17 LOVETT ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Ulf
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Offici4WIse Only
Building Permit Number: Date pplied:
4i a
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Adt! J3: 1.2 Assessors Map& cel Numbers
1 l.r�UG' S7: .S4�Ln._ rt't-•' ��_Q'j[.�� G
Lla Is this an accepted street?yes IC no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
-A a /KGS .4 1 Jam;` 00 (O' I
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(11)
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:
Zone: _ Outside Flood Zone?
Public♦$. Private❑ Check if yes❑ Municipal L?f-On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
Name(Print) City,State,ZIP
7 1 W1/G7 T ay
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': Tug A- Suo—/bu.w 'AA EZ, I- s,
a
�IOc.GG d� loaner W,'adowt v- ,'.rtU�f,'�.+. �✓ � .. f' � 3�5 - �'
t,i• tG. i .LhhL ..✓a,[/� wd� .Secs..d w.. s � vf' � ir�__ s r �' s�__
ticar5
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 13 100 1. Building Permit Fee: $ 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: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ !3� � 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1' Construction Supervisor License(CSL) C 5-10(147 41 / l
G G f nCP� License Number Expiration Date
Name of CSL Holder /
List CSL Type(see below) (J
CI 9 0"
No.and Street Type Description
�q� �, U Unrestricted(Buildings up to 35,000 cu.ft.
Yew. Y= n y R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
C9$)122 113 y/ I 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
�M3ys /y /
HIC Registration Number Expiration Date
H(I�C Company Name
'or 'IC Re t Name tl4
No.and Street Email address
5-4., L,, 41� 0 2/Yy C5713j 5o9 -3-w/
City/Town,State,ZIP Tele hone
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
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACr1T�OR/APPL/IES /FOR BUILD/ IN/G PERMIT
I,asOwnerofthesubjectproperty,herebyauthorize Ivt.Llr/_v.( kQe,SAfr- ! /4/4 P I cx.rjqaa�rH,
to act on my behalf,in all matters relative to work authorized by this building permit application.
Arf hoK Ncrh'hy 10 ,3 12
Print Owner's Name(Electronic Sign ture) Date
SECTION 7b:OWNER' 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 best of my knowledge and understanding.
Print�th zed Agent's Name(Electronic Signature) Date
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(II IC)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
www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass. og v/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) 6-3 e, (including garage, finished basement/attics,decks or porch)
Gross living area(sq.ft.) yy 0 Habitable room count /
Number of fireplaces r Number of bedrooms AM
Number of bathrooms ( Number of halffbaths U
Type of heating system r cod pb.E we fcr Number of decks/porches o
Type of cooling system K/A Enclosed AM Open ,y.,t
3. "Total Project Square Footage"maybe substituted for"Total Project Cost'
c%%ga„�rza�s„u,lt�o��Gl2xa�k.4et
Office of Consumer Affairs&Business Regulation
1 43 W
DOME IMPROVEMENT CONTRACTOR,egistratlon: 172345 Type: t
xptration 6l14/2014,. LLC T.
r ALL IN 1 CARPENTRY LLCL
MICHAEL KOESTER`�y`
99 GREENDALE STD`' g---s�->�P t
METHUEN, MA 01544 Undersecretary
Ift Massachusetts+-Department of Public Safety
Board of Building Regulations and Standards
Cunstruihun Supervisor
License CS 101467
�'rrs n
MICHAELIP KOESTER-,
99 GREENDALE ST'Q
ME EN lytA 0184�•'
i
Expiration
Commissioner 04I1912014
i CTTY OF S.0 E`4 NL-1SSACHL'SETTS
BuUMI IG DEPART\IIiT
'f 130 WASHINGTON STREET,3so FLOOR
TEI- (978)74S-9595
FAX(978)740-9846
[QSBERIEY DRISCOIL
MAYOR T konu ST.Pw-RRE
DIRECTOR OF Pu BLIC PROPERTY/BL'ILDLNG COSL\RSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibly
Nalne(Businx OfgaoilatioNindividuap: All /i / fare
Address: 8 Penoi"Cl- <-,A
City/State/Zip: Sfam.e" JLI� Oa/SG Phone#:(929) F01 -e3y/
Are you an employer?Cheek the appropriate box: Type of project(required):
LEI❑ I 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
2.h 1 am a sole proprietor or partner- listed on the attached sheet.: ?• ®Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised the 10.❑Electrical repairs or additions
w
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.[]Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No work era' 13 ❑Other
comp.insurance required.)
•Any appliram that dtccks box sl must dw fill out the xertim below showing d cir worker'wmp",ol n policy inrumtation.
'linx wownen who submit this affidavit indicting they are doing all work and then him outside wntracmis must submit a rxw affidavit indicting such
:C0mrawn that chock this brat must anached on additioral abet showing the name of the subaanu ctll and their..,km' V.policy iafatmmion.
I am an employer that it providing workers'compensation insurance jor my employees. Below Is die polley and Job site
injormallum
1n
Insurance Company Name: C6/ t(Jr
Policy#or Self-ins.Lic.#: //'' Expiration Date:
Job Site Address: /7 Acik&* Ciry/State/Zip: :54 1fatit t I/ 4 , 014 90
Attach a copy of the workers'compensation policy declaration page(showing the polity number and expiration date),
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine 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. Be advised that a copy of this statement may be forwarded to the Office of
investigations ul'the DIA for insurance coverage verification.
I do hereby,cerrdj&under
the pains"and penalties olpeiJury that the iajormation provided above is true and correeL
Si at ire•
Phonc d-
OJfcial use only: Do not write in this urea,to be completed by city or town oJfc'ial
City or Town: PermidUcense#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.Cily/town Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person' Phone#:
ACORD., CERTIFICATE OF LIABILITY INSURANCE 10/02/20)
PRODUCER (781)942-22,25 FAX (781)942-2226 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Gilbert Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE -
137 Main Street HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Reading, MA 01867-3922
INSURERS AFFORDING COVERAGE NAIC#
INSURED All in 1 Carpentry INSURERA: NORFOLK & DEDHAM INSURANCE 23965
8 Prospect Street INSURERS:
Stoneham, MA 02180 INSURER C:
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 kDD'L TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS
GENERAL LIABILITY R1220906A 09/21/2012 09/21/2012 EACH OCCURRENCE $ 1,000,000
X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 300,000
CLAIMS MADE FX]OCCUR MED EXP(Any one person) $ 10,000
A PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 2,000,000
X POLICY PROJECT LOC
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) $
ALL OWNED AUTOS BODILY INJURY
SCHEDULED AUTOS (Per person) $
HIRED AUTOS BODILY INJURY
(Per accident)
$
NON-OWNED AUTOS i
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO OTHER THAN EA ACC $
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $
OCCUR CLAIMS MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
WC STATU- OTH-
IR
WORKERS COMPENSATION AND Y_UM
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ANY PROPRIETOR/PARTNER/EXECUTIVE
OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $
If yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
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 MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY
Town of Salem OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES.
Salem, MA AUTHORIZED REPRESENTATIVE
Mark Gilbert, CIC
ACORD 25(2001/08) OACORD CORPORATION 1988
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