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27D MARION RD - BUILDING INSPECTION , j a The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of Massachusetts State Building Code, 780 CMR, 7ih edition JUG Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a 1 One- or Two-Fandly Duelling This Section For Official Use Only Building Permit Number: Date Ap lied: /— Signature: Building Commissioner/Ins or of Buildingsy I IT Date SECTION 1:Alft INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers I.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) 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❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: O 017):) DiV j1'TJ. Name(Print) Address for Service: r�c9— 6J5- fg 5-3 h Signature Telepne SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Aiteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify:Il L�L�c�M Brief Description of Proposed Workr: 1 1J8&9 5, ' /6 qcry tl / G°Lrgs S�_�/iAIYG I�cot frcFrr�l'e At3;' ZZ C�L I D I/yC SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only m Labor and Materials I. Building S '7 jj�rj 6 I. Building Permit Fee: S Indicate how fee is determined: 2. Electrical g ❑Standard Ciry/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: $ 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees: S Check No. Check Amount: Cash Amount: 6. Total Project Cost: S 7 7�0. ❑ paid in Full ❑Outstanding Balance Due: �Ck n , SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) & J rS 5- 3 �j/ "( �o�� License Number Expiration Date Ngmc of CSL- H Wer [[ ��d List CSL Type(see below) d T Description Ad U Unrestricted(u2 to 35,000 Cu. Ft.) R Restricted I&2 Family Dwelling na r M Masonry Only �-� RC Residential Roofing Covering elephone WS Residential Window and idin SF Residential Solid Fuel Burning A2pliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) t 3 b e a �'`� Re-gistration Number HIC mpSny Name or HIC Registrant Name x suo ��� �H��� � q i Address 7��.6 q? - G '�'�2J` Expiration Date Signature Telephone 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 CONTRACTOR APPLIES FOR BUILDING PERMIT I, R v ) D 7/t} as Owner of the subject property hereby autho E 5 Ham" to act on my behalf, in all matters relative tow it u rize y is bu' ing permit application. n re of Owne Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION as Qiuu-•^-Authorized Agent hereby declare . that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and behalf. Print a i I,�a..Y—fb S to of Date i ne un r the ains nd nalties of er'u NOTES: I. An Owner who obt ns 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 not have access to the arbitration program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively. 2. When substantial work is planned, provide the information below: Total floors 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 Type of cooling system Enclosed Open 3. "Total Project Square Footage" may be substituted for"Total Project Cost" The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations 600 Washington Street o Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrician s/Plumbers Applicant Infornation Please Mgt Legibly Name (Business/Organization/Individual): Address: F6 X ,�/� tj e<30 f City/State/Zip:�- 62Q y Phone #: 7�f _ Are you an employer? Check the appropriate box: Type of project (required): I.El I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub-contractors 6. New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ 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 their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 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' comp. insurance required.] 