64 MEMORIAL DR - BUILDING INSPECTION 1 ,
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
\ Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
— One- or Two-Family Dwelling
1(v\ This S For Official Use Only
\� Building Permit Number: V Date Applied:
Signature: h l�
Building Commissioner/In ect r ofBuilffings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
64 Memorial Drive
1.1 a Is this an accepted street.9 yes x no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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❑ Private Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Kathleen Lapointe 64 Memorial Drive, Salem, MA 01970
Name Print) -. Address for Service:
� �z d a,�� C. (2 978-744-2301
S gn ure Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) IB 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWork2: Strip roof shingles on complete house and
apply 30—yeararchitectural shingles
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 7300 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
7300 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
20958 2/22/2010
Peter C. Farmer License Number Expiration Date
Name of CSL-Holder List CSL Type(see below) U
P.O. Box 5201 .
Address Type Description
Beverly Farms, MA 01915 U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
Frontier Construction Company, Inc. 104711
HI C&mppj Nnejo HIC Registrant Name Registration Number
x ev rly arms, MA 01915 7/15/2010
Address
978-922-2900 Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.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 of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........El No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 Kathleen Lapointe as Owner of the subject property hereby
authorize Peter C. Farmer, Frontier Construction Co. , Iraeact on my behalf, in all matters
relative to work authorized by this building permit application.
9/28/09
Si a ure o' weer Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, Peter C. Farmer as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
P t C. Farmer
P tN
9/28/09
Signanlre of Owner or Aut d Agent Date
(Signed under the pains and penalties ofperjury)
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),will not have access to the arbitration
program or guaranty fund under M.G.L. a 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
�t
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): Frontier Construction Company, Inc.
Address: P.O. Box 5201
City/State/Zip: Beverly Farms, MA 01915 Phone #: 978-922-2900
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 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 sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
workingfor me in an capacity. employees and have workers'
Y P tY• 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.*
required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LE] Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.[E Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.0 Other
comp. insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 64 Memorial Drive City/State/Zip: Salem, MA 01970
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
fine up to$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIAAr insurance coverage verification.
I do hereby cert• u er t e p 'ns and penalties of perjury that the information provided above is true and correct.
Si ature: Date: 9/28/09
Phone#: 978-922-2900
Official use only. Do not write in this area,to be completed by city or town offlicial
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact 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 employee 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 house 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,MGL 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 presented 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)name(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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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 out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license 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.a dog license or permit to bum 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
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 4-24-07 Fax# 617-727-7749
www.mass.gov/dia
.:1
a�Ogp. CERTIFICATE OF LIABILITY INSURANCE F ruar°y#d§,(jw,TY,
PRODUCER
THIS CERTIFICATE IS ISSUED 4S A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CEg71FICATE
ALTER THEHCO ERAGEIS CAFFORDED BDOES Y THE POUC S REDOW
Culver Insurance lot.
- -----
INsuREo --20-fenhaF&tsert--_.._.._._ INSURERSAFFO
Satem,KA 01970 AFFORDING COVERAGE
INiUHER N
„ NDrtnland Insurance "'—' -- -
INSURER
Robert Doyle dba Doyle Construction INSURER C. Travelers IOCEMhity--
248 Center Street INSURER D' -"—
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED ANY REQUIREMENT. TERM OR CONDITION OF ANY C SU D NAMED ABOV
MAY PERTAIN,THE INSURANCE AFF CONTRA OR OTHER DOCUMENT WITH E FOR THE POLICY PERIOD INDICATED.MOTWlTHSTANOING
OROED BY THE POLICIES OESCFIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS ICA CONDITIONS U S
POLICIES.AGGREGATE LIMITS SH WN RESPECT 70 WHICH 7HIS CERTIFICATE MAY BE ISSUED OR
.•-.—_., O MAV NAVE BEEN R IniRi --_ EDUCED By PAID CLAIMS.TYIE OF INSURANCE SUCH
POLICY NUMBEq `%EFEF%lCTIVE ROLICY EXD "— "' --
GENEgALLtABILITy IR�710N -
- I LIMITS
I_ COMMERCIAL GENERAL UABILfTY EAC>.UCCURgENC_E
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GEN'L AGOREGATE OMIT APPLIES PER, I '.3T000 000
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DESCRIPTION OF OPEAAYOON OCATiONSNEMICLESJEXCLU61ON3 ADDED BY EN00Am ENp6rrECgL PROVISIONS
contracting
CERTIFICATE HOLDER AM71ONAL INSURED;INSURER LETTER:
CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIE5 BE CANCELLED UfFOgE THE EXPIRATION
Frontier Construction DATE YMEREOF.THE ISSUING INSUgER WILLENOEAYOA TO MAIL _
Essex,MA NOTICE TO ME CTHT ISSUIN MOLDER ryA ILL N THE LEFT,TLURE DAYS WRITTEN
Ann: peter F2rMer O PC SO 6HAUL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE N6YRER TR5 AGENTS OR
REPBEBENTATIVES.
