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14 LEMON ST - BUILDING INSPECTION "4umb,, The Commonwealth of Massachusetts Department of Public Safety MassachusettsState Building Code(780 CAIR)Seventh Edition City of Salem Permit A lication for an Buildin other than a 1-or 2-Famil Dwellin(This tiection Fur Official Use Only) Date Applied: Building Inspector: �ySEC LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available) p SECTION 1:- i , S H I'll; No.and Street City /Town Zip Code Name of Building (if.applicable) SECTION 2:PROPOSED WORK If New Construction check here ❑or check all that apply in the two rows below Existing Building J11Y Repair❑ Alteration ❑ Addition ❑ Demoli lion,�. (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/ur construction documents being supplied as part of this permit application? Yes 'OyNo= Is an Independent Structural Engineering Peer Review reilu ifed? J /� Yes ❑ No ❑ Brief Description of ropose Wo k: i2lel /O X /E+ �/I.n,Z S /, d t4, L� SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION, OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑ Existing Use Group(s): Proposed Use Group(s): -t• Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: LSECTION-4:-BUILDING HEIGHT AND AREA Existing Proposed No. of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.) Total Area (sq. ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4❑ M: Mercantile❑ 1 R: Residential R-10 R-2 ❑ R-3❑ R-4 ❑ S: Storage S-1 ❑ S-2 ❑ U: Utility ❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ 111B ❑ IV ❑ VA ❑ VB ❑ SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Infomaation: Sewage Disposal: Trench Permit: Debris Removal: Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site Cl Pri va tl' ❑ or indenlifa Zone: ur on site Nvstem ❑ required ❑or trench or+pecifc: permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: \IA I ti,h,nr l ioo f'n,— ..\ol :\pplicabll'❑ I.Structure withua.airport approach.area' I. their recirav<um ,1 Ic0.•d' I ,n"( nmenl to BUlld endo.ed ❑ Ye, ❑ or .No❑ Yes ❑ -\o ❑ SECTION 8:CONTENT OF CERTIFICA"FE OF OCCUPANCY 1'..IWnn Q Code L".e GnnipL G lcpe ul Con>truction: llcaipent Lund per hour: D-WI till'buildual;contain an Sprinkler Scstem': Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION .. Name and Address of Property Owner d/9t� No. and Street City/Town Zip Name(Print) /JJ Properly Ow tier Contact Information: f�t/CMd o—, Ln L Title Telephone No. (business) Telephone No. (cell) e-mail address It-applicable. the property owner herebv authorizes Name Street Address Citv/Town State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit application. .SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (if build in g is less than 3500 cu. ft.of enclosed<pare and/or not under Constriction Control then check here O and skip Section Ill.t) 10.1 Registered Professional Responsible for Construction Control Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name:- Name of Person Responsible for Construction License No. and Type if Applicable n Street Address City/Town State Zip Telephone No. (business) Telephone No.(ce11) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.GL.c.152. 