11 LINDEN ST - BUILDING INSPECTION r '
The Commonwealth of Massachusetts
�- Board of Building Regulations and Standards CITY OF
I t, SALEM
Massachusetts State Building Code, 780 CMR
g Reviaed,llur2(!ll
NBuilding Permit Application To Contt epair, Renovate Demolish a
One-or Two amily welling
This Se tion For Q4cial Use O y
Building Permit Number: a Applie . F9
Building 011icial(Print Name) Signature Date
SECTION 1:fillf E INFORMATION
1.1 Property Address• 1.2 assessors Map& Parcel Numbers
/r 2/:t/dc.✓ sue-
1.1 a Is this an accepted street?yes V11- no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
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 Zone: _ Outside Flood Zone? P p
0� Private❑ Check if yes[] Munici al fd�On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of ReSSQQrd:
y,✓y,A /LOSS/ — �-ln ✓��'
Nai a(Print) City,State,ZIP
// ,L Alael-n/ ST•• /- 6a, zi '7- BOBS
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ I Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: _
E n o�f.Pr/ L d/Work': AarZllcef Itf
,eo . a sii`✓/.�3
dni i5 siiN
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Nlatenals)
1. Building 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical $ — ❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing $ — 2. Other Fees: $
4. %lechanical (I-IVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost $ 14,pa-p• 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES t
5.1 Construction Supervisor License(CSL)
17.4A��i9l� l�/�'-OY3JJ/J/ d I.icense Number Expiration Date ,
Name of C'SI.. Holder _ -
�^ List CSL T)'pe(see below)No. and Street _ Type Description
.G .✓F.E/d �P-/�. a/s�o is U Unrestricted(Builcin�s uh to 35,000 cu. It.)
Restricted Id2 Family Dwelling
Cit /Town,State,ZIP M Masonry
i .
RC Roolin Coverin
dow WS Win and Sidin
SF Solid Fuel Burning Appliances
/ 7d'/- 339 33e'g I Insulation
"reie bona Email address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
omP7-OJ✓ ePwt/f y Cf NJ ,mac /ISO /�io 8 3-/3- /a
I11C licgistration Number Expiration Date
III6C Compan Name ur I IIC Re p��Iis ant Name
S/�F'i9PF/
No and Street Email address
L > FId �/AO/ /7,P/334'-336'r
Ci /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
FIr
affidavit will result in the denial of the Issuance of the building permit.
idavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r of the subject property, hereby authorizey behalf,in all matters rreelative to work authorized by this building permit application.
's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
3
contained in this application is true and accurate to the best of my knowledge and understanding.
7f i4n/�A// C .C'd/�J,yid J✓ �1C.r y 3 7. O//
Pnnt Omer s or Authorized Agent's Name(Electronic Signature) Data
NOTES:
I. 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
y_s�sy.m:u,�^ov oca Information on the Construction Supervisor License can be found at w w.n :is S.go_'dpx
?. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basementlattics,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"
OP ID:WL
sat`coizo CERTIFICATE OF LIABILITY INSURANCE °^0 9/111 Y"'
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
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. N SUBROGATION IS WANED,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 endorsemen s.
PRODUCER 978-750-0044 COMACT
William J Lynch Insurance Agcy NAME. FAX
92 High Street 978-750$�8
Danvers,MA 01923
ADDRESS:
Wn
m,CROMPTI
INSURER(S)AFPORDING COVERAGE NAIC9
INSURED Crompton Carpentry&Constr. INSURERA:Max Specialty Insurance
6Spearfiields Lane INSURERB:Travelers
Lynnfield,MA 01940-2553 INSURER c,Commerce insurance
INSURER D:WBstBM Surety Company
INSURERE:
INSURERF:
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.
ILTN TYPE OF INSURANCE im POLICY NUMBER Yr NIn UP UNIT
GENERAL UABRJIY EACH OCCURRENCE E 1,000,00
A X ceMMERcwL GENERAL LUIBILm MAX013100001669 10131/10 10/31/11 PR��� I E 50,00
CLMNSiAADE QOCCUR MED EXP(Any core pe ) S 5,00
PERSONAL a ADV INJURY E 1,000,0001
GEHERALAGGREGATE S 1,000,0()
DOM AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO S 1,000,00
X POLICY PRO- LOC $
AUTOMOWELL46U Y COMBINED 64NGLE UMIT E 100,00
(Ea modenq
C ANvauro VV3519 08/17110 OB117/11 BODILY INJURY(Per person)) E 300,00
ALL OWNED AUTOS BODILYINJURY(Perarddenl) S 100,00
X SCHEDULED AUTOS PROPERTY DAMAGE
HIREDAUTOS (Peremden0 S
NON-OWNEDAUTOS E
E
UNBRELIA UAB DCCUR - EACH OCCURRENCE S
EXCESS UAB CLAI:UADE AGGREG6TE S
DEDUCTIBLE S
RETENnON E S
WORKERS COMPENSATION WC STATU- OTF4
AND ENPLOYFRS'LIABILITYB ANYPROPRR:TORIPARTNEWE1a:CUTNE YIN SKUB-773 07MI10 07MI71 - E.LEACHACCIOENT 5 100,00
0FFICERIMEMBER EXCLUDED? N/A
(Marelaeory N Ise E.LDISEASE-FAEMPLO S 100,00
Ryes,demipeu '
DESCRIPTION OF OPERATIONS RNoa• EL.DISEASE-POLICY LIMIT S 500
p Bond 70641597 061=08 1 06/08/13 Bond 10.00
DESCRIPTION OF OPERATIONSI LOCATI(MI VEHICLES(AuKh ACOND 101,AddM*W kn rab 5N ,edul ff re ape t3 reyulmdI
All carpentry operations for the above insured.
