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11 LOVETT ST - BUILDING INSPECTION (2) �3g S ctc i �� S RECEIVED 'rlie Common%vealth of blassacliitsetts CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 78 ✓� p` 11' Revised,11ur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Divelling This Section For Official Use Only . Building Date plied: 3 A / Building Otcial(Print Name): Sigaaltue Date li I SECTION t:SITE INFORiIMAT1ON' 1.1 P perty Address: 1.2 Assessors Nlap&Parcel Numbers li Lo t/P 5}` SaleM I.1 a Is this an acce ted street7 yes no Map Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions•. Zoning District Proposed Use Lot Tres(sg R) fronmge(R) 1.5 Building Setbacks(R) Front Yard ' Sidee Yards . Rear Yard Required Provided 'Required Pr d. Required - Provided , a . && 1.6 Wate Supply:(M.O.L c.40,§54) 1.7 Flood Zone Informa on: 1.8 Sewage; ewage 9isposal System: Public Private❑ Zone: _ Check if es Outside Flood Zone? Municipal On site disposal system ❑ - SECT[ON2: PROPERTY OWNERSHIP) 2.1 nert of Record: 2&16-d W14 o�iss me(Print) City,State,ZIP - I /I i5N �F r» t21� �Q7-Y38-.53a3�IP5"d ��'n7'NIdCY Hn7<iti�1 ., No.and Street Telephone Email Addrt9. SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply) New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory81dg.0 Number of Units_ Other ❑ Specify: Br'ef Description of Proposed Work-: r r5piq o )J r s SECTION�: ESTIDIATED C NSTRUCTION COST3 e c it Itc n Estimated Costs: - Official Use Only Labor and Materials I. Building $ Loon I. Building Permit Fee:E Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S I, ❑Total Project Cost](Item 6)x multiplier s J. Plumbing S 7500 P Pther Fees: S 4.Mcchanical (HVAC) S 0 List: 5. Mechanical (Fire Total All Fees:S —Sworess Check No. Check Amount: Cash Amount: 6. Ti tal Project Cost: S 51000 0 Paid in Full 0 Outstanding Balance Due: 1 , EETION 5: CONSTRUCTION SERVICES 5.1 Constructiml.Suptervisor License(CSL) 65D77JCL�3 4t J )i', License Number pins n n Date Name— ofCSLHoldeer,, List CSL Type(see below) Z ��/�G�/� Description No.igul Sue Unrestricted(BuildingsUPI to 35,000 cu. It. R Restricted I&2 Family Dwelling City/Ibwn,State,ZIP M Masonry RC Roofin Covcrin WS NindmvanJSiJin �� SF Solid Fuel Burning Appliances 1 Insulation Telephone. Email ad ss r D I Demolition 5.2 Registered Home Improvement Contractor("IC) HIC Registration Number Expiration Date IIIC Company Name or HIC Registrant Name No.and Street Email address Ci /Town Stale ZIP Telephone SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.151.$ 25C(6)y, 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 pe Signed Affidavit Attached? Yes ..........❑ No........... SECTION 7a-OWNER AUTHORIZATION:TO BE COMPLETED.WHEN OWNERS AGENT OR CONTRAOR APPLIES FOR BUILDING PER CT *I1T I,as Owner of the subject property,hereby authorize tg act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION 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 st o my knowledge and understanding. C r rr r Print Owner's or \uthorized Agent's Name(Electro c ature) 5m. 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 or have access to the arbitration program or guaranty fund under M.G.L.c. Id2A.Other 1m octant information on the HICYro mm can a form 3t -- vvww mass eov/oca Information on the Construction Supervisor License can be found at www.nmssov:'dns . 2. When substantial work is planned,provide the information below: 'total floor 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 uPhalf/baths Type of healing system Number of decks/porches Type of cooling system Enclosed Open . 