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LIBERTY HILL AVE - BUILDING INSPECTION ,t 'i The Commonwealth of Massachusetts J Department of Public Safety Iv-,..•f ..%Iassadrusetts Slate Building Code(780 CMR)Seventh Edition City of Salem Building Permit Application for any Building other than a 1-or 2-Family Dwellin (This Section For Official Use Only) Building Permit Number: Date Applied: Building Inspector: SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available) �1,11 Ay'E Srilfl-- b79-tom I&, _a Sc.. 1 No. and Street Cite /Town Zip Code Name of Building(it applicable) SECTION 2:PROPOSED WORK If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 Change M Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No-14 Is an Independent Structural Engineeringyeer Review required? Yes ❑ No Brief Description of Proposed Work: jJY1f��P�✓1��i VI �$yyt- 120 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): p Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: SECTION 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 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ 1-1-5❑ 1: Institutional I-1 ❑ 1-2 ❑ 1-3 ❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3 ❑ R-4 ❑ S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use O and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ IIB ❑ ILIA ❑ III80 IV VA VB ❑ SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: Public'% Check it outside Flood Zone ❑ Indicate municipal ❑ \ trench will not be Licensed Di>posal Site ❑ Pricale ❑ or indentif. Zone:_ or on zite%,tem ❑ wljUired.❑or trench ur .pecif\: permit is enclosed ❑ Railroad right-ot-way: Hazards to Air Navigation: \IA l li,hmi;( Nec Pn,•..: \• t \ppliCoble❑ I.Slrlllt W'e cvuhin airport approadi ,i rea 1, then recicw Completed' .a l 1m1e1t to Bulld cncl•"cd ❑ Yv, O or.A'"❑ 1"es ❑ \o ❑ SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY L.iilinn I C eile- L.e Grou pta: rcpe•dCon>trnicWm: OCCUpant load per Iloor: D) W' the I•uildhng Contain an Sprinkler Sv,tem': Special Stipulations e / (?JWhU f I SECTION 9: PROPERTY OWNER AUTHORIZATION t"f and Address of Property Owner N -ID Name(I'rin ) No.and Street City/Town Lip PrupertY CTvner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address If,applicable, the property o%%ner hereby authorizes Name Street Address City/Town State Zip to act on the vro perty owners behalf, in all matters relative to work authorized by this buildin aermit a licatiun. .SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) (If building is loss than 35,000 cu. ft of enclosed s ace and/or not under Construction Control then check here❑and skip Section I0.1) 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 �PWx� ✓1G Cg m RN Name: C 5 S� c? �l 7 No m 11`t `I1� + �2 Nam PPye.son Responsil�e(ur Construction License No. and Type if Applicable Street A dr ss City/ToWfl St a Zi�enlz�, v _= K �rre,mYli�ti � . net Telephone No.(business) Telephone No. (cell) e­m6iI address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(61) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor 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) $ Enclose check payable to 6.Total Cost S (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. eroV tiJlc 3yt Y��rooT¢(� 5� Sys 1'leare rint and iign name - Y`a Title Telephone \'o. Dale Ze �� /lve � 1 �01 t tilrrrt :Address City,Town titate Lip Municipal Inspector to fill out this section upon application approval: `° Name Da e c pt Ylassachm etts - Department of Public Snfct'N Board of Buildim-, Re-ulations and Standards Construction Supervisor License License: CS 53693 Restricted to: 00 ROGER A TREMBLAY JR 29 HATHAWAY AVE BEVERLY, MA 01915 Expiration: 5/9/2011 ('ianm isiwwr Trfl: 14698 t, y e' DPSCA1 0 40M-08/pe DRSUFORMCA108212008 /Tj Y�Fff.M1'7 X[47lid C¢LCM O�aiZ24000f�K'K[dEL�A vY..Y:.,. . Board of Building Regulations and Standards • HOME IMPROVEMENT CONTRACTOR Reglst pn: 145375 E eat _312011 TMt 282954 Corporation ROGERA.THE - _Q ORS,INC. ROGER TREMBL a€l 10 COLONIAL RD SALEM,MA 01970 .� Administrator t I CITY OF SOU ENI, 2UNSSACHUSETTS BUILDING DEPARTMENT t 30 WASHINGTON STREET, 3'0 FLOOR TEL (978)745-9595 FAX(978) 740-9W Kj�tBEy. FY DRISCOLL MAYOR THomm ST.PmRitiz DIRECTOR OF PI:BLiC PROPERTY/BUUMING CONMITSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in IJt>vi�, e C°C'41�m (name of facility)'ci —T(address of facility) c� gnature of permit ap licmt date a�n �w�r.a<x 04b CITY OF SiuxE tt AxSSACHUSETTS .... ;,.: ._. 