8 MAPLE AVE - BUILDING INSPECTION (2) r J .
1 1'he Commonwealth of Mussachuscus
Board of Building Regulations and Standards CITY
n ',1 Massachusetts State Building Code, 780 C MR, 7' edition (IF SALEM
Rrrurd Juiwarr•
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or o-Family Dwelling
Jfiis S tion For onicialUse Onl
Building Permit Numbe D Applied: n
Z �f
Signature: 5
Building Comrnissioned Inspect V
11dildlintis Date V .' -
S CTION I:SITE INFORMATION
1.1 Pro erty d 1.2 Assessors Map& Parcel Numbers
s 1c, �u�
�— Ma
1.12 Is this an accepted streeo t. yes no D Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Ama(sq 11) Frontage(11)
1.5 Building Setbacks(R)
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 O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system O
Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
` 2.1 OWnerl of
Rceo�rdte^�
Name(Print) Address for Service:
t
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building O 1 Owner-Occupied ❑ Repairs(s),❑ 1 Aiteration(s) O 1 Addition ❑
Demolition O Accessory Bldg.❑ I Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': v t✓1 e e (-d
l t� 3o-ur Amrj�eL-WA k
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Of/lclal Use Only
Labor and Materials
I. Building is I. Building Permit Fee: S Indicate how lee is deterincd-
0
2. Electrical s ❑Standard City/Town Application Fee
Total Project Cost'(Item 6)x multiplier x
3. Plumbing s 2. Other Fees: S
4. Mechanical (tIVAC) S List: / t�
S. Mechanical (Fire s
Suppression) Total All Fees:S
^ Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 0V ❑Paid in Full 0 Outstanding Balance Due:
L
SECTIONS: CONSTRUCTION SERVICES
5.1 icens Constructors 5upervlsor(CSL) $ Cl o Y01
License Number liipiration )me
Nam I�l'Sel h der ,Q I D ( \ List CSLfype(see below)
r Description
Address U tinmuicted(up to 35,000 Cu. Ft.
R I Restricted l dZ Family Dwelling
Signature ^, Q_ iy lr� q(„) a M I Masonry Only
RC Residential Roaring Coverin
f0ephone WS Residential Window and Siding
SF Residential Solid Fuel Bumin Appliance Installation
D Residential Demolition
3.2 Reg terms Notate
f3v%tmproveme Cont toV► }) g 6
JP t n
f IIC Companyy Name
me or fIIC Registrant Name / �Ch r5(/. Regapimlim
umber
L� rl oLoll
Address ''� �� =� ��'
�' � � . ate
Signature 'relcphune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I52.! 2SC(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 AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I , 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.
siansture of owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
1 �' 4-7'r ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc We and accurate,to the best of my knowledge and
behalf. f4 / '` ,-
Print Name O' !A"`� CY
Signature of Owner or Authorized Agent Date Z
Si under the pains and penalties of 'u
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
(not registered in the Home improvement Contractor(HIC)Program),will HW have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I0.R6 and 110.R5,mspectivrly.
When substantial work is planned,provide the information below:
Total aloonarea(Sq. Ft.) (including garage, finished basementlattics,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"
CITY OF SALEM
f PUBLIC PROPRERTY
.L, DEPARTMENT
Jw11H N:Pl•:)KNCw n.l.
1.I.sn)a 12C WMHI\C.I ON STREET * SAL E.M.MA Lsm.i it it l l i 0197-�
Tla.:978-745-9595 • f.\x: 978.74C.9846
Workers' Compensation Insurunce Affidavit: Builders/Contractors/Electricians/Plumbers
,\ ) tlicant Information Please Print Le ibiv
V 01mt:
City,'Stale;%ip• Il Cv � /7-4 0MO ('hone ;.•:
\ c v in an employer! Check the appropriate box: 'Type or project(required):
I. I am a employer with 4. ❑ 1 en a general contractor and 1 6. ❑ New construction
• employees(full and/or pan-tine).• browse hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 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. workers' comp. insurance. 9, ❑ Building addition
INo workers' comp. insurance 5. ❑ We are It corporation and its 1o.❑ Electrical repairs or additions
required.] officers have exercised their
3.El I ;tin a homeowner doing all work S exemption P•
fight of er MGL I I.❑ Plumbing repairs or additions
Pon
myself. (No workers' comp. c. 152, j 1(4),and we have no 12.0 Rouf repairs
insurance required.]t eimployces. LNo workers' 13.❑ Other
comp. insurance required.]
