10 MEADOW ST - BUILDING INSPECTION bCITY OF SALEM
PUBLIC PROPERTY
1 DEPARTMENT
KINIBETIEy DKISCO _
MAYOR
120 Wnsl-nNcrON S'rRle'.'r*Snt.r:nl,N[Assacrluse:rls 01970
978-745-9595♦ I+Ax:978-740-9846
APPLICATION FOR PLAN EXAMINATION AND
BUILDING PERMIT
ALL BUILDINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
IMPORTANT:Applicants must complete all items on this page
SITE INFORMATION
Location Name Building
Property Address
Iy !-IEAI�ow SAC , Sat._qa" MW o14't0
Located in: M Conservation Area YN N Historic district
APPLICATION DATE 5tw��1 �004
Use Groups
(check one)
Group Homes R3_R4
Residential(3 or more Units) R2 ✓
Type of improvement Residential(hotel/motel) R1_
(check one) Assembly(Theaters) At_ r 5 �
New Building_ Assembly(restaurants&clubs) A2r_A2ne_ lit p!n
eT
Addition Assembly(churches) AI_
Alteration Business B
Repair/Replacement ✓ Educational E rV i c.Q
Demolition_ Factory(moderate hazard) F1_
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard H_
Accessory Building Institutional(residential care) 11_
Institutional(incapacitated) 12_
Institutional(restrained) 13
Mercantile M_
Storage S1_Moderate Hazard
Storage S2_Low Hazard
OWNERSHIP INFORMATION(Please type or Print Clearly)
OWNER Name Its u.0
Address 5o=) sa k�AN1ERY�l1MFi
Telephone 9"19 3'13 3024
Signature
DESCRIPTION OF WORK TO BE PERFORMED
R P FaCG -Ottty -AE (-A ' CCC0&AkCMI E 30
NEVI ft 81 Q 4Z oe TKINES pym 1> a o PRE T< AAllt V_ 4,d
-t�e .so�-02k wk-s, cxi-w'Fe..c.Nev-s: -A ca'eS-
ESTIMATED CONSTRUCTION COST 7-S.Z St.0O
CITY OF SALEM
�a PUBLIC PROPERTY
DEPARTMENT
KmuveKr r_v nkisc:ou.
MAYOli
120\K/r\SLIING'I'ON SfR61i7*$ALEd[,bL\SSACHU58TI'S 01970
'F).1.:978-745-9595♦ FAX:978-740-9846
CONTRACTOR INFORMATION nn
L\ Name �06J P; leJ /tti`IWPJl
Address CtihW V si /Aed Fo4J t'A 1,:1 j
Telephone 79t �3$1, Itq
Construction Supervisor's Lie RaG67
Home Improvement Contractor# a S03
ARCHITECTIENGINEER INFORMATION
Name
Address
Telephone
Mass. Registration #
PERMIT FEE CALCULATION
Estimated Cost x $11/$1,000 + $5.00=
COMMENTS
The undersigned applicant does hereby attest that all information stated above is true to the best of my knowledge
under the penalties ofperjury
Signed (owner) (agent)
APPROVED BY:
DATE APPROVED: I��' L
i CITY OF &U.ETNI, 2ANSSACHUSETTS
BL'II.DLNG DEPARTI(E.2iT
0• 120 WASHINGTON STREET,3w FLOOR
T L (978) 745-9595
FAX(978) 740-9846
KIJiBERLEY DRISCOLL
MAYOR DIRECTOR
ST.PtEttRB
DIRECTOR OF PIBLIC PROPERTY/BUILDLNG CO\5BSSI0NER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Busim< organizationiindividual): LAS p90PCE24. SCRUIC 5,
Address: a)b VE A-i1 9— S , 5UtTS- 3\-a
City/State/Zip: t`CeL92QL�j "Pt Otq(oO Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
L LJ 1 am a employer with '4 _ 4. ❑ 1 am a general contractor and l 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors r y
2.❑ tr1 1 am a sole proprietor or partner- listed on the attached sheet.t ?. Remodeling
ship and have no employees These sub-contractors have g. ❑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.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑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' I3.❑Other
comp.insurance required.]
