1 MARION RD - REPLACE DECK B-11-260 , .
/ '� � fhr Cbmmumve•rllh uf'Massachusctts
�� l3o•rrd ul'Building Regul��iuns anJ S�anJarJs CITY
1\ � Massachusras Stue BuilJing Cude, 780 CMR, 7'"cJition ��F tiALkM
�" � RrvierJJmniw�•
���� IluilJing Prrmi� Applicatiun To Cunstrucl, Rrpair. Rrnurrte Ur Drmulish a /. :rNAY
Unr-or T� -Fumilv Owrlling
Thi� ect Fw OlTicid Onl
BuilJing Permit Num Date pplied:
Signawre: "`a""'� //i,�./���
HuilJin�{ ummisaianeN Inapeciauf Bu d � (Yr�s
SECTIO I:.S�TB INFORMATIOP/
I.1 Properry Addnv: 1.2 A�sn�on M�p R Parcel Numben
/ r�I�rie•v R�
1.1 o Is�his m acce ted streel?yes no Map NumDer Pa�eel Number
I.J Zootn�loformatba: I.0 ProPerry Dlmemloss:
Yuniny Dis�ric� PmpoxJ Use La Arcu(sq Il) F�onmgt(fl)
�.3 Bulldla�Setb�eb�fl)
Fronl Yard SiJe Yard+ Rw YW
Rryuircd PruviJed Required Proridcd Requind Provided
1.6 W�ter Supplr:(M.G.L c.ao,§Sa) 1.7 Flood Zoae tn(orm�tlo�: I.a Sew�Q�Dbpoaal Sy�tem:
Public O PrirWe O Zone. _ OWid�F�ood Zoro? Munfeipal O On�ita dt�posd system O
Check if a�
SECTIONS: PROPERTYOWN6RSHIP�
2.1 Owner�of Reeord: �- ��f /�
fe (�/ 'F' QR-C IYK�� / U(�COC � /Y!/�P ��O/// FZ cP
�A /
Nome�R t�— Add,ess fw Service:
�
Signmure Telephom
SBCTION 3: DESCRIPTIOIV OR PROP09ED WORK�(chcek�U th�f�pply)
New Corotruction❑ Existing Building O Owner-Occupied O Repairs(a) O Altention(s) O Addition ❑
Demolition O Accessory Bldg.� Number of UniU Other O Specily: �
rief Description of Proposed Work': 2
R.�'l�!S �
-r- - �
SECTfON 4: ESTIMATED COIVSTRUCI'IOIV COST9
Item Eslima�ed Cosb: 011lcid Use Only
Labor and Ma�erials
I. DuilJing S I. Ouilding Permi�Fee:f Indicate how ke is dotermined:
� O Smndard Ciry/Town Application Fee
?. Elnctrical S �
�Total Projeet Cost (Item 6)a mul�iplin x
3. Plumbing S I. O�her Fm: S �� ��
�. Mechanical (fIVAC) S List: e Cu
S. Mechanical �Firc S
5u rcuion To�al All Fees: S
Check No. Check Amount: Cash^mount:
6. Total ProJect Cost: 53 O �
� O Paid in Full ❑Outs�anJing Balance Due:
�
,l�
� � 1� d�e�/
Yhc-,-�-� �
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) 796 7y
17f1 -,J L a f a-ol le- V T! ` Liccrue Number I:xpinliun 1 we
Name of CSI.- I lulder List CSL Type 1%.v below) L/
2 MA, ,I n oQ 5� ���?
�i f Ikscri ion
ors 70
& 1� U Restricted lld2 Famil
y U00weClul.n
Signature MOnly fl
M Onl
PolcpMne w5 nestuenuur wmw.. anu arum
7� SF Residential Solid Fuel Burning Appliance Installation
-13
7 — 131 / D Residential Demolition
5.2 Registered Home Improvement Contractor (HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
AJdmss Expiration Date
Signature relephtne _-
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.1 2$C(6))
Workers Compensation Insurance alTidavit 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 AfRdavit Attached? Yes .......... 0 No ........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
as Owner of the subject property hereby
to act on my behalf, in all matters
relative to work authorized by this building permit application.
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1. , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate, to the best of my knowledge and
behalf.
Print Name
Date
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 gg 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 790 CMR Regulations I t0.R6 and I MRS. respectively.