•.rtny up plicaut not chucks boa III must:dso lilt out the section Wow showing their workcis'cumpcnwtton policy Infurimuiuu.
'1 Wmauwnen who submit this affidavit indicating they are doing all work and then him outside conrrxtos,must vuhmil a new ai'ndiivit indicating.arch.
-fontrwturs that chuck this box most attached an additional sheet showing the none of the subcontractors and their workers'cmp.policy information.
/am all entplayer thut ix pro'iding workers'carnpen.cation insurance jar my employees. Below is the policy and job sole
information. L,t'G6"y il (viLA ` -
InsuranceCompanyName: _--..__
WC � - � 1 � 3/9Date:
Policy q car Self-ins'. Lic.rt: �__. Expiration �/n7�
Job Site Address:Address: �qPl e Y 1 ive City,,Slate/Zip: ✓"G� gem J �"
Attach it copy of the workers' compensation policy declaration page (showing; the policy number and expiration date).
Failure to secure coverage as required older Section 25A of.161-c. 152 can lead to the imposition of criminal penalties of a
tine up b)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 till to S250.00 it day aguinst the violator. Ile advised that a copy of this statement may be lurwarded to the 011tce ut
lee"i athalt Oils uI ll)e DIA for insurance coverage \cl'llleatmn.
/do hereby rrrt�ijj ,uu I•r the ,aury mud /tics ufperjury that the infurmation provided cab ve s true and correct.
Sena illic _
1,11"re;i: c17���'(S ���tQ
O jiciul Ilse only. Do not write in this area, to be completed by city or town oJJiciuL
City or Town: __ Pcrinit/License tl__ __-_ _. . . . . .
Issuing Aulhurily (circle one):
1. Board of Ilcalth 2. Iluilding Dcparturert .i. Cityi roi%a Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other _- -
Coutacl Person: _.. . .__. Phone ft:
Information and Instructions
.Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this mutate,an empluree is defined as"...every person in the service of another cinder any contract of hire,
express or implied, oral it written." "
An employer is defined as"an individual,partnership,association, corporation or other legal entity, or any two or more
art the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the -
receiver or trustee ut 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."
.%tGL 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. MGL 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 fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) nnmc(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
be 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 be Sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permiblicense number which will be used as'a reference number. In addition,an applicant
that must submit multiple pennit/licensc applications in any given year,need only 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 tilled 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 burn leaves etc.)said person is NOT required to complete this affidavit.
I he Office of Investigations would like to thank you in advance for your Cooperation and should you have any questions,
please do not hesitate to give us a call
The Deparanent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. M 617-727-4900 ext 406 or 1-877-MASSAFE
aeviscd 5-26-05
Fax N 617-727-7749
www.mass.gov/dia
DATE(mNuuDnwY)
ACDRD CERTIFICATE OF LIABILITY INSURANCE 09/09/2010
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
PRODUCER (976) 745-6464
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Rose insurance HOLDER. THJS CERTIFICATE DOES NOT AMEND. EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW,
66 Loring Avenue
F.O. sox 958.
Salem MA. 01970- INSURERS AFFORDING COVERAGE NAIC R
INSUREP YINSURER A:240,T;Chant3 insurance
Truant, Adam dba APT Builders INSUREReLibe=ty MLTtL141 _
46 Linden Street . INBUPER C:
INSURER b: - —
PeabDcl 147E 0196U^ INSURER :
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 CONINTiCIN 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.
