164 MARLBOROUGH RD - BUILDING INSPECTION CITY OF SALEM
PUBLIC PROPERTY
yy�� —� DEPARTMENT
KISLL1F11 Ey DIUXOIL%
MAYOR v 120 WASHINGTON$IREEC*S ALF2/,5{A.ccAtHt,'Stl-rs 01970
'Mi 978-745-9595 4 FAX 97&740-9M
APPLICATION FOR THE REPAIR, RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address: 161}
Property is located in a; Conservation Area Y N Historic District Y
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: Ap
Address: 11p �`4j O t-0
Telephone: a-)
3.0 COMPLETE THIS SECTION FOR WORK IN FYICT1Nr, BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work.."Ro- Ao 09 e a„S' I q
S�ir\ -I- ,r2 -G-IDQ`Li C- \S1oQSV��c V 1C�1
('41A0we � 5�'��qS �1 �1cz�1aU?
Mail Permit to: Qx .$A
What is the current use of the Building? S \ `
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone
n
Mechanic's Name Ol 9 2
Address and Phonea CS�� � � 3
HIC Registration#
Construction Supervisors Lic�,ensse`'#
Z to
Estimated Cost of Project$ k Q2b(� Permit Fee Calculation
Permit Fee$ 0�9 Estimated Cost X$71$1000 Residential
Estimated Cost X$11l$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KA1aERLEY DRLSCO[1
MAYOR
120 WASHMTON STREET a SAtEM,MASSACHUSETCS 01970
TEtt 978-745.9595 a FAX:978-740.9846
Workers' Compensation Insurance ABldavit: Bullders/Contractors/Electricians/Plumbera
Applicant Information Please Print Lebersr
Name(BusineWOrganizauon/Individual).
Address:
City/State/Zi IAQC` Phone#:
l
Are you an employer?Check the appropriate box:
1.❑ I am a employer with 4. F67.
oject(required):❑ I am a general contractor and Iemployees(fulland/orpart-time).• have hired the subcontractors construction2.❑ I am a sole proprietor or partner. listed on the attached sheet t odelingship and have no employees These sub-contractors have olitionworking for me in any capacity. workers'comp. insurance,[No workers' com . insurance 5. ding addition
p ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.Q Plumbing repairs or addition$
myself.[No workers'comp, c. 152,§1(4),and we have no I2.[�Roof repairs
insurance required.]t employees(No workers' /
comp. insurance require&] ITT]Other
fAnY apPatant gut cheelu box el must alto fill out the section below showing their wmkme'compensation po6ry informatlos
Homeowners who submit this dfldff t indicuieg they am doing all wodt end then hie outside co meetors must sub oat a new atfldsvit my
=Contractors that check this ban must attached an additional sheet showing the name of the sub-commeton a d �f arch.
their workm'comp.policy inksmadoo.
I am an employer that it providing workers'compensation insuran
information. ce for my employees Below it the policy and job eke
' 1
Insurance Company Name: i_�_7 0 F fit.
c
Policy#or Self-ins. Lic.#: tJ q
—�_ Expiration Date:
Job Site Address:- lD f Y 1 (D r
t City/State/Zip:
Attach a copy the workers'compensation Polley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL$250.00 a c. 152 can lead to the imposition of criminal penalties of a
of up to
fine up t 00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
50. a day
ay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby certify under the pains and penalties ojperfuty that the information provided above it true and correct
v Date r t / i n
Phone#: cT 7 Y (' — �( �
[[Contact
ieial use only. Do not write in this area,to be completed by city or town oJJfeiaL
y or Town: PermittLiceose#
uing Authority(circle one):
Board of Health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
Other
Person: Phone#:
� 1
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their empldyees.
Pursuant to this statute,an employes is defined as"...every person in the service of another under any contract of hire.
express or implied,oral or written."
An employer is defined as"an individual,Partnership,association,corporation or other legal entity,or any two r more
A the foregoing engaged in a joint enterprise.and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing emPloYces However the
apartments and who resides therein,r the occupant of the
owner of a dwelling house having not s p e than three maintenance,
work on such dwelling house
dwelling house of another to as to do maintettanc0.construction or repair "
or on the grounds r building appurtenant thereto shall not because of such employment be deemed to be an employer.
or
ce
MGL chapter 152,§25C(6)also states that"every stater t local licensing ding$in allthe withhold mmonwealth for any
renewal of a license or permit to operate a business or to construct buildings
applicant who has not produced acceptable evidence of compliance with the insurance coverage ubdivisions"shall
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirementschap have presented resented to the contracting authority."
