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111 MASON ST - BUILDING INSPECTION (2) 1 The Commonwealth of Massachusetts t Board of Building Regulations and Standards SIALEM Y OF Massachusetts State Building Code, 780 CMR Revised Mar 20/1 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling I This Section For Official Use Only Building Permit Number: Date Applied ►,�z,/13 BuildingOfficial(PnntName) -`^� � Signature' = Date 'SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers t �} '(11A CTv, C± 2a1_1 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information. 1.4 Property Dimensions: _ P Zoning District Proposed Use Lot Area(sq ft) Frontage(11) 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 D Private D Zone:_ Outside Flood Zone? Check if yesD Municipal D On site disposal system D SECTION 2: PROPERTY OWNERSHIP 1 Owner'of Record: - -. -ICp 5 a M a try, ` C Flame(Print) I City,State,ZIP k t I ffl srn 9-16 -74S -Az N1A No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) , New Construction E)dstingBuildingX Owner-Occupied Repairs(s)D Alteration(s) D AdditionD Demolition D Accessory Bldg.D Number of Units i Other �,Specify: Brief Description of Proposed Work : 9- fed 0:C clntFjolnc SECTION 4-ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: abor and Materials) Official Use Only 1.Building $ S D ob 1. Building Permit Fee: $ Indicate how fee is determined: D Standard City/Town Application Fee , 2. Electrical $—� �D Total Project Costa(Item 6)x multiplier x 3.Plumbing $ e� 2. Other Fees' $ List: w 4. Mechanical (HVAC) _ 5. Mechanical (Fire $ — Suppression) 'Total All Fees $ Check No. Check Amount: Cash Amount 6. Total Project Cost: $ 5 ; D o i) D Paid in Full D Outstanding Balance Due: ? r5I - 953 -0N�h SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1 1ST ( 1 ., 1• S la r rJ I CD M r "T'el Lrcense Number Expiration Date Name of CSL Holder 5 S D a e e {2 List CSL Type(see below) No.and Street Type Description V\h MAA (q 0 Li U UnreM (Buildings s u to 35,000 cu.ft.) City/Town,State,ZIP R Restramil DwellinM MasoRC RoofWS WindinSF Solidng Appliances 144 ( \qq �OInsulTele honemail address D Demo 5.2 Registered Home Improvement Contractor(HIC) RAvtcloO Cemr �d ��t $ � I _ HIC Compaal�ty Name or HIC Re stram Name HIC Registration Number Expiration Date 4C I4,et.� I�° Ka"I NQ.andStreet �Ae�e1� IR4tcm �tu \ CI�w, F t\rl tM"a l q o al C�S� 0 4 Ema l ad ess Cit /Town, State,ZIPi Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(NLG.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 ofthe Issuance of the building permit. Signed Affidavit Attached? Yes ... .......hK1 No...........D SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT °ry A Wesf Hwy` I, as Owner o the subject property,hereby authorize �+> v clt ( e u��o Z R e t�� V"`0.vs a n�— to act on half, in all matters relative to work authorized by this building permit app ication. Nay Print er s Name(Elec me rgnature) Date S CTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained ' this application is true and accurate to the best of my knowledge and understanding. Print Owner or Authorized Agent's Name(Electronic Signature) - (1 2 0, 7 01 L gn ) Date NOTES: 1. 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 naLhave access to the arbitration program or guaranty fund under M.G.L.c. 142A. Other important information on the HIC Program can be found at www mass ov/oca Information on the Construction Supervisor License can be found at www mass eov/dp 2. When substantial work is planned, provide the information below: Total floor 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 halfibaths Type of heating system 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Massacti"SettS - Department of Oublfc Safcry Board OF Building Regulations and Standards Cominir[inn 4upeni�+r '"'� L.t:ense. CS-0759M7 ter' 1 - s •; RANDEL G COMITO 43 BOWLER ST . 