28 MASON ST - BUILDING INSPECTION (2) --- I'Ile C'onumumecahh of bhu,achusclls
n Board of Building Regulations and Skutdards Cl FY OF
sI \las"clltlsetts SIMC Building Code, 790 CNIR \Lli�l
I)uilJin9 1'ennit 1\pplicillion To Construct. Repair- Renuvale Or Dentulish a R,•ri.a,/ I LPr`n//
()Ply- Or rich-Panid), Uurlliug
This Section For 011cial UseDnl
Building Permit Number: Date, pplied:
Ituilding Olilcia (Print N;une)
Dale
SECTION 1:SITE INFORMATION
iY /�1 �tIJl11'dtire
< l 1.2 Assessurs.slap dr Parcel Numbers
Y'
I.la Is this an acce tad street? •es no Map Nullifier 1'arcul Nuuther
I.! Zoning Information: 1.4 Property Dlmenslonsl
tinting Distract Impose (Ur—�— LotAmula II
4 1 1.5 Building Setbacks(R) Fronla gotll)
Front Yard Silo Yards
Yard
Required I'mviJed Reyuirod Providedvided
Reyuind Rear 1'mviJeJ
1.6 Water Supply:tM.G.I.c. JU,§34) 1.7 Flaad Zone Informations 1.11 Sewage Disposal System:
Public❑ Private❑ Zane: _ Outside Flood Zone?
Check if us❑ Municipal❑ On sIN disposal s)slmn ❑
SECTION2. PROPERTY OWNERSHIP'
N,mwtPnnq d��'7 70
C u),Slule,l.IP
Nu..uw amer tale Aunt
p Email AJdress
SECTION 2: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ E.vistin I Building❑ Owner•Occupied ❑ Repaints) ❑ Aheratlon(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify;
Brief Description of Proposed 1Vorks: E GGB Lti,� �av�
SECTION a: ESTI I.41ED CONSTRUCTION COSTS
llolll Estinsaled Costs:
ILabur and Materials) Official Use Only
1. Building S I. Building permil Fee: S - Indicate how fee is determined:
i `. Flectrlcal S ❑Standard City Tusvn Application Fee
t 1'lumhiny S ❑Total Project(•usl'I Ilens 6)X nullip,it(
I. Other Fear. S -
I J, \l"ballical ill\ \(') i List:_—
? \IcJI.IIIiv.II I FPre _._�_
total \II Fees: S_ '
r, l'otul 1'rnject Cost i ��O ( heck \u. _. . _( hack .\nlwun: (',I,h \waunC
❑ P.IiJ ro Full 0(hilsCUlJing Oal.usce Due:
Stl'.( I-IONS: ONSI'MIC. ION SFRIll
q1 17Y-�� .. .. . r I
—Nuillb i:r
enteldl'SL
P4:
Deicriplian
No. 311d Street
K
Sidii
SF Solid I:Ugl 1111ritills,\pPliaill
I Imitation
c Millolitill"
D
:11lailai.drl
I In LL�
tl red Ilume Improvement Contractor 111,C) /14y, Uwe
if 11 - Ije&i1Ir;lIiunNumber 1:\piralill,
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lic Upiv) Y, 5;1,—a did M Is
U. Id Tile------
Ci /Town. State ZIP l ulna M.G.L C. 152-1 25C(6))
SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(
Workers Compensation Insuranca 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 .......... NIPLETED WHEN
TOBEC
SECTION 7st OWNER AUTHORIZATION
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
hereby authorize
1, as Owner of the subject pr( relative to work authorized by this building Permit OPPlication.