13.0 Other *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information: t Homeowners who submit this affidavit indicating they are doing all work mid then hire outside contractors must submit a new affidavit indicating such. 1Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'cornp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. //�� Insurance.Company Name: /7�i� Policy#or Self-ins. Lie. #:_ CY�7 O 2 'Z Expiration Date: Job Site Address:- eP7 D lAF&-) ) � 5t� f�j l r /State/Zi 6 � -76 - G'ty p 9 l Attach a copy Of the workers' compensation policy declaration page (showing the policy 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 $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 cc i u the pai and penalties ofperjury that the information provided ab a is tr a and correct Si lauue: Dater o�9 /d 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#: IL _ - Aue lU 211U') I810N( 13: 52 61ALCOLNI k PARSONS INSURANCE _ lfAAll /�615g919L] r. Dul/ Uu:: AC OQD� CERTIFICATE OF LIABILITY INSL)RANCE DATE(MMIDDIYYYY) PRODUCER (781)344-3200 I FAX (781)344-142S 08/10/2009 Malcolm & Parsons Ins. Agcy. Inc. ONILY ANDIFICATE IS CONFERS NORIG TS UPONT E CERTIFICATEAS A MATTER OF 6 R•eenlan St. HOLDER.THIS CERTIFICATE DOES NOT AMEND, E%TEND OR P.O. Box 527 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Stoughton, MA 02072 INSURERS AFFORDING COVERAGE INSURED PI"OWTIId OWS IryC. NAIC 9 P.O.Box 540630 INSURER A: Wes tern World Insurance LJal sham, MA 02454 INSURER B: ACE; Property'L & Casualty INSURER C. j INSURER D: I IIJSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE PIiiOLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT T?ALL THE TERMSTEXCLUSIOHIS INIS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.INSR DD' TYPE OF INSUR ANCE POLICY NUMBER POLICY EFFECTIVE "POLICY EXPIRATION GENERAL LIABILITY MMIDLIMITS COMMERCIAL NPPI233696 07/23/2009 97/23/2019 EACH OCCURRENCE 5 1,000,000 X CLAIMS GENERAL LIABILITY DAMAGE TO RENTED S 1NM5 MADE OCCUR -tia�_ SO,000 q MED EXP(Any ane person) S S 1000 PERSONAL A ADV"JURY 1100010,30 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER'. j POLICY D rRo LOC PRODUCTS-COMPIOP AGO S 1,000I000 AUTOMOBILE LIABILITY ANY AUTO COMBINED SINGLE LIMIT (ER accident) ALL OWNED AUTOS SC HEpULED AUTOS i BODILY INJURY S (Eel parson) HIRED AUTOS ' NON OWNEDAUTOS I BODILY INJURY -- (PelawitleM) PROPERTY DAMAGE S (Per..Idenp GARAGE LIABILITY ANY AUTO AUTO ONLY-EA ACCIDENT S OTHER THAN EA ACC S AUTO ONLY: AGG S EXCESSIUMBRELLA LIABILITY EACH OCCURRENCE S OCCUR ❑CLAIMS MADE AGGREGATE S DEDUCTIBLE 5 _ RETENTION { S WORKEREMPLOYSS'LIAbCOMPENSATION AND C45787436 66109 22009 '06/09/2010 We sTAru;EMPLOYERS'LIABWTY @ ANYCERIMEETORFARTNEPoEXECUTIVE E.L.EACH ACCIDENT S Soo QQQ OFFICERIMEMBER E%CLUDEUP ' IT Y.I.dascriLn unda� E.L.DISEASE EA EMPLOYE 5 SQQ,QQQ SPECIAL PROVISIONS Mdow - - _ OTMEk EL DISEASE-POLICY LIMIT 5 500,00 DESCRIPTION OF OPERgTION51 LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Tnlow installation and sliding doors I i i I CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 1 EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL DAYSIW RITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY InsuredlS Copy OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Evidence of Insurance AUTHORIZED REPRESENTATIVE N�--� David ParsI ..-- ACORD 25(2001/08) ons ©ACORD CORPORATION 1988 I �Ltssachuscns - DcparUucnt of Pu61ic tiafcrc Board of Building Rc;;ulx[ions and titand:u(in-' Construction Supervisor License License: CS 66853 Restricted to: 00 JEFFREY P FISHER PO BOX 540630 y, WALTHAM, MA 02154 Expiration: 4/2712011 ._ ('„unuissiouer Tr#: 13582 iA QbG���YYd11♦�•'���b((i�Ali�f{'tl'f��..St. HOME IMPROVEMENT CONTRACTOR Registration: 123088 Expiration: 1274I2010 Tr# 278232 Type Private Corporation PROWINDOWS JEFFREY FISHER..-.. 