A43G�REGATE LIMITS SHOWN MAY HAVE BEEN IREDUCEDTSY'PAID CLAIMS, POLICY EFFECTIWE LICY EXPIRATION
INSR AOD'L TYPE OF DiSURANCE pOLICYNUMBER DATE MMIDDIYY DATE MM/DD/YYj LIMITS
LrR 1 D 500,000
A GENERAL LIA81L7TY / / / / EACH OCCURRENCE 3
DAMAGETORENTEO 50,000
X. COMMERCIAL GENERAL LIABILITY PREMISES Ee arrurroncfl ,a
cwIMS MADE p oceuR BDH9095566 06 Ofi/2010 06/06/2011 MFD EXP An ono emo 5,000 PERSONAL A nD1/INJURY S 500,000
GENERALAGGREGATE T. 1,000,000
GEN1 AGGREGATE LIMIT APPLIES PER:
P DUCTS-CUMPIOP AGG $ 1,000,000
POLICY woT. LOC / / / /E (Ea acINFD SINGLE LIMIT
AUTOMOBILE IIABILfTY S
(Ea flcclnnM)
ANYAUTO
AIJ.OWNED AUTOS BODILY INJURY S
(Per pemon)
SCHEDULED AUTOS
HIRED AUTOS ✓ / BODILYINJURY S
(P"accleent)
NON-OWNED AUTOS
PROPERTY DAMAGE., x
(Per.cnIdony
GARAGE LLA$ILITY AUTOONLY•FA ACCIDENT S ANY AUTO / OTHER TMIMI E0.ACC
AUTO 01 ADG S
EXCESSIUMBREULA^�LIABILITY / / ✓ / EACH CCCURRCMCE S
OCCUR I CLAIMS MADE AOGREOAT[ x �-
x
DEDucnBLE
a
RETE TION
I Wf A'V. O'I•I•
$ WORKERS COMPENSATION AND WC2-39.8-8782 06/02/2010 OE/02/2{11.7. % TGii 2 0R
EMPLOYERS'LIABILITY E.L.EACH ACCIDENT S 100,000
ANY PROPRIETOR/PARTNER/EACCUTIVE 1()0,000
OFFICERMEMSER EXCLUDED? / / / / E.L,DISEASE-EA EMPLOYES 3
I}yet,tl crlCn under E.L.DISEASE-POLICY LIMIT S 500,000
SPECIAL PROVISIONS"Imv
DESCRIPTION OF OP£RATIONS,LCCATIOWSNER�ICLEWFXCLOBIONS ADDED BY ENOORSEMENTISPECIAL PROWLS WNe
CERTIFICATE HOLDER CANCELLATION
(979) 740-9646 I ) SNOULO ANY OF T e ABOVE DESCRIBED POLICIES HE CANCELLED BEFORE THE
Attn: Sally EXRRMTION OATE THEREOF, THE ISSUING dNSURER WILL ENDEAVOR TO MAIL
80 BAYS WRITTEN NOTICE TO THE CERTIFICATE MOLDER NAMED TO THE LEFT,BUT
Salem Building inspector FAILURE TO DO SO$HALL IMPOSE NO ORLICATION OR LIARILITY OF ANY KIND UPON THE
INSURER ITS AGENTS OR REPRESENTATIVES.
REPRESENTATN Q
CITY OF SALEM
r ,. PUBLIC PROPRERTY
DEPART'NIENT
',1 r • s.\n \r,
Construction Debris Disposal Affidavit
(required li)r all dentolition and renovation work)
In accordance ww ill, tile sixth edition of the Slate Building Code, 780 CMR section 111.5
Debtis, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting front
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
I t 1. S 150A.
The debris will be transported by:
A T r w��s
(name of ItanlCV)
hey pdebris will be disposed of in
(name Of facility)
laddrers of I'arrlityl
�ignuture of prnuit applicant
,late
�a.M~,M.
Board,of Buildlcg ReguliliDea"eod Standards r'
Cottstrucoon SUpeririaor
Licensa• CS `98390
Tiff 98390
Ex0ratlon 8/4/2011 3.. *..
h
R�sateaon?_oo� Y �.
i ADAM TRUFANT
,r3,. 46UNDENROAp r. � '9 �
'k ` �EABODY MA 0196g ; +e ,Cmumiotoser " y
�.
8AffarORrre of consumern Regnianos, d
i. • HGM61MPRf.TVEMENT CONTRACTOR'
t Registration 148622 `1. +` ExPiratfon 10.N21201i - TrI# 700251l
p
i 'S
f A.P:7 BUILDERS
` \DAM TRUFAN
46 LINDEN
. Urdenrrreter vc
1 �` PEABODY MA 01960 -. 4iy ,` •
s
Thomas McGrath
From: sargeatlarge74@aol.com
Sent: Thursday, September 09, 2010 9:28 AM
To: Thomas McGrath
Subject: Roofing job
Tom, Mr. Adam Truafant of APT Builders will be coming in for a permit to roof my house at 8 Maple
Avenue. Thank-You, Arthur Sargent.
Sent from my Verizon Wireless B1ackBerry
J
t