to act,on my behalf,it,all m
Will
sN alum)
allill AUTHORIZED AGENT DECLARATION
SECTION71b.OWNER' OR AUTII
By entering my Ma CIO I hereby attest under the pains and penalties of perjury that all of the information
contain
In ecurate to the best of my knowledge and understandin
Icat is true and a
contain In a
it
1. it ),il i k %tal
No,rES:
egisicred ixtilra0ur
an owner Nvho hiresan tair
a building permit to do his her a
I An o\%tiql\%ho obtain$ ,iiigliiiproveitignicuntr-,icturtHICIPrograni).Nvill!U) have ac�css to the arbitration
i lot registered in he Hu Olhcr impuriant information on the HIC Prograll',I be I-ound at
Program or guarail liulid under
-tion Stipemisor Li"Mse can be round at
i Information On the Cor"I
111, - n bil 010\v�-
it llll.url�
I 'l lit,th
s plIllarted. pro%ide the i ifurtintiun below:
1ICn liubstalltial%�ork 1 g;III,
I ,ge. I'lilislul bascilicilLattiM l Pk'"
rl Floor area 14 Habitable fOu'll.0'1111
Gruii li\ing arra l iq. Number l livdilion's
\llubel hattirvoills llkirOles
11VAI i[I l; ) li:In l',.I it
I re I I;oo 11114 N OQ Ill
I oi.il Ill 1:0013l he ;lb,Ilttll,l:d ll I ollil Prolli.
r 1
�! CITY OF SM.E111, Ir'L-1SSACHUSETTS
BUILI)ING DEP 1RTNffNT
a+• 120 WASHII NGTON STREET, 3'a FLOOR
TEL. (978) 745-9595
F.kX(978p 740-9846
KINBERT RY DRISCOLL THOFL►SST.PtERRf3
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BI:ILDIING CO\L\fISS[ONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� Please Print Legibly
Name(OusiiiosOrganizatiom'Individual):/ if,,IJ X,, r0 /.. 1 c !'r•'a<
Address: 7 / 13 c / r cz
City/State/Zip: j2- !r7 Phone ✓ : y
Are you an employer?Check the appropriate box: 'type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hind the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp:insurance 9• ❑Building addition
[No workers comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I l EI Plumbing repairs or additions
myself. [No workers'comp. c. 152,g 1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13.❑Other Gera O/grt
comp. insurance required.)
;An, an"
that chaka box Al must also,rollout the section below showing their workers'compensation policy infurmation,
ILxneuw'tw•n who nuumit this affidavit indicating they am doing all work and then hire outside contractors most submit anew affidavit indicting such.
:C°ntracws that check this box meet attached an additional sheet showing the nurse of the sub�conlracton and their workem'mmp.policy fnfomtntion.
l um an employer that is providing workers'compensation insurance far my employees. Below Is the pollcy and Job site
information. 4
insurance Company Name: Pe h 1, / I yf
y RAC � � 2 / / 9,1�iii-Policy#or Sclf--ins. eLi�c. q: � q � N Expiration Date: M
lob Site Address: o! ��'.�f%'< �J'�' City/State/Zip:i��Blit/j'�� •' GI7 ,�
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
tine up to S 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigutions ofthe DIA for insurance coverage verification.
!do hereby certify wader rite paint and penalties of perjury that flit information provided above is rr a and c orretG
S o,naturr De' [)are: � 7 ��
Phony,#;
Official use only. Do not write in Nrfs urea,to be completed by city or Iowa offkial
City ar'rown: Permit/lAcense
Issuing Authority(circle sane):
1. Board of Ileallh 2.Building Ilepartment 3,City/fawn Clerk 4. Electrical Inspector 5. Plumbing Inspector
6,Other._-- ---_-----
Contact Person: Phone#:
f�
r
GUIMARAES CONSTRUCTION
21 BALCOMB STREET
a SALEM MA 01970
FONE: 978-836-7279
V ri
r4QUOTE/CONTRACT
QUOTE: 01
DATE: September 10, 2012
Salem MA01970
r` 978-8217412
t� 3
Description Amount
Replace 9 windows
Install 2 doors 6 panels
Install panel 6 panel door
Install crown molding in:
Living room
Dining room
Bedroom on the second floor
k' Install baseboard with the cap
Build 12inch wall and trim both sides
t sal r Cover 19 windows with aluminum trim
xv
Trim 9 windows
/ /"�
Total Price includes: Labor, Material, Disposal, and Permit. U$7,200.00
Price
Quote valid for 30 days. Quotation prepared by: Rodrigo
1st payment due at signing of contract for purchase of material
2nd and final payment on last day of the job
GUIMARAES
CONSTRUCTION To accept this quotation, sign here and return:
21 BALCOMB STREET Complete Name of person signing this quote:
SALEM MA 01970
FONE: 978-836-7279 Date: /�_ 1a5 A 3bbz
t009IH UCe di
�.'v['IfGAIQC�•torgp
Office ofConsumer A ails irsmess Regulsnon License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
F
Registration: ,1ggg39 Type: Office of Consumer Affairs and Business Regulation
Expiration: 2/13/2014 DBA t 10 Park Plaza-Suite 5170
Boston,MA 02116
O CONSTRUCTION
I
MICHAEL MERCURIO I-- ? /7
127 OAK STREET
WAKEFIELD,MA 01880
Undersecretary 1 Not valid without signature
C
"ilassaChusetts- Department of Public SH1'cls
Board of Building Rct!ulations and standards
Construction Supervisor License
License. CS 91942
MICHAEL L MERCURIO
127 OAK ST
WAKEFIELD, MA 01880
Expiration: 1/4/2013
f onnni..imei, Tr=: 9263
zo�z-oo-1s Io.as z1
ACdRD CERTIFICATE OF LIABILITY INSURANCE OATSIY
09/13/213/2012
PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Lauranzano Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE -
4 Y HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Beverly MA 01915- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A.Penn America Insurance Co
Rodrigo Guimaraes INSURER B Travelers
Guimaraes Construction INSURER c.
21 Balcomb Street wsuRER D.
Salem MA 01970- INSURERS
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 INSRO TYPE OFINSUF NCE POLICYNUMBER DATEYMMODNY) POLICY E(MMI�DIYIIO')N LIMITS
TR ADDIL
A GENERAL LIABILITY PAC6978224 03/09/2012 03/09/2013 EACH OCCURRENCE $ 1,000,000
$ COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence 5 100,000
CLAIMS MADE OCCUR / / / / RED EAR(Any one person) 5,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG $ 2,000,000
R Poucv JEGT LGC / / / / NOWND
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT
ANY AUTO (Ea accident) `+
ALL OWNED AUTOS / / / / BODILY INJURY
SCHEDULED AUTOS (Perperson) 5
HIRED AUTOS / / / / BODILY INJURY
NON OWNEDAUTOS (Peraccidenl) 5
PROPERTYDAMAGE
(Peraccldent) 5
GARAGE LIABILITY AUTO ONLY EA ACCIDENT $
ANYAUTO / / / / OTHER THAN EA ACC $
AUTO ONLY. AGG $
EXCESSIUMBRELLA LIABILITY / / / / EACH OCCURRENCE $
OCCUR F—ICLAIMS MADE AGGREGATE $
5
DEDUCTIBLE / / / / $
RETENTION R $
B WORKERS COMPENSATION AND 7PJUB-5059PB6 02/26/2012 02/26/2013 ][ WC STATU OTH-
EMPLOYERS'LIABILITY TORY LIMITS ER
ANY PROPRIETORIPARTNERIEXECUTIVE E L.EACH ACCIDENT $ 100,000
y OFFICERNEMBER EXCLUDEDc / / / / E.L.DISEASE EA EMPLOYEE 5 100,000
It yes,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICYLIMIT 5 500,000
OTHER
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
Re: 28 Mason Street Salem MA 01970
CERTIFICATE HOLDER CANCELLATION
( ) - (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
City Of Salem FAILURE TO DO BO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
One Salem Green INSURER,ITS AGENTS OR REPRESENTATIVES.
AUTHORIZED REPRESENTATIVE
Salem MA 01970- ......->_-
ACORD 25(2001/08) a ACORD CORPORATION 1988
r,-INS025(01oa).05 ELECTRONIC LASER FORMS,INC.-SOU327-0545 Papa I al l
To: Pa9a 2 0!2 20'12-09-13'19.95:2'1 (GMT) La uranza nu In¢u ro nce Agancy Frum: Larry Lauianiano
R'
IMPORTANT
If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this
certificate does not confer rights to the certificate holder in lieu of such endorsement(s).
If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an .
endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such
endorsement(s).
DISCLAIMER
The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing
insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively
amend, extend or alter the coverage afforded by the policies listed thereon.
ACORD 25 (2001/08)
��,;INS025(0108).05 Page 2or2