25C(6)) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and ffidavit will result in the denial of the issuance of the building permit. submitted with this application. Failure to provide this a Is a signed Affidavit submitted with this a hcation? ""`"' - Yes❑ No 0 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs: (Labor Item and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)=$ 3. Plumbing $ Note:Minimum fee=$ (contact municipality) 4. Mechanical (HVAC) $ 5. Mechanical (Other) 1 $ It Enclose check payable tom-�C-7 6.Total Cost $ (contact municipality)and write check number here SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I her by at under the pains and penalties of perjury that all of the information contained in this application is true and accurate t e best of m knowledge and understanding. aelo Please print and>igl n, me title Telephone No. Dale 6/ ZeIn art J�z••fi 'treet Address City/Town State Lip 1unicipal Inspector to fill Out this section upon application approval: Name Date CITY OF S.0 EM. AxsSACHUSEM BL an LNG D EPA ATIEI iT .__,..,, .. -120 WA:iHINGTONSTREET 3no,FLOOR TEL (978) 745-959S Is FAx(978) 740.9&M KI.j3ERjEY DRjSCOLL HAYOIt Tuottw ST.PMAM D I RECTOR OF PL OLIC PROPERTY/gL a-DLNG CO-%LNRSSION ER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers >pnllcant Information !v� h Please Print Legibly VbITle lBurin.�sOryytitatiorvinJtv�djwl): 1 1(�1�R ,S IC (��A� Address: y p�� city/state/zip: b �L My \ n ( � t S Phone M: e ICJ 9�J ,\re you to employer!Cheek the appropriate box: Type of project(required): I.MI I am a employer with 4. ❑ 1 am a general canagetor and 1 6. ❑New construction employees(full and/or pan-time).• have hired the sub-contractors 2.❑ I mn a sole pmprietw are partner- listed an the attached sheet: y ❑ Remodeling .hip and have no employees These subcontractors have g. ®Demolition workingfor me in an capacity. worker'-comp.insuratus y p ry. 9. C] Building addition INo workers'comp. insurance 3. Cl We are a corporation and its 10❑Electrical repair of additions required.l officers have exercised their . 3.❑ 1 am a homeowner doing all work right of exemption per MCI, 11.❑Plumbing repairs a additions myself.(No worker'comp. c. 152.41(4),and we have no 12.❑Roof repairs insurance required.( t employees. LNG worker' 13.0 Other comp. insurance required.) 'Any applicants that attacks boa el must Am fin raid raw section below showieg their workwo'eanrpmandan puliey infumtadosr 'i l,v wtrwnw,who subma this affidavit indicating they an doing all work and them him outside contractors mum suhmit a tow am,6vii indicating such. :C.maabn dot chaek this ben mud anmbd an additwrwh alwat showing an none of the a►tontrston and their wurkaa'comp,policy inrOlmadem. t arts aft etwp/oyer titer is previd/ng workers'compentadon lnsorsaee for my employM, t3slow is the pNlry anI/ob si(e information. / Insurance Company Name: !�� -/ 121 /LIU l G� Policy 4 or Self-ins. Lie.M: I 8 :0 �Q --/L&2(, 'U 1 Expiration Date: ,//q�,��� �q/J ,1 Job Site Address: /V L G Wj S/d/A� City/Sta izipi TLCC//C/r W/Y+0 q� v ,snack a copy of tha workers'compensation policy declarafba pop(showing the policy number and explratlos date). Failure to secure coverage as required under Section 23A 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 well as civil penalties in the farm of a STOP WORK ORDER and a line Of up to$250.00 a day against the violator. Ile advmul[hats copy of this statement maybe forwarded to the Office of Invcangationn ol'dteD1A for insurance coverage verification. /de hereby certify under rho pains and penalties of perjury that the/nforetedna provided above is true vied carreca r titre Uater Pconc 4, DVrIria/ace only. Da nor write in this area, to be completed by City or towtt oJftcieL City or rusvn: eermivl.lccmtM___ __ f.suing.\whonly (circle one): 1. Ifuard of lleullh 2. Ruiltllnu Department .). City/rown Clerk 4. Electrical litspeclor 5. Plumbing Intpeetor 6. 