AVT RQED NEFRE6EMTAlIVE
ACOR0 25-S(7197)
0 ACORD CORPORATION 1980
TO/10 3E)tld 30Nv8nsNI d3Alfl0 a7CcneIOIC TI
CITY OF S�UENl, .NAxssACHLSETTS
BUMIMNG DEPARTJIENT
120 WASHINGTON STREET, 3' FLOOR
eT TEL. (978) 745-9595
PAX(978) 740-9946
KL%fBERL-EY DRLSCOLL
MAYOR THomm ST.Pwim
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%MSSIONER
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
111, S 150A.
The debris will be transported by:
DumpstersRUS
(name of hauler)
The debris will be disposed of in
DumpstersRUS
(name of facility)
3 Randall Road
_Ipswich. MA 01938
(address of facility)
signature of permit applicant
9/28/09
date
dcbrisalfAm
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^4e eby submdsp"O' cabons and eshmaies forworkro bei'W1 *antl iW40ilstd tie used ,gr+ y w, t s ✓,',` i ' x q7+
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�t� ry s-Strip all ode and two-ply,roof shingles to bare sheaUung Y,i t(*', ry + u D1, ,.' ^, n 1
ik�g l �"Ap�ily ice and water`shteld 3'feet at eaves�clvair}ey and complete left stile low-sloping roof , r 1+
i�3 Apply#15161t paper to"remin aderoofsurf ace,
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4`, Riaiallnewioof vent flanges ,i°,,J ;r,at, I,:,w r ( r, ", i ✓ ' " r;
t4, s+5 "tfInstall new leadnbase flaslnng on`all f Iiir(4)sdea of ichtney. I%
t'r 6 ii,Install S-uti�hralitmtnum drip edge at'eaves and rakes 4i .✓ µ"i`t l,"
�,. 4�s'APPIy CextainTeed XTj30-year roof shingles r, yr , yl��,� ,++ ! ' s +
0" $I ,Open up m',amindge for venting an'd install cobra contmupus ridge vent �{ 'j
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,f n10;Remove and properly dispose all lob-related debris I„
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r 11-Provide CertainTeed✓30-year maniifacturef s hooted
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�I4, QACCeptanCQ G0rltraEt I have read lath sides of this amment anld adpe it the prices speafcebons and conddans stated: i tinderstantl that µlppnsigning this proposal becomes a Mnding oorltrac ,,ly are aydtonz�p,to do the work as speafied Payment will to made as tlin a,You the Buyer,'may'cancelthistransactfowatanytimepriortomlrnigoftvN , x s `tanaction Cancellation must ba done In,N riNng , s" T SIGNITNIS,CONTRAQT
vDD NO IF TF�ERE A Y BLANK SPACES '
�'r— ti r b 5 a s +
1r n ySrgnatare" G �i°yR h w �D^ Date
+ ' J, rf V � 'Audan¢ed 8ignatu4e , Peter Farmer President ,k
Date r "s^ 1 r Nom This proposal maY wiMArewn by us door acce red 4i in 30 dells S 5,
a+' CUSTOMER RETAIN WHl�'E COPY,�RETURN YELI;lOW COI' 1: IMPARTANT INFORNIATIONON. ACK
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..ale 6 m.mi ........ r�� l�iu„a��i�aelta
Board of Building Re{;ulatians and Standards
� HOME IMPROVEMENT CONTRACTOR j
i
Registration: 104711 P
Expiration: 7/15/2070 Tyf 269830 i
Type: Private Corporation
a
FRONTIER CONSTRUCTION COMPANY, INC. 1!
Peter Farmer f
198 Common Lane ��C�W\ II
Prides Crossing, MA 01965 i
Administrator
t
Tie -VrcmmaiarwalC�r o�...��aw,c�ruoe!!a
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 20958
Expiration: 2/22/2010 Trill 17467
Restriction: 00
PETER C FARMER
PO BOX 5201 -�-- �y
BEVERLY FARMS,MA 01915 Commissioner
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