92 LORING AVE - BUILDING INSPECTION ] , The Commonwealth of Massachusetts
J Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'h edition OF SALEM
N Revised Jannury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or Two-Famd wr 'ng
1- This Section Kor Official se Only
Building Permit Number:. Date Ap lie _-.
Signature:
Building Commissioner/lns to'r of Buildings Da
SECTION I: SittINFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
GF�-b {i, b.G� /AitS �//G
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: - 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(tt)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.0 c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?Public❑ Private❑ Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1Qwnerf of e'yAlf.0 14ee-VM,
( A1 �a (r�tias6 AyE-
Name(Print) Address for Service:
Signature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ AdditionJ
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of roposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S Dd I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
. Plumbing S Other Fees: S
4
. Mechanical (HC)VA $ List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) y5 Jr / a - 3 — a0/2
HL,ylw ��Q�yL>r� License Number Expiration Date
Name of CSL-I folder �AL�T List CSL Type(see below) C S
o /�Bl CZ ✓ Description
of Type
Ad dre U Unrestricted u to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Sig ture M Mason Onl
97,Q 7 Y4 �9.24-- RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
U Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
,r LY /1//]NG y Lrp
HIC Company Name or tIIC Registrant Name Registration Number
o s d t�,e 6- _ ,� _ 622 /a
Add;,,
Expiration Date
Sign T(elepUUhune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 ..........Lf No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 , as Owner of the subject property hereby
authorize ' .(cer i ' n^^' to act on my behalf,in all matters
relative to work authorized by this building permit application.
S Signature of Owner Date
SECTION 7b: /O/WNEW OR AUTHORIZED AGENT DECLARATION
1 �� t ,;�,� )( /,Q ,as Owner or Authorized Agent declare
that the statements and information on the foregoin application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 Volhave access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively.
2 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenL/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"
CITY OF SALEM
,,. it PUBLIC PROPRERTY
DEPARTMENT
�.
fin
.1\111 KI Ry 1ANCt,LL
12.W mild.Nt;i ON SI RELT 4 SAutx4,Mxtis,vc:ncsr;rl ti 0197�
11L 978-745-9595 • pox:978-74V 984G
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A I tlicant Information Please Print Le ibly
N a trot:I Hum ncss/Org-anizationi Individual):
Address: //,/
ily sraLC �p: dzs�er�-/ �1 y76 Phone i:: 9��
(. 7TY'ra�7L
A,r�c/youart employer'.'Check the appropriate box: 'Type of project(required):
I.IYJ I am a employer with— 4. ❑ I am a general contractor and 1 G. ❑ New construction
employees(fill and/or part-tuna).' have hired the sub-contractors
2.❑ 1 ant a sole proprietor or partner-
listed on the attached sheer. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. -workers' comp. insurance. 9• ❑ Building addition
No workers' cum insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption a MGL 11.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work S P P' LPy(I
myself. [No workers' comp. c. 152, g 1(4),and we have no 12. Roof repairs
insurance required.] t employees. LNo workers' 13.0 Other
comp. insurance required.]
-Any:gtplo,at thut chucks box MI must:dso till out the u:aiml below showing Choir workoni compumution pulicy intimrrulion.
'i lomcuwmns who sdunit this affidavit indicating Ihcy,are doing all work and then him outside contrneton most sutmdl a new al'r:davit indicating such.
-Como ton that dwck this box must attached an additional Accl showing the nmne of fire sub-contractors and their workers'comp.policy information.
I urn Cur employer that is providing workers'compensation insurance for sty employees. Below is the policy and Job site
information. Q �('!
Insurance Company Name:--"---..
Y __ .... _-.....___..._.._..-----
1'olicy4orSelf-ins. Lic.�te::,p"f-3/S''.�1�2Jy/�r.-0il�(� Expiration Date:
Job Site :\tldress: 9a r 1i1 City'State/"LiP: r741 d
,\much it copy of the workers'cum ensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A uf:vlGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. Ile advised that a copy of this stalemunt may be lbrwarded to the Office of
II,esligan nts ol'thc DIA i'or instuarcc coverage\erilieation.
l do hereby certify under the pains and pnm Less uof perjury that the infarnulion provided above is true and correct.