01her l.,nwct Person: _ ._ _.. Phone iv: .... -.................... ._ ACORD CERTIFICATE OF LIABILITY INSURANCE 9ii6i200 PRODUCER (978)532-5445 FAX: (978) 532-2217 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION S.K. McCarthy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR- 10 Centennial Drive ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. West Entrance Peabody MA 01960 INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA.Scottsdale Ins. CO. Mark's Disposal, Demo & Cleanouts, DBA: DBA INSURER B.Safety Indemnity 33618 445 Elliott Street INSURER C'. INSURER D: Beverly MA 01915 INSURER E: OVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING AN 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. REG NTE LIMITS SHOWNMAY HAVE BE NREDUCEDBYPAID CLAIMS. INSR ADDL POLICY EFFECTIVE POLICY EXPIRATION TYPE OF INSURANCE POLICY NUMBER DATE MM/DDIYY DATE MM/DD LIMITS GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED lOO,OOO PREMISES Eacccurtence $ A CLAIMS MADE rx]OCCUR CLS1400596 7/2/2009 7/2/2010 MED EXP(Any onePerson) $ 5,000 PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP ASS $ 1,000,000 X POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ 11000,000 ANY AUTO (Ea accident) B ALL OWNED AUTOS 3947843 5/27/2009 5/27/2010 BODILY INJURY X SCHEDULEDAUTOS (Per Person) $ X HIREDAUTOS BODILY INJURY X NON-0WNEDAU(OS (Per aalden0 $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA A 8 AUTO ONLY: AGG $ EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION S $ WORKERS COMPENSATION AND I VIC TAT - OTH- EMPLOYERS'LW BILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED? It yes,descriee under EL DISEASE-EA EMPLOYE $ SPECIAL PROVSIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Workers Compensation certificate has been requested from the carrier and will be forwarded directly by them under separate cover. CERTIFICATE HOLDER CANCELLATION dkmd@verizon.net SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Debra Kircheimer EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 14 Lemon Street 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT Salem, MA 01970 FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE �C eH^ A John McCarthy/LG4 ACORD 25(2001108) ©ACORD CORPORATION 1988 IMRMc m,no�no.. Pane i nr? IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). 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 endorsement(s). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend,extend or alter the coverage afforded by the policies listed thereon. ACORD 25(2001108) INS02510108l.0ea Page 2 of Additional Named Insureds Other Named Insureds - DBA Mark E. Pyne Doing Business As OFAPPINF(02/2007) COPYRIGHT 2007,AMS SERVICES INC ADDITIONAL COVERAGES Ref# Description Coverage Code Form No. Edition Date PIP-Basic PIP Limit 1 Limit 2 Limit 3 Deductible Amount Detluctible Type Premium 8,000 Ref# Description Coverage Code Form No. Edition Date Waive Collision Deductible WVCLD Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date. Underinsured motorist BI split limit UNDSP Limit 1 Limit 2 Limit 3 Detluctible Amount Deductible Type Premium 250,000 500,000 Ref# Description Coverage Code Form No. Edition Date Medical payments MEDPM Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 5,000 Ref# Description Coverage Code Form No. Edition Date Uninsured motorist BI split limit UMISP Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium 250,000 500,000 Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium Ref# I Description Coverage Code Form No. Edition Date Limit 1 Limit 2 Limit 3 Deductible Amount Deductible Type Premium OFADTLCV Copyright 2001,AMS Services,Inc. RightFax