3. "Total Project Square Footage"may be substituted 1'or"Total Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance-Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information LL Please Print Legibly Name (Business/Organizatioii/Individual):_ e l' I') Address: to re Y) C-a City/State/Zip:_ V�6 9A Phone #: Cl 1 Z I '1 !2 L Are you an employer? Check the appropriateyx: Type of project (required): 1.❑ 1 am a employer with 4. & I am a general contractor and 1 6. ❑ New construction employees(full and/or part-time).* have hired the sub-contractors 7. ❑ Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. worker's' comp. insurance. 9. ❑ Building addition No workers' comp. insurance 5. ❑ We are a corporation and its [ P- 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 1 L❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] -Any applicant that checks box N I must also fill out the section below showing their workers'compensation policy information. f Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such. Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp. policy information. I am an employer that is providing workers'compensation insurance far my employees. Below is the policy and job site information. Insurance Company Name: Policy N or Self-ins. Lic. #: Expiration Date: .lob Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration slate). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a rite tip to $1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c lify ndarl 17 p?11115,,and tatties of perjury that the information provided above is true and correct. Si natur Date: Phone# Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License#_ Issuing Authority(circle one): I. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone#: CITY OF SALEA A ASSACHLBE M BtnrDrNGDEraR7AAENr 120 WAM41MMSIRM,3XDFLOOR UL(978)745-9595. PAX(978)740.9846 R.I1vI8ERI8YDRISQ7L1. MAYOR 7MMU STAEM DIREcroRorFuB rcrRoFERTr/BurDmoaww SfomR Construction Debris Disposa/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 c40, S 54; Building Permit g is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: L (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) 4Signat re of applicant Z'-9 u/ C'V Wit--e 1 i t 1 • i { o�'� ... 4-`�'fi 4+# �i V'r 1 l��f k� e�+�w ° '•'� '7 .,ti i4 . c.w 1 josepb g 1 cCa rtby' r 23 Florence Street- Medford MA 02155 I a e S n Y � yy { f zN#yYy .y r 1 " may i . t o -PAOv � . h t'CO 1 v IT, � f .•.n �,�� Lam; ��"� if PP r p� fo n ct i C11'7J iJ:7�A'J Cpi "C.F � t DATE(MM/DDIYYYII A�o CERTIFICATE OF LIABILITY INSURANCE 03/01/2016 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 POLICIE 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 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 endorsements. PRODUCER CONT E:ACT N M Insurance Center Snecial Risks, Ltd. PHONE EXu. 888-773-7975 a No: 413-781-0050 20 Gold Street ADDRESS: info@specialrisksltd.com P.O. Box 1250 INSURERS AFFORDING COVERAGE NAIC4 Agawam, MA 01001 - INSURER AESSEX INSURANCE COMPANY INSURED INSURER B: BLESSED AND PARTNERS PAINT GROUP INC INSURER C: 154 FERN ROAD MEDFORD, MA 02155 1INSURER O: INSURER 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 PERIO 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 POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCE POLICY NUMBER MMIDDIYYYY MMIOD LIMITS A GENERAL LINWLITY 3EA4154 06/03/2015 06/03/2016 EACH OCCURRENCE $ DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PR FM" Ea occurrence S 50,GOO CLAIMS-MADE ❑OCCUR MED EXP(Any one rson) $ 1,000 X $50ODeductible PERSONAL B ADV INJURY $ GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 1,000,000 X POLICY PRO- LOC S AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident 