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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 MEN MEN M 0 NNE NNE I � - ' ;r � l r il � i�r�� ; i I III � '� jl � ; � Ir �iil � I � 1