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75 LORING AVE - BUILDING INSPECTION � + - 'rile Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR S ALEM Revised,dMar L/nr 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date,A ied:, - Building Offiou (Print Nume) --.Sign ure e SECTION 1:SITE INFPiKNIATION ` LI Prop rty A�Idress: ^ 1 1.2 Assessors Map 3c Parcel Numbers '7 J...p'62♦ r1� I'M I.1 a Is this an accepte street?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq it) Frontage(R) IS 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: LS Sewage Disposal System: Zone: _ Outside Flood Zone'? Public❑ Private❑ Check if yes[] Municipal❑ On site disposal system ❑ SECTION 2. PROPERTY OWNERSHIP` 02.1 am' 9f Record: i (Print) City,State,ZIP r No.an Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description of Proposed work'-: Der' C, l9-ROw^Cl 7t<.�a #ggAe-ft Deft o Ll`f`l iJ IG e l\ SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials I Building S 1. Building Permit Fee:S 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: S 4. Mechanical (HVAC) S List: , 5. Mechanical (Fire S - Total All Fees:S Suppression) Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ a O rJ O ❑Paid in Full ❑Outstanding Balance Due: a45r OL � 78 - 335'--16 �z SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) /D L/7 9E .3 y \✓4 rJ C e,� G f-f"Y\ D License Number E.epira ion Date Name of CSL Holder W- "'1+,--- ,J' •- List CSL'Pype(see below) W _ CS a Types Description No imlStreet U Unrestricted(Buildings up to 35,000 cu. It.) +'��l)J�I__� - -t'i -Q•:� o_v"/ R Restricted 1&2 Family Dwelling City/Gown,State,ZIP �� M Masonry RC Roo ring Covering WS Window and Siding d / �� SF Solid Fuel Burning Appliances 4- [ 1 Insulation Telephone Email address D I Demolition 5.2 Registered Home Im v(e�ment Contractor(HIC) -, �S O c 3 6 S S7, �Ifir,\�S �ro 1J� HIC Registration Number Expiration Date HIC Comport r>1� Name or HIC li i W Iranl Name No.and Street W O 6 PN n Email address City/Town, State,ZIP d 1 Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c: 152.g 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 Is§uance of the building permit. Signed Affidavit Attached? Yes .......... No........... ❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN: OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT' I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. X Print Owner'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 contained in this application t rue and accurate tq the best of my knowledge and understanding. Print Own�r Authorized Agent's Namn(Elec ySic Signature) Date 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 bLG.L.c. I42A.Other important information on the HIC Program can be found at www.mass..,•ov;'oca Information on the Construction Supervisor License can be found at www.nmss.sov."dns 27 When substantial work is planned,provide the information below: Total floor area(sq. R.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. R.) 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" v CITY OE SM-ElM, lLkSSACHCSEM BUILLILNG DEPARTNI.04T 120%VASHCNGTON STREET,3"'ROO& TEL (978) 745-9595 FAx 978 740-9846 KIMBERt FY DRISCOLL THOAL►sST.PmRRa MAYOR DIRECTOR OF Pl:OLIC PROPER'fY/Bl:1tDLYG C01L\IfSSIO.iER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aliplicant information T/ p� Please Print Legibly ViIInC II)WIIktiLt)f6•aalraltaNlndlVldU811: �� • f`.K''� f"So �e— Address: City/State/Zip: SAJ-e� rviH OI -LO Phone M: 978 7 y Y Y5-L/5� Are you an employer?Check the appropriate box. Type of project(required): 1 r9 1 am a employer with 2 — 4. 0 I am a general contractor and 1 6. ❑Now construction employees(full and/or pan-Limo).• have hired the sub-eontractora 2.0 I am a sole proprietor or partner- listed on the attached sheet t ?• ❑Remodeling ship and have no employees These subcontractors have 9. Demolition working.for ma in any capacity. workers'camp.insurance. 