy 4 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 1,500_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 5250.00 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. Ida hereby certify and the pains and peaalder of perjury that the informailon provided above Is true and correct Simaltireffi � �� Date- 11-4-11 Phone N: 603-329-6101 Official use only. Do not write in this area,to be completed by city or town of kiai City or Town- _ Permit(Uccuse# Issuing Authority(circle one): I. Board of health 2.Building Department 3.Cityfrowu Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person• _ _ Phone#: a OP ID:TF .4�orzo CERTIFICATE OF LIABILITY INSURANCE OgT081081/1'YYY) 8/08/11 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. ,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 endorsements . PRODUCER 781-935-WO CONTACT DeSanctis Insurance Agcy, Inc. 781-933-5645 NAME:NONE FAX 36 Cummings Park E MAIL ac Na Woburn,MA 01801 ADDRESS: cuooucER e,ENVIR-2 INSURERIS1 AFFORDING COVERAGE NAIC A INSURED Environmental Restorations Inc INSURER A:Everest Indemn4 Insurance 10 Hazel Drive wsuRER a:Harleysville Insurance Hampstead, NH 03841 INSURER C:Commerce&Industry 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. INSR TYPE OF INSURANCE I.DDL UB POLICY NUMBER 0NUODMW MNIDOYD/YYYY LIMITS GENERAWABILRY EACH OCCURRENCE $ 1,000,00 PAGA X COMMERCIAL GENERAL LIABILITY EF4ML01532111 06/01/11 06101/12 DREMISES Ea N rrenra E 50,00 CLAIMS-MADE ®OCCUR MED EXP(Any ale person) $ 6,0001 X Inc.PollutionLiab ' PERSONALS ADV INJURY E 1,000,00 A3best05/Lead GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO S 2,000,00 _ POLICY X PRO- LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT 4 1,000,00 ANY AUTO lEa amidenU ALL OWNED AUTOS BODILY INJURY(Per parson) $ B X SCHEDULED AUTOS BA00000064339E 04M2/11 04112/12 BODILY INJURY(Per scddenl) $ X HIRED AUTOS PROPERTY DAMAGE S (Per accident) X NON-OWNED AUTOS $ E UMBRELLA IIAB X OCCUR EACH OCCURRENCE S 5,000,00 EXCESS LIA9 CLAIMS-MADE A tEF4CU00090111 D6l01111 06/01112 gGGREGATE g 6,000,000DEDUCTIBLE X RETENTION 1OOOO S AND EMPSCOMPELIATIONILIT WC STATU- OTH- AND EMPLOYER5 LVIBNTY XC AWPROPRIETORIPARTNER/EXECUTIVE YIN 3603167 08/01/11 08/01/12 OFFICERIMEMBEREXCLU(35W NIA E L EACH ACCIDENT E 1,000.00(MarMatory In NM) ,RI,NYE.L.DISEASE-EA EMPLOYE E 10)0,00 U es,desmlEe underDESCRIPTION OF OPERATIONS below 00,00 D Equipment 607813 04/13111 04/23112 Scheduled 152,78D Stored Materials 607813 - 04/23111 04/23112 IStored 50,00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Adich ACORD 101,Additional Remarks Schedule,II more spec.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 FIT E VE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD Of fice�t'cod'�� es HOME IMPROVEMENT CONTRACTOR Registration: 117430 Type: Expiration tEjF2�012 Private Corporation ONMENTA4- INC CHARLES MINIS 10 HAZEL DR I _ g _ HAMPSTEAD, NH 036, �- \ ',a,- Undersecretary i .. iVlassachusctts - Dcp:utnunt of Public S:detN Board of Bui Id in_ Reflu Iution, and Slit[I(lit Ids Construction Supervisor License License: CS 71077 CHARLES J MINASALLI 9 EPFING AVE HAMPTON, NH 03842 Expiration: 7/25/2013 ('nnmissiinrr Tr.# 998