258 LORING AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
*/ ) Massachusetts State Building Code, 780 CMR,x7ih edition OF SALEM
t�✓ Revised Jmmary
Building Permit Application To Construct, Repair, enovate Or Demolish a 1. _nr18
One- Two-Fumily Dw ing
Yl7hisJS!Von For O cial Use Only
Building Permit Number: ale Applied: t t t 17
Signature: /t+ U
Building Commissioner/lnspccW#f Buildings Date
S TION 1:SITE INFORMATION
1.1 M Address: 1.2 Assessors Map& Parcel Numbers
Hit
1.I a Is this an accepted sl rl?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(it)
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❑ Private❑ Zone: _ Outside Flood Zone?Check iF es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 e /1ZC_d.
Name IPrint) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': KiC
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl
(Labor and Materials y
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
. Electrical S ❑Standard City/Town Application Fee
_
❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (ItVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Protect Cost: S C f 00Q ❑Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licen ed Construction Su ervisor(CSL) 0 f �� �4 G
ye&zlk 0�� I.icense Number I:xpirui
N:une u'C'SL- lugJer / p/ List CSL Type(see below)
T pe I Description
:\JJres u Unrestricud u to75,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature c11 M Maso Onl
1 RC Residential Rootin Covering
Telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 R�e�gl't�ed Home Im�ov � onlracl;$
IIIC, inmy /{:�mc HIC ee°°g''istram Nam ,- Registration Number
_$ _2 . lZ
AJd _ 3p3� Expiration Date
Si uture relephone
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 .......... No...........O
SECTION 7a:OWNER AUTHORIZATI N O BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 �� C� ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name /�`(`�✓ tl /Q, /�
Signature o1'Owner or Aug d Agent Date
Signed under the ains nalties ofperjury)
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 1 have 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.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basement/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
). "Total Project Square Footage"may be substituted for"Total Project Cost"
Fax sent by : 7017294460 SHIELDS @ ASSOC. INS 84-20-10 89:49 Pg: 1/2
ACORD DATE(MMMFA- )
TM. CERTIFICATE OF LIABILITY INSURANCE 1 0412U/2010
PRODUCER P :(Tet)7 1090 Fff. USI)72e-4460 THIS CERTIFICATE 19 ISSUED AS A MATTER OF INFORMATION
SHIELDS&ASSOCIATES INSURANCE AGENCY INC. - ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
' 176 WASHINGTON STREET SUITE 621 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
MHNCHESTER MA 01890 __.ALTER THE COVERAGE AFFORDED BY THE
INSURERS AFFORDING COVERAGE NAIL 8
INSURED INSURER A: Nautilus Ins.Co.
O'KEEFE BROTHERS CONSTRUCTION,INC. INSURER B: Charlie Ms.Co.
397 LINEBROOK ROAD INSURER C:
IPS MCH MA 01938
INSURER D
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN IS6UED TO THE INSURED NAMED ABOVE FOR THE POUCYPERIOD INDICATED.NOTWITHSTANDING
ANY REOUREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TOWHICH THIS CERTFICATE 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.
N8RJI," TYPE OF INSURANCE POLICY NUMBER POI1CYEicacrrvE POucr EKMAToN LIMITS
ungivwxiOn
° UMBa
^' NNO14121 0UO9N0 84109/11 FACH OCCURRENCE i ,000
X COMMERCMLGENERALUAMUIY a'^ TOR O i Wow
PRElASEE(Fe mx«Fe)
CLAIMS MAOE� OCCUR MED.E%P Waolle pa,Eon) 3 kDO01
A _ PERSONALSADVNLURY f 11000,080
GENERALAGGREGATE f 2,000,000
GENL AGGREGATE OMIT APPLIES PER PRODCTSLOMPCPAGG. f 2,000.000
rPOLCY LOC
AUTOMOBILE LIABILITY
(E.*=COMBINED SINGLE LIMLIMITM i
ANY AUTO (Ee eaManO
ALL OWNED AUTOS BODILY MURY
SCMEWLEDAVTOS (Per Pm ) 4
HREDAUTOS BODILY INJURY
NON-OWNED AUTOS (Pa. wwO f PROPERTY DAMAGE f
�AN
as LIA&LRYAUTOONLY-FA ACCIDENTVAUTO OTHER TRAIN EA ACC f
AUTO ONLY' ACC. f
EXCESS UMBRELLA LL480 M EACH OCCURRENCE f
OCCUR [:]CIAMS MADE AGGREGATE f
i
DEDUCTIBLE f
RETENTION$ Is
MIORxERSCOMPENSATIONAND INC 742248810 INIM4110 04114/11 ro UMFIS OTNFR
EMPLOYERS LIABILITY E.L.EACH ACCIDENT f 500,000
B ANYPBoaAlETORmARR m
� ��'Em ' EL.DISEASE-EAEMPLOYEE f S00,000
YIv.4nul4s wtla
M4XILALP{OVIEIPNB AeIaN EL.DISEASE-POl1CT'LSAI7 i &q,ODO
OTHER:
DESCRIPTION OF OPERATIONSILOCATIONSIVEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
.. _ ..._...-._......___—_ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED Im