CERTIFICATE HOLDER - CANCELLATION
WINDOVE
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
- -_ THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORQED REPRESEHrATWE
01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registersd marks of ACORD
• 1
�b CITY OF S.0 EM, lNWs.kcm;sET rs
BUMD0413 DEPARTMENT
110 WASHNGTON STRErm 3'FLOOR
` TEL (978) 745-959S
FAX(978) 740-9846
Kl.%j3E LF-V DRISCOLL
MAYOR THO.UAS ST.PtERRs
DIRECTOR OF PLBLic PROPERTY/BUMDLNG CONNISSIONER
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:
7,t dyli d® t2g e
(name of haule )
The debris will be disposed of in
(name of facility)
C'am�nFQrJ�L 5 � .Cy.�.K .�-t95s
(address of facility)
signature of permit appfficant
Ca Z ;to
date
4.bnulf J•x
a CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
M1%nIty InlK toi
Ntltw
. 11.\ttnsnl.�tltla,�ilnl:hl' • S,ul+.vk,M.uvnt.uk u I n3pq�
Ila.: 774711•/iv3 0 1:IN 9711•74C•9346
lvurkers' Compensation Insurunce :\tndavi(: Builders/Cuntracturs/Eleetrlclans/Plumbers
I illcant Inforinalion
/J PI •rs Print Le 'ill
Name I IluwfwvaiOrpanuarinNlndfvf,luull: (w�strr7�D� ��R���� aG�
Address: G
City,Srarc,%ip4- 9� - Phone it: -A 3 ¢- 3�
Are),to an employer?Check the approprlua box:
11. 1 am a employer with 4. 1')M o/prvtJect(required):
❑ I aln a general contractor and 1
mnpluyres(full and/or part-time).• have hireJ tlife suh•cuntracturs 6. 0 New construction
2.0 1 am a sole prnpricnu or partner- listed on the attached sheet t y ❑Remodelin`
.ship and have no mnpluyccs These sub-contractors have a. 0 Nololirion
Ivorking firs Inc in any capacity, po
rkers'rkers'comp, insurance.
I No workers'cutup• insurance J. 10 We are a corporation and its 9• ❑Ouilding addition
3.0 required.) on7cers have utmsircd their 1o.0 Electrical repairs or additions
land a homeowner doing all work right of exemption pur NI IL 11.0 Plumbing rupuirs or additions
myself. [NO Ivnrkers'cutup, c. 152.Ills).and we hnv.no
ilmuranco required.)t anpluyces.(No worke 12.❑ Ruul'repaira r
rs'
comp, insuranw r.quind.J 1 J•0 Oiller
•bly.gglhavm film crocks It"el mual:dw fill fnn the.ecuuu L"s,ewwcing their wwhurt,efMfInMwll,nt Inaiwy m6utrtuliurl
'I tunw,twfmn ohm afafmil this emeavit ineiutina fhfry aw Juine All work ane Itle1 hilt/uuside nnmrtmfoe must Ww"il a nw akftdaw k inaicttinx wtek.
'r.MlMCI"1hm eMck thie box m am attached an 3da11kaw Afro tltnwlna the ffanq tithe rub.eemr000ms and them wurkme'i°'n/.Inflict,InlMmtarlua
/nfn un employer that If prev/d/rag 1vorhtra'rurnprnrndon Lrsarvmea/or nsy nnp/uyrrr. Brlate Is tilt pu/lay and/otl.rih
Illfaf/rtat%IIr1,
Insurance C'umpany Name:
Policy 4 ur Sulr•ins. Lic.d; - — -_
_ Eepirattun Date:
lob Situ�\ddnss: �� LiN�Fir S%.
CUy'slatelzip;
.\ltach it cftpy of Ilm workers'cumpenaatlun pollcy declaration puge(ihowing the polley numbar and e.tplratlua data).