13UI DLNG D EPA RT.%W,'gT w. 120 WASHLNGTON STREET, )w FLOOR TEL (9711) 74S-959S FAX(978) 740-98" IU.,,jBEJU_EY DRISCOLL T MAYOR hOatAs ST.PmRRs DIRECTOR OF PL BLIC PROPERTY/BC QDLNG COMMISSION ER Workers' Compensation Insurance AMdavit: builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeaiblY Nagle (Busirkv0rgan1rati0rvindsvtdual))1' Address: / l7 c City/Statc/Zip �,6 >m wy,_ cm� )J Phone q: l ��3 `�P 5'-3 os-1, Are you an employer'Cluck the appropriate boat Type o/project(required): 1,1_1�am a employer with 4. ❑ t am a general contractor and 1 6. ❑New construetios employees(full and/or part-time).• have hired the subcontractor 2.❑ 1 am a sole proprietor or panner- listed on the attached sheet.: 7. ❑ Remodeling ,hip and have no employees Them subcontractor have S. ❑ Demolition working for mein any capacity. worker'comp.insorsa e. 9. ❑ Building addition I No workers' comp. insurance 5. ❑ We are a corporation and its required.] ) officers;have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. (No workers'comp. c. 152.§1(4),and we have no 12.0 Roof repairs insurance required.] t crrtployees. (No workers' 13.0 Other comp. insurance required.1 'Any applicant this check&box rl must aim rill ool the rretim 11e1M showing their worker compensation policy infumtadon. 'I I.nnetrwrwss who submit this affidavit indicating they at*doing all work and than hit*outside contractors must submit a new amdavil indenting suck -(',mttsYon shot check this boa must attached an additional shore showing the more of to subeoetrwlon and their workers'comp,put icy information. l am an employer(hot b providing workers'comprnsation Inearence for my emplayeer, Below Is the polley anal fob slit informarion. insurance Company Name: Policy M or Self-ins. Lic. H: tn) 1J Expiration Date: ) Job Sire Adds css: City/State/Zip::3:-Jp M MA O� Attack a copy of the workers'compensation policy deciaratbs page(showing the polity number and espiradr s data). 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 well as civil penalties in the form of a STOP WORK ORDER and s fine of up to S250.00 a day against the violator. Ile advised that a copy of this statement maybe furwarded to the Office of Invcaugatiuns ul'the MA for insurance coverage vcriticutiun. /do hereby crrrify underr_h_opt ithes�an/Jd pepsaf les of prrfury that the informadow provided above is true and ca°recL �n9rtlllre: CI!iN h live v�Ci7 �� I)atc: ` S- Phone 4: cel 7 jD1,rhial axe wdy. Do not write in this area, rr be raneplered by city or town officia4t I City or ruwn: _ PermiuTicense M__ hsuing Aulhurity (circle one): I. Ituurd of Ilealth 2. Ruilding Department 3. City/rown Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other 4-wilact Person: _ _ __, _.. Phoneli• AGORR, CERTIFICATE OF LIABILITY INSURANCE 07/08/20 9' PRODUCER (508)651-7700 FAX (508)655-8853 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC - Commercial ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 West Central Street HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Natick, MA 01760 INSURERS AFFORDING COVERAGE NAIC# INSURED Roger A. Tremblay Contractors, Inc. INSURERA: Selective Insurance Co of SC 19259 10 Colonial Road INSURERB: National Union Fire Ins Co PA Suite 4 INSURER C: Salem, MA 01970 INSURER D: INSURER E: COVERAGES 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.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. NSR OD• TYPE OFINSURANCE POLICY NUMBER POLICYEFFECTIVE POLICYEXPIRATION LIMITS GENERAL LIABILITY S 1842342 04/15/2009 04/I5/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO REMED $ 100,000 CLAIMS MADE O OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 3,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 3,000,000 POLICY X JECT LOC AUTOMOBILE LIABILITY A 9091419 04/15/2009 04/15/2010 COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY X SCHEDULED AUTOS (Per person) $ A X HIRED AUTOS BODILY INJURY $ X NON-OWNED AUTOS (Per accident) X $500. DEDCUTIBLE PROPERTY DAMAGE COMP./COLL. (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSIUMBRELLALIABILITY S 1842342 04/15/2009 04/15/2010 EACH OCCURRENCE $ 2,000,QQQ X G•.GVR JGv.n.0 .,.uAGGREGATE A $ DEDUCTIBLE $ X RETENTION $ $ WORKERS COMPENSATION AND WC3531587 07/01/2009 07/01/20 0 -X WCSTATU- I OTH- ER EMPLOYERS'LIABILITY B ANY PROPRIETOR/PARTNEWEXECUTIVE E.L.EACH ACCIDENT $ SOO,QQQ OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATIVE Rosemary Fulham PMA ACORD 25(2001/08) FAX: (781)586-8120 ©ACORD CORPORATION 1988