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138 MARLBOROUGH RD - BUILDING INSPECTION (2) �I The Commonwealth of Massachusetts � t Boar) of BuilJing Regulations and Standards CITY (1 f Massachusetts State Building Code, 780 CMR, 7"cJition is SALEM "'www Revised hutn,irt. Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 21)(Al One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: Signature: ' Building Commissioned Inspector of Buildings Date SECTION I:SITE INFORMATION 1.1 sty Addnss: 1.2 Assessors Map& Parcel Numbers I.l a Is this an accepted street?yes ✓ no Map Number Parcel Number 1.3 Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area(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: Zone: _ Outside Flood Zone? Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 wner fRecord: 1 (y- Name(Print) ress for S rvice: �' ? 7`2-- cis— 0V Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied — Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ 1 Accessory Bldg.Cl Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building S 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IiVAC) S List: 5. Mechanical (Fire S Su ression Total All Fees:S � �� Check No. Check Amount: Cash Amount: 6. Total Protect Cost: S ❑Paid in Full O Outstanding Balance Due: 5 �J p- Do (04C,41 a AO 9,ftif,,s )Llrl . SECTIONS: CONSTRUCTION SERVICES 5.1a ervlso ( SL) 2 /O—3/ License Number Exp/iratilon Date List CSL Type(see below) U Description rcs l Inrestricied(up to 35,000 Cu.Ft. R I Restricted Ik2 Family Dwellin �.. alum M Masonry Only 52 RC Residential Rooting Covering I'dephone WS Residential Window and Sidin ,l SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 2 b ed He prov men Co tnctor(HIC) 1 / 1�6� I IC m�y ne or t ReIN• a (Reggistration Number JJ �T/� &,'�,6 52 Expiration Date alurc [Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 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 ..........0 ' No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S ACE TOR CONTRACT R APPLIES FOR BUILDING PERMIT 1 , 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. Signinturc of Owner Date srhcpolil 7b:OWNE t OR AUTHORIZED AGENT DECLARATION 1 e]_ r ,as Owner or Authorized Agent hereby declare th t he late ents din at' n a the foregoing aApplicu true and cc rat o the best of my knowledge and be alf. P to Name Si a ure of(honer or Au o ized t Date i under the pains nahin f 'u NOTES: 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),wi11 W 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 CM Regulations I IO.R6 and 110.RS, 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 h21f/b2thS Type of heating system Number of decks/porches Type ofcooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" ACORD CERTIFICATE OF LIABILITY INSURANCE DATE /DD rM OS/03/201010 PRODUCER 978,774.8040 FAX 978.774.3581 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Tarpey Insurance Group Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 491 Maple St (Rt 62)-Suite 304 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. PO Box 183 Danvers, MA 01923-0383 INSURERS AFFORDING COVERAGE NAIC# INSURED J. P. Remodeling & Construction, Inc. INSURERA: Safety Insurance Co 39454 220 Yankee Division Highway INSURERB. Travelers Indemnity Company 25658 Danvers, MA 01923 wsURERC 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 DD' rypE OF INSURANCE POLICY NUMBER DATECMM/DDCCTIVE DATE MM/ORATIO LIMITS LTR NSR GENERAL LIABILITY BP00003110 11/05/2009 11/05/2010 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO ED PREMISES Ea occurrence $ 100,000 CLAIMS MADE OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERALAGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 X POLICY PRO JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS (Per person) $ HIRED AUTOS BODILY INJURY NON-OWNED AUTOS (Per accident) $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR u CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION 6KUB0363M82509 09/30/2009 09/30/2010 X I TORYLIMITS ER AND EMPLOYERS'LIABILITY B ANY OFFI CER/MEMBEREXCLUDED?ECUTIVEa E.L.EACH ACCIDENT $ 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under SPECIAL PROVISIONS below _ E.L.DISEASE-POLICY LIMIT $ 500,006 - OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS eneral Carpentry 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 DO SO SHALL �l d 4-Z&-ki IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR City Of ' REPRESENTATIVES. Beverly Building Inspector AUTHORIZED REPRESENTATIVE Bevery, MA 01915 James Tare , CIC, V Pres ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD p� �d �\q .rt Office of Consumer Affairs& ONT BusinC,oR&ulariog HOME lmpROEMENT.CRA Re9istration_",,A5467 -r,# 291216 Ezpiration 13012012: iztion o T;pe � p�v�teiCorP 83 T ""CONSTRUCTION,INC ,J p.REMODELI HN NG�At pi crctarY JO P O 0 YALIZZOTTI ^. 