ter
of this
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to Your situation and,if
necessary,supply sub-contnwwr(s)name(s),address(es)and phone nttmber(s)along with their certificate(s)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
_be sure The affidavit should
Accidents for confirmation of insurance coverage.for the permit orolicense is beingshe requested,
ut Department of
be returned to the city or town that the application to obtain a workers'
Industrial Accidents. Should you have any questions regarding the law or if you ae required should enter their
compensation policy.please call the Department at the number listed below. Self-insured companies
line.
self-insurance license number on the a
City or Town Officials
it is complete and printed legibly. The Department has provided a space at the bottom
Please be sure that the affidav
of the affidavit for you to fill out in the event the Office of Investigations has to contact You regarding the aPPuclecant
Please be sure to fill in the permitli ruse numbed which will ns m an be
used
ear,need only submit one affidavit indicating current
that must submit multiple perm as a reference number. in addition,an app
it/license applications Y given y applicant should write"all locations in (city r
policy information(if necessary)and under"Job Site Address"the provided to the
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be p
applicant as proof that a valid affidavit is on file f errs ure ease or r�� not licenses.or led to any business or t be fined
ne al out
each
year.Where a home owner or citizen is obtaining permit
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The 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 Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of industrial Accidents
Me of Investigations
600 Washington street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF S11LEM
PUBLIC PROPERTY
DEPARTMENT
Neroa t3alYet�mt�oM s�astr•s�tm�xes�eaa�ts ot97o
Tn.M745-ft"•Fete M74&9W
s
Constmedon Debris Disposal Affidavit
(required tar ail demlidon and movadom work)
In mow wm with the snuh edition of the Stm BuMns Code,780 Cb1 section 111.5
Debr*and the provisions of MGM a AA S 54
Buddies Perrnit M is luoed with the oondWon that the debris resultky 8Om
this wort shag be disposed of in s properly liemsed waste disposal 6eiIIt1►as defined by Mo.is
1114 ISO&
The debris will in transported by:
rt AC 1
tinge as banjo)
The debris will be disposed of in:
ran
i�+e•r rxility)
(ate of fheility)
sioas
tparntit�pFlieaat
due
i
ACORDW CERTIFICATE OF LIABILITY INSURANCE
11/13/2006
PRODUCER (978) 745-6464 THIS CERTIFICATE IS MUED AS A MATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFIC/ITE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AJ;FORDED BY THE POLICIES BELOW.
E.O. Boa 950
Salem ML 01970- INSURERS AFFORDING COVERAGE NAIC6
INSURED INSUREN A'.NantilnS Lns Co.
North Shore Roofing INSURER YY Hartford
281 Andover Street INSURERa
INSURER 0:
Danvers MR 01923- INSURER 6:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCf PERIOD INDICATED.NOTIINTNSTANONO ANY
REQUIREMENT,TERN OR CONDITION OF ANY CONTRACT OR OTHER DOCUh1ENT MATH RESPECT TO VBIICH THIS CERTIFICATE MAY BB ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES DESCRIBEO HEREIN IS SUBJECT TO ALL THE TERMS, EXCLQ.'JONS AND CONDITIONS OF SUCH POJCIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR WI POLICVEFYECTIVE PO yOy 6XPIRATIOH
LTR NB40 TYPE DP INSURANCE POLICY NUMBER OATSRANDDM•) OATS IMMIDONY) UNIT"
A GENNTALUABILITY / / / / EACH DCCURRENCE Y 500,000
X COMMERCMLGENE MaL1TY MAGETORERTm
X C..B MADE �OCCUR NC434418 05/24/2006 05/24/2007 PRtIIIDF6 En Wewnna 0 30 ,006
wm eW Am oro YIYM Y 5,00
PERtlONAL A ADV INJURY Y 500,000
OENERALAGGRE"TE Y 1,000,000
GEN'L AGGREGATEppLIMIT APPLIES PER: ARODUCT3-COMFO AGG 0 .1,000,00D
POLICVEl JECT LOC
AUTOMOBILE LMSLRY / / / /
0.M MAn SINGLE LIMIT
A
NY AUTO TEA UYMYnD 0
NED AUTOS / / / / LYINJURYLED AUTOS IPGIPOw) 0
UTOB / / / / -30DILYINJURV
NEDAUTOS TwattMYBTJ 0
PROPERTY DAMAGE
1P a¢WnD Y
GARAGE UABIUTY AUTD ONLY.EAACCIDENT I
ANY AUTO / / / / OTHER THAN EA:CC 0
�4UTO ONLY, qOG Y
EXCESSIUMBRETJA UABIUTV / / / / ACH OCCURRENCE 0
OCCUR ED CUINS MADE .OGGRT$ATE 0
Y
DEDUCTIBLE
RETENTION S -
0
8 YWRNERSCOMPENBATIDN ANO BC549990 07/25/2006 07/25/0007 :IC TORY uwIr Iw EMPLOYERS.LMBILRY
ANY PNOFRIETOfUPwRTNERIEYECUY'IVE I:.L.EACH AOC®ENT 100,000
ORICERMEMSER EXCLUDED?