Siulouue; -_-- Date- 0/7
--
Official use only. Do not write its this area,to be completed by city or totem oJJicial,
City or Town: Pcrmit/I.icense4---___
Issuing,\uihorily(circle one):
1. Board of Health 2. Building, Department 3. City/fown Clerk 4. Electrical loipector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an empluree is defined as"...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152. §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally, MG .chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants -
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their -
self-insurance license number on the appropriate line.
City or Town Officials
Please he Sure that the affidavit is complete and printed legibly.,The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has'to contact you regarding the applicant.
['lease be sure to till in the pennidlicense number which will be used as a reference number.- In addition,an applicant
that must submit multiple permit/license applications in any given year,,
need on y`submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address" the applicant should write"all locations.in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the -
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The OI lice of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents -
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Revise) 5-26-05 Fax #617-727-7749
www.mass.gov/dia
'10 CITY OF SALEM
� k&',
PUBLIC PROPRERTY
DEPARTMENT
I A ��111%;.:ONS IS 1A T * SA I r M. \1\1;u :I q I
)78.74n.9;95 \x:9,8.174 9846
Construction Debi-is Disposal Affidavit
(I-CLILlired I'L)r all demolition and renovation work)
In accordance with the sixth edition of the Statc.Building Code, 7S0 CNIR Section 111.5
Dcbris, and the provisions ofMGL c 40, S 54;
Building Permit # __ is issued with the condition that the debris resultingfront
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:
(narne of hauler)
The debris will be disposed of in
signature of perwft applicant
7/14/2010 12:36 PM FROM: Soucy Insurance Soucy Insurance TO: +1 (978) 799-2252 PAGE: 001 OF 002
ACORD' CERTIFICATE OF LIABILITY INSURANCE DATE IMMIDDNYYVI
,„ 07/14/2010
PRODUCER 978. 744.7110 FAX 978.741.2059 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Soucy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P. 0. Box 4467 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
201 Washington St.
Salem, MA 01970 INSURERS AFFORDING COVERAGE NAIC#
INSURED J. B. Kidney & Company, Inc. INSURER A. Hanover Insurance Co. 22292
41 Osborne Street INSURER BI
Salem, MA 01970 INSURERC.
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.
INSR DD'L rypE OF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICYEXPIRATION
LTR INSR DATE MMIDD DATE MMIDD LIMITS
GENERAL LIABILITY ZHN 0797293 01 07/22/2009 07/22/2010 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 100,DDD
CLAIMS MADE T OCCUR MED EXP(Any one person) $ 5,000
A- PERGONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMF90P AGG $ 2,000,000
POLICY JECT LOT
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMIT $
ANY AUTO (Ee edaitlenu
ALL OWNED AUTOS
BODILY INJURY $
SCHEDULED AUTOS person(Per person)
HIRED AUTOS
BODILY INJURY $
NON-OWNED AUTOS IPer accident)
PROPERTY DAMAGE $
(Pei Mc iideiip
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY A[TO OTHETHAN EA ACC
AUTO $
O IJrO ONLY. AGO $
EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
T
DEDUCTIBLE
$
RETENTION $ $
WORKERS COMPENSATION WcS ATU- OTH-
AND EMPLOYERS'LIABILITY YIN TORY LIMITS ER
ANY PROPRIETOFLPARTNERIEXECUTIVE E L.EACH ACCIDENT $
OFFICER/MEMBER EXCLUDED'
IManCator in NH) EL DISEASE-EA EMPLOYEE $
Ifves dGcr Lo under
SPECIAL PROVISIONS below EL.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
ertificate of Insurance for Workers Compensation policy will be sent under seperate cover.
or: 92 Loring Avenue, Salem, MA 01970
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
City of Salem-Public Properties Dept. IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
120 Washington Street REPRESENTATIVES.
Salem, MA 01970 AUTHORIZED REPRESENTATIVE
Paul Soucy
ACORD 25(2009101) OO 1988-2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
7/14/2010 12:36 PM FROM: Soucy Insurance Soucy Insu came TO: +1 (978) 744-2252 PAGE: 002 OF 002
w
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
This Certificate of Insurance 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(2009/01)