Any applituat that chucks box 91 most also rill out the section below stowing their wohaa'compensation policy information.
t I Inneawnpa who submit this affidavit indicating they are doing all work and then hire onside contractors must submit anew ar idevit indicating such.
=Cuntrnxom that cheek this box most attached an additional sheet showing the name of the sub-emonuWra and their worker'comp,policy insinuation.
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name:
Palicy#or Self-ins.Lie.#:S?"1-77 SCfeO Expiration Date: t I$1[0
Job Site Address: 10 City/State/Zip: C-JHtYcM tA11�Q)R 0
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Scction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby c fy r-M - and pertallies of perjury that the information provided above is true and correcL
i l id
t ire• Date: t/ U
Phone#:
Official use only. Do not write in this area,to he caarpiefed by city or town official
City or Town: Permit/I.1cense#
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.Cily/town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: __ Phone#:
CITY OF SAL.EM, -Y-kss xCIiusETTS
BUILDING DEPART1tENT
W 120 WASHNGTON STREET, 3°°FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
Kl,,t$ERT FY DIUSCOLL
MAYOR T HosLu ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
('fnF�tzlES �Pc�fge 'TRix— q
r
(name of hauler)
The debris will be disposed of in :
_PUGS �(11,3 a_------___
f facility)
1�tTC El'B(,112.Cn1-�- h—1 Pt _
(address of facility)
si6nature of permit applicant
Jaw
03/11/2009 WED 16:01 FAX 978 750 0082 FRAVEL INSURANCE AGENCY 2001/001
ACORDOATS lMM D0 mT
�, CERTIFICATE OF LIABILITY INSURANCE 1/13/09
PRODV CER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Frave-1 Tneurance Agency ONLY AND CONFERS NO RIGHTS UPONTHECERTFICATE
h Street _ HOLDERTHMCERTIRCATEDOE5N0TAMMEXTENDOR
6 EEi
4 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Danvers, MA 01923
INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURHtA'Ma,L $peC].a1tV Ins CO.
VS Property Services wsuR : Granite
Lisa Gomee iNSURMC-
ICI 200 Andover Street, Suite 312 INSURHRD:
Peabody, MA 01960 INSURER E:
_ COVE3tAGE5
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDiCATEU.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUEO OR
MAY PGRTAIN,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. ._ .... _
m—wt TYPE OF 11151.190CIF POL C YNUMBER AA POUCYEFm IVIE I U aIPIRQONILIMPACHOCCMETICE E 1 OOO OOO
GEN9RAL UABO.lTT ER7�_
9 g caMMISRcwLc�NERALua61UTY MM023902000208 1/9/09 1/9/10 PREMLSFs Fa S $0 000
w
CIAMS NEAOE �OCCUR NEED EXP A S 51000
pERSONALAADVOQURY $ 1 000 000
GENEILLL AGQRWATE $ 2.000,000
GEN'LAGGREGATE UNR APP SP5k: PRODUCTS-COMR'OPAGG S 2_OOO,OOO
PRICY Oc
IWTOM081LE tVBSJ17 COMBNEDSINGIEUMR S
IFe BAMaeAll
pNYAUTO
ALLOWNEDAUTOS I '("00 Y=RY S —
SC WULEDAUTOS MIRED AUTOS BODLY=RY_
C NON-OWNED AUTOS
PROPBITYOWAGE S
1Fwawao
GARAGELIasalrr AUTO ONLY-EAAGCNENT- S
EA ACC $
I ANYAUTO I MITD ONTILM.