22NKEE DIVtHYWYr�,. UnYs de . DANVERS, Ivtassainuxas% oepartntupr w rumiu o V*tr ' Board of Buildint;"Regul itions itnd Standardv Construction Supervisor License .• ..,4icense: Cs 45529 Restricted to, 006 MU "J'OHN1$ POLIZZOTTI ~ , 2�0 YANKEE DIV HGWY ids DANVERS, MA 01923 Expiration: .1013112010.; t.Comndssiuniri Tr#: .4784 . TD OS'DY 220 Yankee Division Highway Free EsltimaLC6 Danvers, MA 01923 Licensed and Insured aeirLoc�e%r�, CC^. l�P/ZQ'�/GGCCLpfli, �l/LG. Ma aehu,bett,s llolne IrhprovenlenL Cont-racLor #115467 Panpos.u.xuanuTrEOTo (978) 777-7637 fax (9'78) 762-7606 Jean nPAry PHONIC DATE 978-852-05-04 3-12-10 m1"`38 Marlborough Road '2 "A E CITY.STA':v:d PJP CODE damaged skylites by wind/rain storm. Sa�em, Ma. 01970 '°°""°" Sa We hereby wbnat spccificaions and estimates for: me 1 - Remove 2 existing skylites that were damaged by wind/rain storm. 2- Install 2 Veluz #VSE 606 _electric R.O. 44. 3/411x46z" with. flashing kit & screens . Install W.R.Grace on 4 sides of skylitei & reroof 3 tab white roofing shingles. It is unknown if any reframing is needed, also it is unknown if any new wiring to skylites will be needed if so additional charges will apply. 3- Electrician to reconnect 2 existing power supply. 4- Install new 1x4 T&G ceder trim out 2 skylites& apply 1 coat of stain & poly, new stain color may not match existing stain color. 5- J.P.Remodeling & Const. will; A- issue a copy of insurance to owner & pull permit. B- be responsible for all waste from above work only. I Contractor obligated to inform Customer ofany and all necessary permits and to obtain said permits.Calitantill who secure their own pern+i6 will be excluded from the gmmmec Cond of h1nsc Gen_Lams Ch. 142 Propo hereb to fu h ma I and Wa plat dunce with above r,m ii,arrinu,for dm sum or: Five thousand fiveiunredory eigYi c�or�� ars . 75 Y, an net ^ao as rmmsss' dollars(s $5, 5 4 8 .7 5 "�/ �epoist 1 /3 start of work balance on completion 849 . 58eGr49..m51Jnl ntu Neke m t curdi in tnnQerd tic, y ninon or deym u�sa s wnl n1Y upon wrinen Authorized Signature _ ors, and become an exw charge over end above the esnimme. All - eemens camingem upon suikes,accidents or delays beyontl our control. :ceptanee of Proposal — roe nboye prices, spenmrations and Do not si s eitions are rdsfaanry and tie nernty ne«pma.vo are aumoriznd to do tna 6n i. •onlract if the a are any blank spaces 'k its sµcilied.Paymem will be mudgaa du�h'nyW�ave' v of Accepiytce:�_ Signature .. - Customer has legal right to cane nlract within 3 days of acceptance rtmctor shall perfomn the work in conformance with such plans and specifications,if any,its have Y Contractor shall not be liable for any delay due to circumstances beyond its control including sni kcs, n provided by the owner or the contractor,which plans and specifications shall be deemed casualty or general unov"iiability of materials or We discovery of the conditions or defects upon the site _ apomted into this contract by reference,and will do so in a workmanlike manner.Contractor is or in the itrucmre(s)thereon not known to the Contractor at the.lime of exeo m i on cf this can mill and responsible for performing any work not specifically referred to In this contract. which n.,be discovered during the course of the Contructnr's completion of all,work Ill m event any installment is not paid when due,contractor nay stop work without breach until Owner nckn.wledges and agrees that in cert addition,the ain remodeling work the demolition of portion.+of in, pre room is made and for five(5)days thereafter.In the event any installment is not paid within let,(to) existing structure may reveal additional defects,conditions or the need for additional work which mush n after it is due,contractor may,al its option deem this contract terminated by the owner and may be repaired,altered or carried outin order to commence or complete the work such action as may be necessary,including initiating legal proceedings,to enforce its rights ecut'acl.In ork called f in this such case,rite Owner agrees than the duration of the work and all,ork alledu far date of :under.At all times during construction,owner shall provide and maintain free and unobstructed completion may vary front that which may be sat forth herein and Owner agrees aecculc a chums ss to all areas of the slte.where the work will be performed and shall provide,at owner's sole order detailing the cost and scope of the additional work necessary to repair,corrcot nr aher such wise,water and electrical service,including 220 amp outlet. additional ddecs:rod condilion" tractor shall not be responsible for claims for damages to persons or property occasioned by owner Contractor'winnuits all work for a'period m 36 months following completion. s agents,third parties,acts of God or other causes beyond contractor's control.Owner shall hold Ownicr agrees that in the event it be ll""sarY fur Contractor to collect tiny nvvmenn 'actor completely harmless from,and shall indemnify central,.,for ill.,.a., a..,........, n..__ ___ I . __ _ CITY OF SALEM PUBLIC PROPRERTY ;Kv ' DEPARTMENT \\.\iIII\,..,NS1MAT ♦ SAHM. NhIi%( :I l :I I ;, lFl 'CSN i-0j9j � I'.\s:'i'YJ3 'I\i�i Construction Debris Disposal Affidavit (required lirr all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit fk 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 111, S 150A. The debris will be transported by:ed 4 1 ) d- �e j "(nanie LoFtlhauler) The debris will be disposed of"i�•'�C.1/t-� _ r R� (nal a ul facility) . 0 6FL (address of lucility) ,wlialure of rmit a t cant (late -- drhn.a: d„c CITY OF SALEM rr PUBLIC PROPRERTY DEPARTMENT NI.1!1'DKISCOLL lit 12^�WAiHlNt;fON S I KEET •SALhxl,M.vss.%ct u:sc rl s 0197�. TEE:978-745.9595 • 1>sx:978.740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers :oL 3 tlicant Information h A A Please Print Le ibly Name (13U.1locssiOrganizatio Individio W Address: 2Z c ,uo . Ci[y,'Sta[cilip: 23 Phone ,'./: / 20 722 2637 Are you an employer?Check the appropriate box: 'Type of project(required): . ❑ 1 am a general contractor and I. 1 am a employer with A G. ❑ New construction employees full and/or art-time).` have hired the sub-contractors ( P' 7. ❑ Remodeling 2.❑ 1 :can a sole proprietor or partner- listed on the attached sheet. : ship and have no employees These sub-contractors have S. ❑ Demolition working far me in any capacity. workers' comp. insurance. 9, ❑ Building addition -No workers' comp. 5.. ❑ We are a corporation and its insurance officers have exercised their 10.❑ Electrical repairs or additions required.] 1 I. Plumbin•repairs or additions 3.❑ I am a homeowner doing all work right , exemption per MGL ❑ b P' myself. [No workers' comp. a 152, 1(4),and we have no (2.❑ Roof repairs insurance rcyuired.J t employees. LNo workers' 13.0 Other comp. insurance required.) •Any::p pl,cant that checks box#1 must also till out the wclion lwtow showing their workers'cumpunlniott policy infurmariwt. ' I tomeuwm:rs who submit this atTdavir indicating they arc doing all work and then hire outside contractors mot eubmii anew alGdavil indicating such. :C,1no:wmrx that check this box mtul aoaehcd an additional sheet showing the,auto of the subcontractors and their wurkets'comp.policy infurmatiun. I amt can employer that is providing vur ers coal cn.sation insurau a car lily eagx 'ees. B law t he pull and lob site information. Insurance Company Name: -..._._. _. r ._. _ .. .. Pulicv Scar Sclf-ins. Lie. >t: _ - _A Expiration Dale:/1 Job Site Address: I / City'StateiZip: Y 1�ri, .%ttach 11 copy of like workers' compensation policy declaration pale(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of.\{GL c. 152 can lead to the imposition of criminal penalties of a tint up to S1.500.00 and/or one-year imprisonrncnt, as wall as civil penalties in the form of a STOP WORK ORDER and a fine of up to$230.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of Investigations ul'the MA for insurance coverage verification. l da hereh certify tiler the p a sun penal es of perjury that ore information provided above is true and correct. en;uure: Q' Date. Si _ Phw:c:.1 � V 6 Qfjicial a se only. Do not Ivrire in this area, to be curnpleted by city or tmvrt official C'ityor'I'own: PermitiLicense0__.___ issuing Authurily (circle one): 1. Board of Ilcalth 2. Building Department 3.Cityffosin Clerk a. Electrical Inipector 5. Plumbing Inspector 6.Other Coulacl Person: .__-- Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an etnplgree is defined as"...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more Of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of 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 louse 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." 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, WIGL 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.piesented 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) nume(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 continuation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be retuned 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 fill not in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple permit'license 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 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 bum leaves etc.)said person is NOT required to complete this affidavit. The Ol lieu of Investigations would like to thank you in advance fur your cooperation and should you have :my questions, please du not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 acviscd 5-26-us www.mass.gov/dia