Failure to wears coverage as required under Section 25A ul'VIOL e. I52 can lead fo the imposition of etiminal penalties of a
sine ufi to 50.0Sl a J y tlofurIdai one-year lmprisumncnr, as wull as civil pcnulllus in the t'unn of a STOP WORK ORDER and a fine
of up res i?3Q.rlo a Jay.gains)the violator. Ile adviacd that a copy ethic smtrincnt may be IurwarJcJ to the Office uC
IIII I\IhJIVII Ia el Ille U1A li)r lnhuravice ;overa.0 %e/'Itktalllln.
/flu hereby k erti/y milder the pm a fmd pnro/�irr if/'perjury that the bt/urtnmNoe provided ubeve is true mud Correct.
uf,ra - q
I'h, I:e:r �� 70� ��J T' ✓��
t)//lriu/fat umr/y. l)a oat fvritlf in this urea, to he rompilted by airy ur solve n//lriu[
' ('ify ur 7btrn: j
Pcnniul.1cense to
Maing .kulhurity (clrclo mle):
I. UffurJ of Ilrahh 2.puddiu; Ikparnacltl 1. t:il'A'Otuk Clerk J. Llecfrical lovpcctur S. Plumbing Imyceror
6. Other
l'�,ut.ret 1'cnuu: I
Thule-t
i
information and Instructions
I'I rsu:uu w thi`+wturta. +n rmPluvea is detiiedras es..Ilevery person in the s)cirs to ervice of anothercompensation
uule1r�nny contract of hire.
t .
cypress or onplicd, oral or written." or aIt two or more
�n.mpluyer is act. >s"an IndiviJwl, puManhip,•Issoewnon,corporation ur other legal eased Y
t the I;,egomg engaged m a joint enterpnse, and including the Ieya1 epren fly,a es loyin deceased
nest I Howcver the
.ecetver or uuaea ut.uu indivlJwl,pssmershrp,assoetatioa or other legal entity,employing a ' P Y
owner of a dwelling{house having not more than three apartments and who resides tlree;n or the occupant of el the
tenance.curistr
,Iwelling house of another who a urten•;uthereto shall uotnbeeausa of such employment be deemed taction Of repair work in ube tin employer."
or on the grounds or building,app
sty shall withhold the Issurece or
MGL chapter 132. 425C(6) also states that"every stets or local licensing ugs
renewal of r Ilcemu or permit to operate a business or to eoastruet buildings Is the cammeaweulre for any
:Ippl,4:dnt ",,a has not produced as�ept ibrtesr Neiniher the once of nnonweAlth not any of its polit calgtubJivisrads,+hall
%dJilionully, NIGL chupter l sl, 4= I )
enter into any contract for the perfomtanca ut'public work until acceptable iJance ofcunlDliurce with the utsuranee
requirements of this chapter have been presented to the contracting authority-'*
Applicants applyto our situation and.if
Please fill out the workers' compensation affidavit completely. M nunrber(s)along withecking ilia boxes h their certificate(s)of
necessary, supply sub-contractor(s)numo(s),aJdess( )' P with no employees other than the
insw race. Limited Liability Companies(LLCwork invited Liability
oe insurancutnershie.(if an)LLC or LLP does have
members or partners, are not required to carry
employees,u policy is required. Ba advised that this affidavit may be sub to the Department of Industrial
artment of
:\ecit Yets.for con licyfli is riqu re i. 90 advised
coverage. Also be sure to sign and date the u(tldavlL The atliagm shoal
g requested,
be rcutmed to the city or town that the applicationras tee ermit Or rding the low or if you is
are required notto obroitrtu workers'
Industrial Accidents. Should you have any 4
compensation policy.please call the Depurmmnt At uhit number listed below. Self-insured companies should enter their
self-insurance licetwe number on the a ro rrte lino.
City orYown 0/11cisls partment
P the affidavit f that the for You to affidavit
1I out in the event the Ott ee of Investigationsibly. The
Ofhas to contact yoprovided
regarding the tapp�lietant
Of th a be sue w till in the pr rtnit/license number which will be used as a reference number. in addition,an applicant
11l
and under"Job Site Addresi'the u lieant should write"all lueutions in (city or
that must submit multiple Dannie'Iiceluwe applications in any given year,need only submit one affidavit Indicating cunen
policy information of necessary) ' roviJcJ to the
town)."A copy of the ufndavit that has been officially stamped or marked by the city or town may be pout
applicant
ant%vh As proof
rc home t a valer or ciid tizen isdavit lobtaining a ls on file for icense or permit noture permits or t elated to any bunses. A now sinessdavit lor c must emsr�I venture
tic :t dug license or permit to bum leaves cte.)said person is NOT required to complete this affidavit•
I he Mice ui Investigations would like to dwnk you in advance fur yourcooperation and should you have:Iny yumuons,
plca,e du out hesitate to give us a call.
the D,:partment's address, telephone and rax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Ofltee of levadgatlons
600 Washington Street
Boston, MA 02111
Tel. N 617-727.4900 eat 406 or 1.877-MASSAFE
Fax M 617.727-7749
www rnass.gov/die