'a �r LYNN MA 0190) y 0 " ..id+•s.l'�.:f r, � nnuruSsfOntlf 07/19/Y015 N- :�� '�Oanrrirarerirrvtl�id n ��turr<�r� 01aee of Coorumer AaLln&a slam Regaladoo HOME IMPROVEMENT CONTRACTOR RegMrWon: ION31 Type: ExpIradon: 3/1=014 IndWual RANDEL COMITO RANDEL COMITO 45 BOWLER STREET 4ir.— LYNN,MA 019M Uodeneem ry iIV.A J11 r��. m .. ' TNeaerdocknawj¢dgea tl�oi.U»nxipimN ooa-duSMOOfutlY complaluda . Y'u 304mm Ooomnitiorw Sit"Mw wom 7tabt1tig Coarao in CorWMxdon go"MV Heaah ,. t(Ior nRnm—pAntar Typo) -(coasa end date) 11119/2013 10:32 lauranzanoInsurance Agency fa P.0011001 -A CORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MWODN"Y( 11/19/2013 PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Lauranzano Insurance Agency ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER- THIS CERTIFICATE DOES NOT AMEND EXTEND OR 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIhS BELOW. Beverly MA 01915- INSURERS AFFORDING COVERAGE I NAIC III INSURED IN ER A:Col Ony Insurance Company _ Bay State Weatherization 6 Construction LLC INSURERB:BafetY Insurance Company 89 Newbury Road wBURERG:AcaCdia insurance Com an INsuR D Rowle 61A 01969- INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY _�YE61BIREME6FT.-TER4W�3YtTGDNO}TIC'PT-0'F=AT1.1'�.'ETN'FFFA't'r'R9R�?TFfER-�0'GDMBN�Cll7 'PEG�fEFU6'Hf6H'-iFfIG'8L�117iF'6fr1R�Rl"NA1'�PER�AI'f7-_ 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 gDD'L PO CY EP CTNE POUCV 1 TION TR NS O TYPE OP INSURANCE POLICY NUMBER OATE(MMIOWTY OATE(MMIDONY) LIMITS A X GENERAL LIABILITY OL3956437 03/24/2013 03/24/2014 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENE LIABIUrY PREMI TTO EN EO �6 Ea a 0,,ce 8 100,000 CLAIMS MADE Li OCCUR / / / / NED EXP A ono croon S 51000 PERSONAL&ADV INJURY E 1,000,000 GENERAL AGORGOAY6 $ 21000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PROOLItTS-C P PA G $ 2,000,000 X. POLICY MY LOC B AUTOMOBILE LIABILITY 6219554 07/31/2012 07/31/2013 COMBINED SINGLE LIMIT S 11000,000 ANY AUTO. (Ea acdevn) ALLOWNEDAUTOS / / / / BODILY INJURY X SCHEDULEO AUTOS (Per pa"n) $ X HIR90 AUTOS / / / / BODLY INJURY X NON-OWNED AUTOS (PM eoodenq 5 PROPERTY DAMAGE (Per acacenD 6 *ARAOE UASILITY, AUTO ONLY-EA ACCIDENT B ANY AUTO / / / / OTHERTHAN EA AC 8 AUTO ONLY: O $ EXCESSA)MORELLA LIABILITY / / / / 60.CN CCURRENC i OCCUR CLAIMS MADE AGGREGATE ! S DEDUCTIBLE / / / / S RETENTION S S C WORKERS WC -2020-004*136-00 05/14/2013 05/14/2014 ron�LiMrcs X ER EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERRXECUYIVE E.L.EACHACCIDENT S 500,000 y OFFICERJMEMBER EXCLUDED] E.L.DISEASE-EA EMPLOYEES 500,000 If Taa.BeSCnDe III, r SPECI,IL PROVISIONS DSIB EL.DISEASE-POLICY LIMIT a $00,000 OTHER DESCRIPTION OF OPERATIONWLOCAri0x6AfENICLESA:%CLUSIONS gODEO BY ENbbR6EMENTJ6PECULL PROVSIONS CERTIFICATE HOLDER CANCELLATION ( ) - (781) 592-5975 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 8E CAHCEL1.E9 BEFORE THS EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERYUIIOATE HOLDER NAMED TO THE LEFT,BUT City of Salem FAILURE TO 00$0$HALL IMPOSE NO OBUGATION OR LIABILITY OF ANY RIND UPON THE 93 Washington Street INSU- R, AGENTS OR REPRESENTATIVES, AU RBPREBENTA VE Salem MA 01970- A(�CORD 25(2001I08) (DACORD CORPORATION 1980 PB rr INS025(0108).05 ELECTRONIC LASER FORMS.INC.