Madeline Starks EXPIRATION DATE THEREOF,THE ISSUING INSURER WILLENDEAVOR TO MAIL 10 DAYS
WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FALLRE
258 Loring Avenue TO DO SO SHALL IMPOSE NOOOBUGATON OR LIABILITY OFANY HIND UPON THE INSURER.
Salem,MA 01970 ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATNE �('(ny�•/.1Av�'
Attention: %MVTILLIA�SHIELDS
ACORD 26(2001M) Certificate 111 $175 0 ACORD CORPORATION 1988
CITY OF S.U.E.`I, NInkssmHusEM
t)L'QDLNG DEP.%M.I NT
12
0
W.\jItCNGTON STREET. )re-FLOOR
hi. (970)745-9595
Rut(978) 744969
pNMEA"Y DRISCOLL TUc& SST.PQiRs
NAYO)t
Dlsutcroa oP Ill eL1c 1'ROP[RTY/n aDaG co�L\rtssloaEa
Wurkers' Compensation Insurance AMdavit: Duilderi/ContraetonlElcdrlclanalf4umbetrs
Analltant Information Please Print Lezibhr
Vaine Itlunne.rOrtamrsnowlnJrvldutl)' O
Address- 3lc2 4"�'"et lit
Cilyishldzilr rr'&( Phone
\re es as empbyw!Check tbyappreprhte bear Type of Proles/(requkea
am a canpbye with (a 1. I ors a aellenl contrtror and 1 6. ❑Now cauouedos
cmployeas(Adl and/or part-time).* hove hired the seek cossracan
1.0 1 am a sob proprietor or pertrrer• listed an the awached shwa/: 7. 0 Remodeling
*hip and have no ampbyes Thew sub•conttesaora have a. 0 Demolition
warkiry for ms in any capecity. mama$'comP6 inwu err 9. (]Building addition
(No worked comp insurance S. Owe an a corps edam ad it
r.0"aL l orlkas have axwelsed their 10.0 Electrical repsin a additions
).0 1 am a homwwnr doing aR woh risht of esampion per MOL 11.0 Plumbing repain or oddkions
myself.INe wrorkero'comp. c- 13Z 11(1).and we have no 12.0 Roof repairs
insurance required.l ► areployaos.(No"arias, 1).0 Otlty
comp.insurann mquiret.l
•Any Wglkae dtw rhea la 01 NOW sons no w the unlit telatr rlwiq th it wakes'mmpmm6w talky inAaat dm
'Mean ., nag who Mines tab aAltkwa indlnrlq are aA doing 1u week aaa dw Mrs modelscaawomm oral not wit a slaw a ndnrl i diem g era►
1 .nnneem s dot reek tw New Two arurlrrl is.,ditkarr.Au.w.rfq d.tr..rnn.A..rr.r..w drk mesas'rarer.Pdkr isarwrYss.
/u/w a rwplayar rho b pnrl/Grg wwtsrs'rowprwwrbrs/wasrrwea�ir q satylytera sebtr 6 di pe/by aw//ar else
informs"
Insurance Company Norae:
Policy s or Self-ins.Lie.M: Expiration Dot..
lob Sire Address: Cityislae/zip:
.\oath a copy of the workers'compensation Ploy detbrarbs pap(sbswing the Policy number and aspirselue dslb}
Failure to sraum coverage a required under Seclios 23A of MGL c. 152 can lead to The imposition of criminal perealtin oft
fine up to S 1.300.00 and/or one-year imprisonment,as well as civil penalties is the farm of a STOP WORK ORDEK and a Hers
of up to S2jo.00 d day idaime the violator. Ifs adviwal that a copy of this statement may be furwurded to the Office of
I nvvau gaaiuna of he nlA for insurance coverage vcriticatwa.
1,10 hereby rerlijy a J. Ike pains enal prneh/ss 0/perjury JAW Ibe infanwedsw previdd.brow is/rw rnI carrrd
e ' pat. l9- �c
� np/rid Yaf JII//a ere Her WII/r la/Abe Y/ef./I 61 rYlllp/irN 6y cify er reeve J//hird �
City or fu%vn: YrrmiUl.leenre s
tstuing.\uthunlylcirrleueel:
1. Ituard of Ileallb 2. nuJdiny Department J. city/rows Clerk t. Elrviriral lnspecror S. Plumbing Impeeror
6.Olher _
l•nrNvl Penan: - . _ ... Phone IF:
CITY OF SALEM
i PUBLIC PROPRERTY
DEPARTMENT
I'x; Ml rl ''Mly 1.11
I_C lt' W 5rNlri •5.u1�4 %f.NJ1t I11 J I...1'I .
I'FI:'17t-;144Hyl �(°1!f:97s•laS'Islh
Construction Debris Disposal A111davit
(rtlyuired I'ur all demolition:aid 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 p is issued with the condition that the debris resulting from
this work shall be disposed of in a properly Ucensed waste disposal facility as defined by MGL c
S 150A.
The debris will be transported by:
nuns ur hauler)
The debris will be disposed or in :
(namtulacilly
(address of I''MINIy) 1
I
.I�nature of lwrmtl ap ant
date
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