5 ANYAUTO BODILY INJURY(Per Person) Is ALL OWNED SCHEDULED BODILY INJURY(PeraaidenU S AUTOS AUTOS NON-0WNED PROPERTY DAMAGE $ HIRED AUTOS AUTOS Per Ident $ UMBRELLA UAB IOCCUR EACH OCCURRENCE 5 EXCESS LIAR I 11�CLAIMS-MADE AGGREGATE S DED RETENTION 5 < S WORKERS COMPENSATION WC STA IT OTR- AND EMPLOYERS'LIABILITY YIN ANY PROPRIETORIPARTNERIEXECUTIVr:] E.L.EACH ACCIDENT $ OFFICERIMEMBER EXCLUDED? NIA (Mandatary in NH) EL DISEASE-EA EMPLO If yas,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT S T[T_ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Resorts Schedule,if more space is rxluired) PAINTING EXTERIOR-BUILDINGS OR STRUCTURES-3 STORIES OR LESS IN HEIGHT PAINTING 6 DECORATING-INTERIOR-BUILDINGS OR STRUCTURES CARPENTRY-CONSTRUCTION OF RESIDENTIAL PROPERTY NOT EXCEEDING THREE STORIES IN HEIGHT EXCLUDING ROOFING AND HARDWOOD FLOOR INSTALLATION CERTIFICATE HOLDER CANCELLATION City Of Salem Electrical Department SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 99 Lafayette St ACCORDANCE WITH THE POLICY PROVISIONS. Salem MA 01970 AUTHORRE EPPR77E,,SE��NTATIV t.f`v LA, ©19 8-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD DS82501105 1 /1!2016 7:10:06 PM PST (GMT-8) FROM: 100005-'TO: 19785486280 Page: 2 of 2 AGE CERTIFICATE OF LIABILITY INSURANCE 311 016 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(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to - the terms and conditions of the polity,certain policies may require an endors ement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . PRODUCER B &S GILLIS INSURANCE - °vwreRreeT 85 MAIN ST C7 PHONE `n/A"c e PEABODY, MA 01960 EMAIL ADDRESS: INSURERS AFFORDING COVERAGE NAICa IisURERA: LM Insurance Corporation 33600 INSURED WSURER B: BLESSED AND PARTNERS PAINT GROUP INC INSURERC: 154 FERN RD MEDFORD MA 02155- NsuRERD: Bg3URER E INSURER F COVERAGES CERTIFICATE NUMBER: 26817197 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. POUINSR TYPE OF INSURANCE p BR POLI WNBEft 1vWD�EFF EXP UNITS LTR COMMERCULL GENERAL LINBRRV EACH OCCURRENCE $ GLAIMSi ADE ❑OCC.UR TJAMAGff4Er6WNcW1 $ MED EXP(Any one person) $ PERSONAL&ADV INJURY $ GENL AGGREGATE LIMIT APPLIES PER: GENERALAGGREGATE $ POLICY❑�`&r LOC PRODUCTS-COMP/OP AGO $ OTHERCOW BI AWOMOBD.E LIABILITY Ea aaident $ BODILY INJURY(Pw person) $ ANY AUTO ALL OWNED SCHEDULED BODILY INJURY(Per acddenq $ AUTOS AUTOS PROPERTY DAMAGE NON-OHIRED AUTOS AUTOS recadNd $ $ MOREL IA UAB O iR EACH OCCURRENCE $ LI EXCESS AR CLAIMS-MADE AGGREGATE $ DED RETENTION $ A WONHERS COMPENSAMON WC5-31S-390838-035 1o122/2015 10/22/2016 SSTTATUTE a AND EMPLOYERS'IJABHU TY Y/N ANYPROPRIETORIPARTNEFF ECUTNE E.L.EACH ACCIDENT c $ 1000000 OFFIOE WMRER EXCLUDED? N/A (Mandamry vI NN) El.DISEASE-EA EMPLOY $ 1000000 If yes,a W in antler E.L.DISEASE-POLICY LIMIT $ 1000000 DESCRIPTION OF OPERATIONS bebw DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (ACORD 101,"dismal Re M Schedule,may he aaached I1 mwe space is required) Workers compensation insurance Coverage applies only to the workers Compensation laws of the state of MA. This certificate Cancels and supersedes all previously issued certificates,only as they relate to workers'compensation coverage. CERTIFICATE HOLDER CANCELLATION _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE CITY OF SALEM THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ELECTRIC DEPARTMENT ACCORDANCE WITH THE POLICY PROVISIONS. 44 LAFAYETTE ST SALEM MA 01970 AUTHORUED REPRESENTATIVE LM Insurance Corporation' 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD 28817197 1-390838 15-16 WC yagech.patilplibertymutual.com 3/l/2016 7:06:31 PR (PSa) Page 1 of 1