AGG 3
EXCETTNMBR0.LALIABILRY EACH OCCURRENCE
OCCUR C1 MADE AGGREGATE S
O®UCTRSE
1 f RETENTION S yyC STA OTI+ S
WORKETscoNPEMSRI mmo 1/13/09 1/13/10
A ENEOLovm-L1ABILRY TEA Q� E.LEACHACCMD S 100,000
OFµFlf.BfTEN.R 8=00�L7)'/W"TNE T, 0'1'7�(po0 E.LD .EA EMPLOYE!= $ 1DD,ODo
B PnoEns 6N I E.LDI�9E-POUCYUMR S 500,000
OTHER
I
i
i
OgICgIPTYfNOF OR.AATIONSILOCATION$/UENCL�/EXCLtb10N5ADOiD BT ENO QRS9AENTl SPECYL PROVI:BONB
CERrIRCATENOLDER CANCg.LATION
SH01A.D ANY OF THE ABOVE DEWRIWO POLICIE98ECANCELL®BffORETHE OWIRATION
DATETHEREOF,TIEIMSUNG INSURER WILL ENDEAVOR TO 30 DAY3WRITIEN
NODCETOTNECERTIRCATEHOL➢ER MOM TOTHE FNLURETODQ$*SHKL
_.. - IMPDSENOOBLIGATOMORUAB OFANYKNOUPO THE WA,ITSAGENTSOR
REPRESENT
AUTHORIZED REPRES A
ACORD 25(2001108) ACORD CORPORATION 1988
. y
A
aT S�,, PROPOSAL NO.
C.S. ��.11°�D]D4'�•1 � �d'.l"�'IQ'�'� PAGE NO. 8995
300 Andover Street, Suite 312 1
Peabody,N1A 01960 DATE 6/1/2009
I. General Information
Proposed by: U.S. Property Services Telephone: (978) 587-2809
300 Andover Street, Suite 312 Fax: (978) 587-2809
Peabody, MA 01960
Submitted To: 10 Meadow LLC Work Performed At: 10 Meadow Street
50 Washington Street Salem, MA 01970
Haverhill, MA
II. Work Description
We hereby propose to furnish the materials and perform the labor necessary for the completion of the work described herein
and to commence on the date listed above:
Interior Repairs
• Replace roughly 60 sheets of GWB damaged by a roof leak
�(� • Replace all window trims throughout
• Replace interior doors with six panel hollow core doors
• Replace the two front doors with fiberglass door
• Install ceramic tile on the floor of three bathrooms
• Patch walls where needed
• Apply one coat of primer and two coats of finish to all of the walls; this includes the front and back hallway
• Homeowner to provide an on-site dumpster /
Total cost of Labor and Materials: Cost: $25,732.00
Y_
III. Exceptions
• Plumbing a
• HVAC
•Carpeting
• Electric 8
• Fire Alarms/Sprinkler Systems (� a
I Terms
a.. We allow one punch-list at the completion of the project to allow for touch-ups. b � d-
b. Color selections are final; any changes made may result in additional charges. a
c. All debris will be removed on a nightly basis. ID
d. Exterior projects are always weather permitting.
e. U.S. Property Services is not responsible for any cracks resulting from the expansion &contraction of wood. c"
f. All U.S. Property Services proposals include a one year warranty on all labor performed.
(Continued on the next page. . .)
U.S. Property Services•Tel:978-587-2809-Fax: 978-587-2809
uspropertyservices@hotmail.com
PROPOSAL NO. 8995
PAGE NO. 2
300 Andover Street, Suite 312 DATE
6/1/2009
Peabody,NIA 01960
(. . . Continued from the previous page)
-Please check the box next to the amount(s) on the previous page to confirm your approval.
All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and
specifications submitted for above work, and completed in a substantial workmanlike manner for the sum of
Twenty Five Thousand Seven Hundred Thirty-Two and 00/100 Dollars ($ 25,732.00 )
Payments to be made as follows: 1/3 deposit, 1/3 work in progress, 1/3 at project completion
'Any alteration or deviation from above specifications involving extra costs will be executed only upon written order, and will
become an extra charge over and above the estimate. All agreements contingent upon strikes, accidents, or delays beyond
our control.
"Note—This proposal may be withdrawn by us if not accepted within 30 days.
Respectfully Submitted Frank Gomes
On behalf of U.S. Property Services
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby ccepted. You are aut rized to do the work
as specified. Payments will be made as outlined above. ,
Date "0z ,0 g Signature
Date —U��o Signature
U.S. Property Services•Tel:978-587-2809•Fax: 978-587-2809
uspropertyservices@hotrnail.com