9• Building addition [No workers comp.insurance 5.'0 We are a corporation and its rcyuircd.J officers have exercised their 10.0 Electrical repairs or additions 3.0 I am a homeuwncr doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.(No workers'sump. c. 152,$1(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' 13.0 Other, sump:insurance requircd.I •Any applicant that chndts box l l most also fill out the auction below showing Nit"Irew'compensation Pollfor n►y inmatio 'I hvnuuwnan who submit this affidavit indicating they ate daing all work and then hire ointide cantwctsxn most submit a paw anWavit indicting such Contrautun that ehcsk this box most atlaehod an addiliund short showing the name of Iho sulo.comraeton and their wor4aw'sump,policy hobstr anon. lain an earpluyer that/s pravfding workers'coinpettsailen insurance for my employees Below/a rho pulley and fob slie h1formatfan. p Insurance Company Name /�o-•. !T co--J[ C.LJ policy 4lurSclRins.Lic, d: W C— ,21b AD ©© QL —930 3 Expiration Date:, /0 ! Job SiteAddruss: S )-0 ftu -46 a City/Statdzip: SA-Cw- rAA 0 j 9 -7 b %Itacb a copy of the workers'co n9pensation policy declaration page(showing the policy number and expiration date). Failure to sceuru coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a tine up to S1,500.00 und/or one-year imprisonmenk as well as civil penalties in the form of a STOP WORK ORDER and aline of up to S?.i0.00 a day against the violator. Ile advised that a copy of this statement may ba forwarded to the Mica of Invesligaduns ufthe DIA for insurance coverage verilicatiun. l du hereby certify rardes•the pules at penalrles ufprr ry that the hifurmutlan provided abuve is true and correct. i I ;i-:nalnre: ►�.-��-�- Qum: 9 /191 13 Phone it* Ojjicial use unfy. Do not write hit t/rur area,to be corrplered by city or town n/Jh•I"Z i City ofrruwn: ___ Permit/l.lcemeis ..+suing Aulhurily(circle one): I. Dourd of Ileahh 2. Duilding Department 3.Cily(rown Clerk 1. Electrical lospector 5. Plumbing Inspector b.Other Contact Person: � ..._. ... PAono ti• I ( CERTIFICATE OF LIABILITY INSURANCE ¢4TEIMM/DDHV ) 6_.I:--I 1 9/9/2013 THIS CERTIFICATE 15 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditionsof 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 endomement(s). PRODUCER CONTACT Berkley Assigned Risk Services NAME. Farquhar& Black Ins Agency q",D°NH_EXIX 800 634-4589 (NC.No.): 866 215-8118 85 Exchange St ADDArESS: PolicySerAces@berkleyrisk.00m Lynn, MA 01901 INSURERS)AFFORDING COVERAGE NAICY INSURER A'. INSURED INSURER B: Patrum Associates Inc INSURER C: dba: Servpro Of Salem INSURER D: 11 Franklin Street wsuRER 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 AODL SUER POLICY NUMBER PO LICY EFF POLICY EXP LIMITS L_TR INSR WVD (MM/DD/YYYY) IMM/DD/YYYY) GENERAL LI ABILITY AUTOMOBILE LIABILITY '$ WORKERS COMPENSATION LIABILITY YIN X WCSTATU- OTH- To YLIMITS ER AND EMPLOYERS'PARTNER gNVCEIMEMBER EXCLUDED' E.L EACH ACCIDENT $ 500,000 A OFFICE/MEMB ER EXCLUDED? NIA WC-20-20-002283-04 09l09/2013 09/09/2014 I d in NH) E.L.DISEASE-EA EMPLOYEE $ 500.000 Ifyeg ye: describe a ewer 500,000 DESCRIPTION OF OPERATIONS OeIdw E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS/VEHICLES(Attach ACORD 101.Addlli.nal Remarks Schedule.I more space isrequ Fed) Coverage Election Category Elect. Status Name State(s) All Entities Locations Officer Exclude Michael Patrisso MA Patrum Associates Inc 374 Forest Ave Swampscott, MA 01907 CERTIFICATE HOLDER CANCELLATION SHOULDANYOF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. • '- AUTHORIZED REPRESENTATIVE Signature: CORD 25(2010/05) BRAC 3139 a7LL�I, -%LksS.ICHusETTS CITY OF J • BUILDING DEPARTMENT N 120 WASHLNGTON STREET, 3" FLOOR T EL (978) 745-9595 FAx(978) 740-9846 NfB RT 1=Y DRISCOLL T lL4YOR Ho.%w ST.PtERRB DIRECTOR OF PUBLIC PROPERTY/HLAMING CM12MISSIONER 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 It 1.5 Debris, and the provisions of NiGL 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 : (name of facility) (address of facility) - i signature of permit appli ant i9 13 date . Jcbiisa O:J.x