-(600)32T-0545 Page I or Proposal Bay State Weatherization 61 Construction LLC. - DATE: NOVEMBER 19, 2013 89 Newbury Rd. Rowley MA 01969 Project Manager Phone 508-330-6646 Randy Comito kelly.goodhue@yahoo.com 781-953-0446 TO NSCAP For: Attn: Chuck Gallant 111 Mason Street Salem, MA Proposal Main roof shingles 1. Strip 1 layer of shingles 2. Repair up to ten percent damages roof boards 3. Apply ice and water shield around perimeter of roof 4. Apply tar paper on entire roof 5. Install 200 feet of white drip edge metal 6. Apply 900 square feet of CertainTeed 30 year architect singles 7. Install 50 feet of Cobra ridge vent 8. Clean and dispose of all debris Total cost 3800.00 Main roof rubber 1. Remove 2-3 layers of rolled roofing 2. Repair up to 10 percent of damaged roof boards 3. Install fiber board insulation attached with disks and screws 4. Apply 300 square feet of rubber to flat roof section 5. Apply 50 feet of bald cleat metal 6. Seal cleat metal and chimney with peal and stick cover tape 7. Dispose of all debris Total cost $1200 Note: There is a flat area on the main roof that has rolled roorinp As stated above. we Propose to use rubber. Grand total $5000.00 Respectfully submitted, Randy Comito, Project Manager The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 YVashiirgton Street Boston, MA 02111 tvW)Rinass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information LL f 1 � `\ Please Print Leeiblt• \ame(BusinesstOrganirationrindis9dual):��_C%A J1r, V.1 t�tnC..(l t L a.T te» �L `�nC1`t2la L�t�N 0-c- Address: ,R 9 &kZl b%AM , YC p p et City/State/Zip: O l Phone #: 6 - - Are you an employer?Cbeck the appropriate box: Type of project(required): l I am a employer with_S 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 sheer. 7. ❑ Remodeling shipand have no employees These sub-contractors have g ❑ Demolition working for me in any capacity. employees and have workers' 9 [:] Building addition (No workers* comp.insurance comp.insurance.' required.] 5• ❑ We are a corporation and its ME] Electrical repairs or additions 3.❑ 1 am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions m self. o workers' coo right of exemption per MGL y � P� 12.0 Roof repairs insurance required.] c. 152. §1(4),and sve have no employees. [No workers' 1311 Other_ comp. insurance required.] kAny applicant that checks box gi must also fill out the section below showing their workers'compensation policy information. Homeowners who submit this affidavit indicating lhew arc doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box mast attached an additional sheet showing the name of the sub-contraclors and state whether or not those entities have enmployees. If the subcontractors have employees.they must provide their norkets'comp.police number. I am an employer that is providing workers'compensation insurance for my employees. Below is the polio`and job site information. Insurance Company Name: Policy k or Self-ins. Lic.# W C-a� D- -Op 4��z k- O Expiration Date: t:� Job Site Address: t r I Sby1 S Cit%!'State/Zip n JCn 0 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 VIOL c. 152 can lead to the imposition of criminal penalties of a fine up to S I,500.UO andior one-year imprisoninem as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be fontarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebi`c r j`under «its and penalties of perjun•that Cite information provided above is true and correct. Si n ture: a-Q:k Date: Phone z1: , $ l, 5 -1 • © (k%k b Official rise onlr. Do not write in this area,to he completed hr city or town official. City or Town: Permit/License H Issuing Authority(circle one): 1. Board of lieaith 2. Building Department 3.City/Town Clerk J. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: