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BUILDING G (3,5,7,9,11,13,15,17) LEE FORT TERRACE - BUILDING INSPECTION • may ee The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF 'r Massachusetts State Building Code, 780 CMR SALEM/ Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This Section For Official Use Only B�uil/d'ing Permit Number iI ate Appl' d. Building Official(Print Name) 9. . Sign!!2,f Date SECTION 1:SITE INF(fRMATION 1.1 P perty Address: 1.2 Assessors Map&Par 1 Numbers Building (3,5.7,g,11,13,15,17)Lee Fon Teneoe 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 yes❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Salem Housinq 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❑ Fisting Building® Owner-Occupied M 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: Official Use Only Labor and Materials 1.Building $ Z 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: $ SE, ❑Paid in Full 13 Outstanding Balance Due: 1 SECTION St CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) CS 71077 7/25/2013 CharlesJ. Minasalli License Number Expiration Date Name of CSL Holder 9 Epping Ave List CSL Type(see below) No.and Street Type 'Description U Unrestricted(Buildings up to 35,000 cu.ft. Hampton, NH 03842 R Restricted 1&2 Family Dwelling 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 Insulat on 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 .......... El No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as er of the subject property,hereby authorize Environmental Restorations, Inc. to ac[ n my behalf,in all matters relative to work authorized by this building permit application. Pr' er's Name(Electronic Signa D e SECTION 7b:OWNER' OR AUTHORIZED AGENT I)ECLAf&TION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in t 'a�ation is true and accurate to the best of my knowledge and understanding. / / 9 //-/ o- Z o i PrintOwn rs'fcfi P�uthorized 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' i CITY OF S�1LENti iN'LASSACHUSETTS • BUHMLNG DEPARTM NT ! 120 WASHINGTON STREET.Ye FLOOR TEL ()78) 74S-959S FAX(978)740-9M KIMBERi EY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BL•ILIMNG COMOSSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name iBwiixssWOrganizmionAndividttal):Environmental Restorations, Inc. Address:10 Hazel Drive, City/State/Zip:Hampstead, NH 03841 Phone#:603-329-6101 Are you an employer?Check the appropriate box: Type of project(required): 1.W1 1 am a employer with 75 4. 111 am a general contractor and 1 6. ❑New construction employees(fidl and/or part-time).* have hired the sub-contractors 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 S. ❑Demolition work ing for me in any capacity. workers'comp.insurance. 9, ❑Building addition {No workers'comp. insurance 5. ❑ We are a corporation and: ]0. Electrical repairs required.] officers have exercised their © pairs oradditions 3.❑ i am a homeowner doing all work right of exemption per MGL 1 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' 13.0 Other comp. insurance required.] ;Any appliemt that dtaim box III must also fill out the secllon below showing their work—,compensation policy infurmatioa '1 h+meawnrn who submit this affidavit indicating they ate doing all work and then hire outside contractors mint submit a new afthJavit indicting suck :Comraaon that check this box must anached an additional dNwt showing the name of the sub-oammoters and their workaa•comp,pal icy infaomtion. I am an employer that is providing workers'compensation insurance for my employees. Be1ow is the pofley and Jab site information. 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 SI,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;or the DIA for insurance coverage verification. I do hereby certify under the ins an penalties of perjury that the information provided above is true and correct oe Date, 11 4-11 Phone#: 603-329-6101 oJrcial use only. Do not write in this area,to be completed by city or town gBlciai City or Town _ PermiUWcense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• OP ID:TF ,4Ro CERTIFICATE OF LIABILITY INSURANCE DATEIMMDOYYYY) O8I08/11 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 781-935-8460 CONTACT NAME: DeSanctis Insurance Agcy,Inc. 781-933-5645 PHONE FAx 36 Cummings Park 6L&IL Arc No: Woburn,MA 01801 ADDRESS: P OLDER ,ENVIR-2 INSURERS AFFORDING COVERAGE NAIC0 INSURED Environmental Restorations Inc INSURER A:Everest Indemnity Insurance 10 Hazel Drive INSURER 9:Harleysville Insurance Hampstead, NH 03841 INSURER C:Commerce&Industry Ins.Co. 19410 INSURERD:ACadia Insurance Company NSURER E: INSURER I: 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 N$R TYPE OF INSURANCE ADDL B POLICY NUMBER MM/ODY� MIn�Y�P UNITS GENERAL DABIDTY EACH OCCURRENCE $ 1'000,00 A tXinc.PollutionL!ab MMERCIAL GENERALLLABILIT' EF4ML01532111 06/01111 06101112 PREMISE aocame ce $ 60,00 CLAIMS-MADE ®OCCUR MED EXP(My one person) $ 5,00 PERSONAL 8 AOV INJURY $ 1,000,00es[os/Lead GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGO $ 2,000,00 POLICY X PRO- LDO $ -AUTOMOBILE UABIDTY COMBINED SINGLE LIMIT $ 1,000,00 6 ANY AUTO (Ea accident) ALL OWNED AUTOS BODILY INJURY(Per person) $ B X SCHEDULED AUTOS BA00000064339E 04/12/11 04/12/12 BODILY INJURY(Per accident) $ X HIRED AUTOS PROPERTY DAMAGE $ (Per accident) X NON-OMEDAUTOS $ UMBRELLA WB X OCCUR EACH OCCURRENCE $ 5,000,00 A EXCESS UAS CLAIMS-MADE AGGREGATE $ 5,000,00 E F4C U 000 90111t04123111 06/01/12 DEDUCTIBLE $ X RETENTION $ 10 000 WORKERS COMPENSATION WC STATU- OTH- AND EMPLOYERS'LIABILITY X C ONY FFICER EMSER EXCLUDED? R/ERECUTIVE YINJN)AC003603167 08/01112 EL EACH ACCIDENT $ 1,000,00 OFFICERA(EMBER EXCLUDED9 ❑ (Mandatory in uroNH) MA,NH,RI,NYE.L.DISEASE-EA EMPLOYE $ 1,000,00 1y9e dascnb under DESGtRIF71ON OF OPERATIONS W. E.L.DISEASE-POLICY LIMB $ 1,000,00 p Equipment CIM025607813 04/23112 Scneduled 152,78 D Stored Materials CIM025607813 04/23/12 Stored. 50,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Addltlonal Remarks Schedule,If more spree 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. / AUTHORIZED RE 1 VE ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD Office �odr�me'rAlIa1F8��'BGyfhe � HOME IMPROVEMENT CONTRACTOR Registration: ,ya117430 Type: Expiration: 012 Private Corporation ONMENT _ INC I CHARLES MINISR- �u 10 HAZEL DR t HAMPSTEAD, NH 0 L -- i��T"�� Undersecretary j i i -�- �'I assachuscttx - Dcp:u-tnunt of Public SaFeh Bom'd n( Buildin Regulations and $tantl:trds Construction Supervisor License License: CS 71077 CHARLES J MINASALLI 9 EPPING AVE HAMPTON, NH 03842 Expiration: 7/2 812 01 3 (' mmisinner Te#: 998