3 When substantial work is planned, provide the information below:
Total eloon 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
Ty pe of cooling system
Enclosed Open
1 J. "Total Project Square Footage" may be substituted for "Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
A -t --1v
D E1'AKTLIENT
• I tX 7'8.'4:'Is Ih
Construction Debris Disposal Affidavit
(required li,r all demolition and renovation work)
In accordance %% ill, the sixth edition ofthe State Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit t is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will he transported by:
I name uC hinder)
i he debris will be disposed of in :
/l/Or`f 51ke (f/}c4iR—
jnameof facility)
<111
(address d facility)
J�euatwe �f permit .ytphcant
lJ
Jatc
.1 I'. 1..,.. ,.. .
`'� CERTIFICATE OF LIABILITY INSURANCE
DATE(MM/DD/YYYY)
8/30/2010
PRODUCER (781) 322-2324 FAX: (781) 397-7672 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
EA Stevens Company, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
389 Main St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P. O. Box 188
Malden MA _02148 INSURERS AFFORDING COVERAGE NAIC #
INSURED INSURERAPeerless Ins 24198
PAUL BRADLEY DBA INSURER a: Excelsior
Bradley Construction INSURER C:
3 Marion -Road INSURER D:
Salem i MA 01970 INSURERS -
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 DADL
INSR6 TYPE OF INSURANCE
POLICY NUMBER
POLICY EFFECTIVE
DATE (MMIDDNYYYI
POLICY EXPIRATIONLTR
DATE fMMIDNYYY1
LIMITS
GENERAL LIABILITY
EACH OCCURRENCE
$ 1,000,000
X COMMERCIAL GENERAL LIABILITY
DAMAGE TO RENTED
PREMISES (Ea occurrence)
$ - 1001000
MED EXP (Anyone person)
$ 15,000
A
I_ -CLAIMS MADE OCCUR
CBP8681475
6/15/2010
6/15/2011
PERSONAL S ADV INJURY
$ 1,000,000_
GENERAL AGGREGATE
$ 2,000,000_
'L AGGREGATE LIMIT APPLIES PER:
7POLICYL-1
PRODUCTS - COMP/OP AGG
$ 2,000,000
PRO n LOC
IECT
AUTOMOBILE
LIABILITY
COMBINED SINGLE LIMIT
$ 1,000,000
ANY A UTO
(Ea accident)
—
BODILY INJURY
$
B
ALL OWNED AUTOS
BA1096016
0625/2010
0625/2011
(Per person)
L X
SCHEDULED AUTOS
— - -
X_
HIRED AUTOS
BODILYINJURY
$
X
I NON AUTOS
(Per accident)
-OWNED
PROPERTY DAMAGE
(Per accident)
$
LGARAGE LIABILITY
AUTOONLY-EAACCIDENT
$ _
OTHER THAN EAACC
$
ANY AUTO
--
$
AUTO ONLY: AGG
E%CEBB / UMBRELLA LIABILITY
EACH OCCURRENCE
$
AGGREGATE
$
OCCUR CLAIMS MADE
$
DEDUCTIBLE
(
_
RETENTION $I
$
A
WORKERS COMPENSATION
EMPLOYERS' LIABILITY
�
ITS
L EACH ACCIDENT
$ 500,000
ANY PROPRIETOR/PARTNER/EXECUTIVE YINE
E.L. DISEASE - EA EMPLOYE E$
OFFICER/MEMBER EXCLUDED'
(Mandatory in NH)
pC8684450
6/15/2011
POLICY LIMIT$
_5-00,000
500, 000
R yes, describe under
16/15/2010
SPECIAL PROVISIONS below
E.L. DISEASE -
OTHER
i
DESCRIPTION OF OPERATIONS / LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT / SPECIAL PROVISIONS
rAMrPl I ATInM
(9 7 8) 745-4638 V `
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
City of Salem
DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
Building Department
93 Washington Street
Salem, MA 01970
NOTICE TO THE CERTIFICATE HOLDER 1M ED TO THE LEFT, BUT FAILURE TO 00 SO SHALL
IMPOSE NO OBLIGATION OR LIABILIL ANY KIND UPON THE INSURER, ITS AGENTS OR
;',.�
REPRESENTATIVES. /.',L:y
AUTHORIZED REPRESENTATIVE `'IIr>E`.u�'�'I
Tr.
Francis M. CiffordI
ACORD 25 (2009/01) v woo-tuuu su.vnu wr<rvrw I Ivry. AH nynu reserves.
INS025 (200901) The ACORD name and logo are registered marks of ACORD
164
.i kW; H: 1'Y :)IIISCt u.1.