Cl-1 9/17/2009 4 :26:36 AM PAGE 2/002 Fax Server ACORD. CERTIFICATE OF INSURANCE DATE(IALWDAYY) 09-17.09 PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE B K MCCARTHY INS AOCY HOLDER. THIS CERTIFICATE DOES NOT AMEND,EXTEND OR IOCENMNNLAL DRIVE - -- - ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. COMPANIES AFFORDING COVERAGE PEABODY,MA 01960 COMPANY 2777W A HARTFORD CROUP INSURED COMPANY - B PYNE MARK I?DBA MARKS DISPOSAL,DEMO&CLEANOUTS COMPANY 445 ELLIOTT STREET C BEVERLY.MA 01915 COMPANY D COVERAGE THIS 19 TD CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWIMSTANDDIO ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO W WCk THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN.THE INSURANCE AFFORDED BY THE POUCIES DESCRWEO HEREIN Le SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIEA UIDTS SHOWN MAY HAVE BEEN REDUCED BY PAN)CLAIMS. 00 POLICY EFF POLICY EXP LTR TYPEOFINSURANCE POLICY NUMBER DATE(MMIDDAYY) DATE LIMITS OENERALUABLITY GENERAL AGGREGATE $ COMMERCIAL GENERAL PRODUCTS-COMPIOPAGG. $. CLAIMSMADE OCCUR. PERSONAL 88 AOV.INJURY $ OWNERS AA CONTRACTORS PROT. EACH OCCURRENCE $ FIRE DAMAGE(Anyone fire) $ MED.EXPENSE(Any one person) $ AUTOMOBILE LIABILITY A14YAUTO COMBINED SINGLE LIMIT $ ALL OWNED AUTOS BODILY INJURY(Par Person) $ SCHEDULE AUTOS BODILY INJURY(Per Accident) $ HIREDAUTOS PROPERTY DAMAGE $ NON-OWNED AUTOS GARAGE LIABILITY ANYAUTOS AUTO ONLY•EA ACCIDENT S OTHER THAN AUTO ONLY: EACHACCIOENr $ AGREGATE $ EXCESS LIABILITY UMBRELLA FORM EACH OCCURRENCE S OTHERTHAN UMBRELLA FORM AGGREGATE $ WORKERS COMPENSATION AND A EMPOLYEW5 LIABILITY UB-0807LB26.09 08.25.09 08.25.10 STATUTORY LIMITS X THE PROPRIETOR/ EACHACGDENT $ 100.000 PARTNERSIEXECUrIVE INCL DISEASE-POLICY LIMIT $ 500.000 OFFICERS ARE: X EXCL DISEASE-EACH EMPLOYEE $ 100.000 OTHER DESCRIPTION OF OPERATIONSAACATIONSNEHICLESIaESTRICTIONSISPEGAL ITEMS THIS RBPLACFS ANY PRIOR CERTIFICATE ISSUED TO THE CERTINCATE HOLDER APPCCIWO WORKERS COMPCOVCRAOD TTIE WORKERS'COMPENSATION POLICY DOES NOTPROVIDE COVERAGE FOR PYNO MARK 6. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE DEBRA KIRCHEIMER EXPIRATION DATE THEREOF.THE 188U0NG COMPANYWILL ENDEAVOR TO MAIL 10 DAYS W RfrTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TOTHE LEFT.SUf FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LMBILITYOF 14 LEMON ST ANY KIND UPON THE COMPANY.ITS AGENTS OR REPRESENTATVEA SALEM.MA 01970 AUT14ORMED REPRESENTATIVE ACORD 25.5(3)03) Ramani Ayer ftlARK'g Mark's Disposal, Demolition & Cleanouts Estimate 445 Elliott St. aI^AL,UZMoacL con Beverly,MA 01915 Date Estimate# 978-828-3398 _ 8/27/2009 1124 Name/Address Debra Kircheimer 14 Lemon st Salem MA 01970 Project Other Shed Removal Item Description Qty Cost Total Labor Labor 24 28.00 672.00 Supervisor Labor Supervisor Labor 12 35.00 420.00 Disposal Disposal 4 130.00 520.00 Environmental/Fu... Environmental/Fuel Charge 8.00% 41.60 Total $1,653.60 Phone# 978 828 3398 , s tt,•. ' CITY OF SALLM PUBLIC: PROPRERTY DEPARTMENT Construction Debris Disposal Affidavit (required Ii)r all demolition and rcnua.ltion well In accurdancr ith tic sixth edition of the Slate Building Code, 780 CAIR section I 1 1.5 Dchris, and the provisions ul'.tiIGL c 40, S 54: Dui Wing I'rrmil ft is issued with the condition that the debris resulting front this work shall he disposed of in if properly licensed waste disposal I'acility as defined by MGL c I11. S 150A. (The debris will he trunsportcd by: 1 A W V" '� pU� k Inamc(ifh tiler) I he debris will be disposed of'in I name u(IaCJnY) .ulJrca. ur I-,luhly I 1 1 I aenalu)e nl p:u tit .gq)hunl //7G •I�ir