1377 MAIN ST WALTHAM,_MA 02451 _ Administrator Reg. 123088 Pro Windows Inc. www.prowindows.com P. O.BOX 540630, WALTHAM,MA 02454 (781)647-9225 30�� FAX(781)647-9392 LICENSED INSURED ................................................................................................................................. NAME: David Charak DATE: 4/13/10 ADDRESS 27D Marion Rd. Salem, MA 01970 PHONE# WORK CELL 978 835 8536 # EMAIL dcharakncomcast.net Furnish and install the following,all to include LowE/Argon filled glass, .30 u value, .20 SHGC,windows are Energy Star Rated and will qualify for Federal Tax Credit for 2010 • 16 HARVEY CLASSIC VINYL FULLY WELDED REPLACEMENT WINDOWS, WHITE, DOUBLE HUNG, TILT IN,HALF SCREENS,NITELOCKS. REPLACEMENT INCLUDES REMOVING EXISTING WINDOWS AND HARDWARE. INSTALL NEW WINDOWS LEVEL AND PLUMB. CAULK AND INSULATE ALL CRACKS AND SPACES. CONTRACTOR RESPONSIBLE FOR REMOVING ALL DEBRIS. 16 double hung @$390.00/window $6,240.00 1 1 HARVEY VINYL GLIDING PATIO DOOR,6'6"X 6' 10", WHITE EXTERIOR AND INTERIOR,WHITE HARDWARE, SLIDING SCREEN. INSTALLATION INCLUDES REMOVING EXISTING DOOR AND FRAME,AND INSTALLING DOOR LEVEL AND PLUMB. INSTALL DRIPCAP,RETRIM EXTERIOR TO MATCH EXISTING DECOR. CONTRACTOR RESPONSIBLE FOR REMOVING ALL DEBRIS. $1,750.00 Less discount ($290.00) Total cost of qualifying windows $6500.00 Total cost of labor and materials $1200.00 Estimated time to complete is 1-2 days JQTAL INVESTMENT = $7,700.Og 7 lly(�G/fir, vs i r 2-7_ MAKE CHECK PAYABLE TO PROWINDOWS INC. ryf�"rkm 5vob Estimate includes cost of all trash disposal. Painting is responsibility of the homeowner. At(woamship is warranted for life. Payment terms are 1/3 up front,and balance due upon completion of contract unless otherwise specified. 10%holdback of Balance Due for 90%completion. Any and all extras will require separate contracts and are payable prior to start of work. Contractor,to be reimbursed by homeowner,will pull permits if necessary. Work to begi weeks following receipt of deposit. Contract is good for 30 days after contractor signature below. I accept the terms of this contract. date: ��j '� 1' J I D CITY OF SALEM PUBLIC PROPRERTY DEPART'�1ENT 12Q \N>TP h1'T ♦ SAI I-\I. \t.\„\I Ill I : :I') I II-')78-?ai-9i9i • 9-8-114 984o Construction Debris Disposal Affidavit (retluired for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Dcbris, and the provisions of MGL c 40, S 54; Building Permit it is issued with the condition that the debris resulting from di this work shall he sposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: ARR Y 5 go s /j/�wT A/ (name of hauler) The debris will be disposed of in (name ul lacility) (aldress ur 1'acilily) I tiigl'�t7nut a plicant 1e TO: David Charak- 27D Marion Road FROM: Jennifer Pappas, Property Manager RE: Window Replacement DATE: November 5, 2009 **t**a***r■r*+**�s****�*s****t***r*as******:e*a*a*:**s*s***********a��*** Please be advised that the Board of Trustees for Pickman Park has approved replacement windows for the above referenced unit. This approval is contingent upon them matching the existing windows and that they fit in the existing opening. They must be the same in appearance from the exterior. The Board will not allow windows with grids, crank outs, etc. We also require that permits be pulled in advance (regardless of what your contractor may tell you), and then a copy of the final approved permit once completed must be sent to APT for the unit file as well. We also recommend that owners obtain a certificate of insurance from the licensed contractor. You will need to bring a copy of this letter to the Salem Building Department in order to receive your permit. Should you have any questions or require additional information, please feel free to call me directly at (781)932-9229. cc: Unit File