KMdm;NSRmw H / / / / l: .OI 31!-EA EMPLoyrq 0
OTND 100,000
OYwER PROv18ION6 BnIw C.L.DISEASE-POLICY LWIT Y 6001000
I / / / /
DESCgIPTgN OP DPERATNIM&LOCpTpNWBNN;���rr�NeIONSADDEO BY ENODRSEMENTAIPBCIAL FROWBpNg
Raoesaq
C TIFICATE HOLDER CANCELLATION
(975) 662-4667 ( - WOULD ANY OF THE ABOVE DESGRISEO POUCWA DE CANCELLED BEYORE THE
EXPIRATION DATE TNEAEOF, THE 3311061 INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRT"EM NOTICE TO THE CeOTFICATE HOLDER NA IM To THE LEFT,BUT
Mr. and Mrs. Dellagratte FAILURE TO DO SO SNAII WGIBE NO IMOLIYATION DR UABILRY a ANY TWO UPON WG
164 Marlboro Road INSURER.ITS AGE T30RAEPREBENTA'fAIEL
pUTNO PR@SEN .
Salem MA 01970-
ACORD M n001108)
t;INS026(0roe).Ds ELECTRONIC LASER FORM INC.. 0 ACORD CORPORATION T9BB
4 (400pTT-0Gs PBSA 10I2
10/10 39Cd ON39V 3owanSNI 3S08 98ELSOL8161 IV:ZT 90OZ/EI/11
NORTHSHORE LOOPING& SEALCOATIN
281 Andover St. Danvers,MA 01923
(978)977-3816 Fax:(978)762-4667
Mr. & Mrs. Dellagrotte 11/01/06
164 Marlboro Rd.
Salem , MA
(978) 745- 6912
The following is a proposal to apply a new asphalt shingle roof at the above address
1)Remove the existing asphalt roof shingles down to the roof deck and legally dispose of the debris .
2)Replace any deteriorated roof decking up to 50 sq_ft. if and where needed at no charge any deterioration beyond the
50 sq. ft. will be an additional charge of$45.00 per hour labor plus material.
3)Re-nail any loose roof decking if and where needed .
4)Apply 3-11.of ice and water barrier around the entire perimeter of the roof as well as around all penetrations.
5)Remaining exposed roof decking will be covered with 15- lb. asphalt roof paper
6)Apply 8-in. aluminum drip-edge flashing around the entire perimeter of the roof.
7)Apply new aluminum flanges over all vent pipes .
8)Remove the existing skylight which is located in the rear of the house,bathroom .
9)Supply and install a new Velux venting skylight, skylight to be the same size as the existing skylight .
10)Apply a rolled ridge vent on the roof peak. ,rnbe.,/)%l -e
11)Apply a 30-year architectural asphalt roof shingle . (color:WekW10 i a
12)All roof related debris will be legally disposed of by North Shore Roofing.
13)Five year warranty on workmanship,thirty year manufacturers warranty .
GUTTERS
1)Remove the existing gutters which are located in the rear right side of the house as well as the gutter in the front of the
house and legally dispose of the debris .
2)Re-apply new.032 aluminum seamless gutters and four(4)down spouts.
TOTAL PRICE ROOF: $5,950.00
TOTAL,PRICE GUTTERS:RS:$8$890.00
TOTAL PRICE ROOF&GUTTERS: $6,840.00
PAYMENT TERMS
1/3 DEPOSIT REQUIRED: $2,280.00
BALANCE DUE UPON COMPLETION:$4,560.00
Acceptance of Proposal-By signing this proposal you have accepted al I of the terms as-state !a ove�
Date of Acceptance Homeowner
. /
v
N. >
Pe r iller
Member of the Better Business Bureau Mass. Reg. #128691