\i X tt m
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12^� W MHING I ON STBCLT • int let, M.%ss.sca n -sc rl S 0197.^
Ti -.I, 918.745.9595 9 F.sx: 978.710.1846
Workers' Compensation Insurance :affidavit: Builders/Contractors/Electricians! Plumbers
ti) )licant Information fj n'Please Print Leeibly
Nilme113uciiwssio(8anilatinNlndividuul): iJ rrvel Le -'';l
Address:
City,slarci%ip: PCC& Thune'.':
Are guts an employer:' Check the appropriate box:
'Type of project (required):
1. ❑ I am a employer with
4. ❑ 1 am a general contractor and 1
G. New construction
❑
employees (full and/or part-time).
have hired the sub -contractors
listed the attached sheet.
�• C] Remodeling
2. 1 ;un a sole proprietor partner -
ship and havevenoo employees
on
These sub -contractors have
S. E] Demolition
working for me in any capacity.
workers' comp. insurance.
5. ❑ We are a corporation and its
9. ❑ Building addition
I No workers' comp. insurance
officers have exercised their
10.❑ Electrical repairs or additions
rcquiTvd.]
3. ❑ I :ort a homeowner doing all work
right of exemption a MGL
S P P'
I L❑ plumbing repairs or additions
myself. (No workers' comp.
c. 152, § 1(4), and we have no
12.❑ Root repairs
insurance required.] t
employees. LNo workers'
13.C]other
comp. insurance required.]
-Airy apphcaiat shut chucks box it] must also till nut the v'aiull W. uw showing Iheir workus' compensation pulicy infurnwtiva
' ilomeuwnen who submit this affidavit indicating Ihuy arc doing ull work and Ihen him outside cultrxton must .uhmit a new tj r.daYil indicamg etch.
-f,winwuwrs that check this box mttsl anwhxd an addilimaLchocl showing the name of the subcontractors and their wurkus' comp. policy information.
I tun un eutployer that Lr providing workers' c•ompensntiom insuriutce for iiiy employees. Below is the policy and job .site
iufwumfiun. _
Insurance Company Name:ca_i
df C
Policv 8 or Self -ins. Lic. >3: �` '-% (� �-_..-p._ .. _.__ Expiration Date: /
Job Site Address: lnllI-/on.. #A -( s �/�� City/State/Zip: c, j/p
.Much it copy of the workers' compensation policy declaration page (showing; the policy number and expiration date).
Failure to secure coverage as required under Section 25A ol'J(GL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 and/or one-year imprisonment, as well ax civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it day against the violator. III: advised that a copy urthis statement may be forwarded to the Office of
Invcsngaunn; ul the DIA Igor insurance coverage verification.
I do hereby car V tinder lifepilldnd/0fifu/lies of erjury! at file information provided abovsee/��s true olud correct.
I�
�4111IUre' �V e�!!/�••// r Dale' a/ /z
Ofjie•iul use oily. Do not write in this urea, to be completed by city or town ojjiciul.
City or 'fawn: _. -. Permit/l.icense x__--._—,- -. .. -.
Issuing Authority (circle one):
1. Iluard of Itcalth 2. Building Department 3. cil)'i roan Clerk 4. Llectrical Inspector 5. Plumbing Inspector
6. Otter --- _
Contact Tl'f)an:
Photic
Information and Instructions
.V assachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an empluree is defined as "...every person in the service of another under any contract of hire,
empress or implied, oral or written."
An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or inure
or the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer, or the
receiver or trustee of lm individual, patmership, association or other legal entity, employing employees. However the
owner of a dwelling horse 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, cunwriction or repair work on such dwelling horse
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL 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, INIGL chapter 152, §25C(7) states "Neither the commonwealth nor any of is 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) name(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 u workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the aooronriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a -reference number. In addition, an applicant
that must submit multiple pennit/licetse 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 locutions 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 filled 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. it dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
I he Of lice tit Investigations would like to thank you in advance for your cooperation and should you have :my questions,
plcaae do not hesitate to give us a call.
The Deparunent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OtHce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Ro,iscd 5-26-05 Fax # 617-727-7749
www.mass.gov/iiia
:Massachusetts - Department of Public Saich
Board of Building Re-ulations and SLtndards
Construction Supervisor License
License: CS 79674
Restricted to: 00
PAULA BRADLEY JR
3 MARION RD
SALEM, MA 01970
Expiration: 5/21/2011
('nnmi.rionrr Tr#: 16655
0