3 MILK ST - BUILDING INSPECTION (2) �R IVIVED 1
WOES—
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CIVIR tDlb f EB I AS��
���, - � . Revtsed,L/ur20/,/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official se Oni
Building Permit Number. Date Applietlt
CI� Building Olticial(Pont Name) Signature DDat /
SECTION 1:SITE INFORiv1A riom.
1.1 Property Addre 1.2 Assessors Hap& Parcel Numbers
L l a Is this an accepted street. yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy R) Frontage(It) -
l.5 BuildingSetbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required - - Provided. Required - Provided
1.6 Water Su :(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Dispo yytem:
Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Public Private❑ Check if vesE3
SECTION2: PROPERTY OWNERSHIP!'
2.1 wnert of Record:
�,ql/
Ntme(Print) City,State,ZIP
No.and Street - Telephone Email Address
SECTION 3:DESCRIPT19NOF PROPOSED WORK'(check all ppiy)
New Construction❑ Existing Building Owner-Occupied ❑ I Repairs(s) Altemtion(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :_ e t! /i 11O®�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated CosWList:
Official Use Only
ltC°t (Labor and Mater
1. Building $ j O�f Permit S Indicate how fee is determined:
City/Town Application Fee
2.Electrical S / t7tqect Cost'(Item 6)x multiplier x
3. Plumbing S 'z 000es: S
y.Mcclumical (FIVAC) S -
F
�Mcchanical (Fire Total All Fees:S
ression)
rCheck No. Check Amount: Cash Amount:
Total Project Cost: S / ❑Paid in Full ❑Outstanding Balance Due:
Cf�kt_t_. �� p
r-4�'L.UIE5D zl tl wL
03V;37
emu. a: irtiivi t 5:. :• SECTION 5: CONSTRUCTION SERVICES
5.1 cunstruc tell S pervisor License(CSL) CS- D�2�1�7 ! '�!o—/7
831 License Number Expiration Date
Name of CSL Huller
g/ 0 / List CSL'fype(see below) (�
ws— JA)e 'G -e('No. mid Street Type. . . . Description .
-
/ U Unrestricted(Buildingsa to 35,000 cu. 11.
A1 0-3 C7 R Restricted 1&2 Family Dwelling
City/town,State,ZIP tN Masonry
RC Rooling Covering
!bCJN�e-eS�nu L'OILI Si o _ WS Window and Siding
SF Solid Fuel Burning Appliances
k77S�d l<OG 1 I Insulation
Telephone Einaif address D I Demolition
5.y'2'�Registered Home Improvement Contractor(HIC) /& 7�y7 r0_3d _/7
M.,S./ CONS HIC Registration Number Expiration Date
Hl :my Name++r�HIC Registrant N me
!�✓� /w )@d�r� Woo ��"
No.mid Street � � n�r��/ Email address
city/Town,State ZIP Telephone
SECTION 6:WORKERS'C.ONIPENSATION 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 o uilding permiL
Signed Affidavit Attached? Yes .......... No...........O
SECTION7a:OWNERAUTHORIZATION:T0BE.COMPLETED.WHEN
OWNER'S AGENT OR CONTRACTORAPPLIE9 FOR BUILDING.PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
1
Print Owner's Name(Electronic Signature) Date
SECTION 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 in this application is true a accurate eb f my knowledge and understanding.
o �t rn p IJ% �2JLZJ Zo!(o
Print Owner's or Authorized AEnt's ante(•lectro is Signature) Date
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 Ligul have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
iv+vw.mass.eo+;'oea Information on the Construction Supervisor License can be found at ww+v.mass.�ov.'Jns _
2. When substantial work is planned,provide the information below:
'Total floor area(sq. ft.) 'x .(including garage, finished basernent/attics,decks or porch)
Gross living area(sq. f.) Habitable room count
Number of fireplaces Number of bedrooms
Ntnnber of bathrooms Number of half/baths
'type of heating system Number of decks/porches
Type ofcoolingsystem Enclosed- Open
1. total Project Square Footage"may be substituted lbr"'Tutu) Project Cost"
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street, Suite 100
Boston,MA 0211 4-2 01 7
www mass.gov/dia
W"Yorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): ?205;,1 T -re-r— CM 5
Address:_1�,5
City/State/Zip:f'd'/i9N i�e S f e,,- A W 03Ph ne M �/7
Are you an player?Check the appropriate box: T
ype project(required):
1. am a employer with '7 employees(full and/or part-time).' ew cc ction
2.❑I am a sole proprietor or partnership and have no employees working for me in odehng
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner Join all work molition
❑ g myself.[No workers'comp.insurance required]}
4.❑1 son a homeowner and will be hiring contractors to conduct all work on m ilding addition
y p ape ty. 1 willensure that all contractors either have workers'compensation insurance or are sole ectrical repairs oI additions
proprietors with no employees.
mbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet.These sub-contractors have employees and have workers'comp.insurance.t of repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. er
152,§I(4),and we have no employees.[No workers'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 than hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box most attached an additional sheet showing the time 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'cam ensation 'P S p insurance for my employees. Below is the pokey and/ob site
Information. '�
Insurance Company Name: /�r?Zr le55 otJS.
Policy#or Self-ins.Lic.#: G 3 p-5—L`G eq Expiration Date: 3ClS�'l(o
Job Site Address: 3 11-7,/1G 5/ City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verifica
I do hereby ce un and penalties ofperjury that the information provided above is true and correct.
Si u.atur . Date: G7 d ZYJ��p
Phone M
Ofcial se only. Do not write in this area,to be completed by city or town 0 iciaL
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 Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALEM MASSAaiLSEM
BtnrDmDEPAtmew
120 WMMYO MSTRERT,3WRlOM
7kL(978)745-9593.
PAX(978)740-9846
SIkI6ERLEYDRISQ7LL
MAYOR 7)fQ"STj%?W
DmEcrcat cFPuBucPRoFwy/BtnDmo3m=ON=
Construction Debris Disposa/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 c40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by.
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Sjgn to a of applicant
GG
Wite
e .
a
Cj3U44j C@ee eonAmz�' Tye
151 North Ave.
Wakefield, MA 01880
Tel (617)895-8606
Fax(603)232-5152
Dec 15, 2015
Estimate for work to be performed at 3 Milk St Salem, MA
15t floor common bathroom remodel
Preliminary work
1) Make drawing for building dept.
2) Apply for permits
3) Order material
4) Order dumpster
Demolition work
1) Gut bathroom ceiling and walls
2) Remove old laundry plumbing
3) Remove toilet to be reused
4) Remove vanity
5) Remove trim work
6) Floor to stay as is but be painted
1 Page
Framing work
1) Install new ceiling strapping as needed
2) Install new wall studs as needed
Plumbing work
1) Install new drain for sink
2) Install new valve for shower supplied by owner
3) Install new drain for shower
4) Install plumbing for new laundry hook up
5) Install new drain for laundry
6) Install new shower unit were laundry used to be. supplied by owner
7) Install new vanity supplied by owner
8) Install new vanity top supplied by owner
9) Install new faucet supplied by owner
10) Reinstall toilet
11)Leave steam pipe as is behind laundry
12)Try to relocate pipes behind toilet for hot and cold water
Must have integral stops on shower valve
Electrical work
1) Install owner supplied vanity light
2) Install new switches
3) Install new gfci outlet for sink
4) Install recess light over shower
5) Install new Panasonic fan/vent
6) Install electric for dryer
Misc.work
1) Install tile board in shower
2) Tile shower walls
3) Tile supplied by owner
4) Grout tile
5) Install wainscot around bathroom
6) Install new base and door trim
2 Page
7) Paint floor 2 coats (paint supplied by owner)
8) Install mirror,towel holder, paper holder supplied by owner
9) Install shower door supplied by owner
10)Add wooden threshold to doorway
Estimated Cost: $20,500
Discount: $ 1,000
Total Estimated Cost: $19,500
Payment schedule
1. A deposit of 30%equal to$5,850 will be required to book job, pull permit, order
dumpster, demolition, and purchase some material
2. A second payment of 30%equal to$5,850 will be required when above is complete and
will cover electrical work, plumbing and more material
3. A third payment of 30%equal to$5,850 will be required when above is complete and
will cover the rest of job until completion
4. A final payment of$1,950 will be required upon completion
General Notes:
1. Price is subject to change after final drawings and choices of material
2. Any added work or changes by homeowner will require a change order and moneys
upfront
3. Any unforeseen work will be an additional charge (Example: termite damage found)
4. Copy of license and insurance will be issued prior to start
5. All proper permits will be pulled
6. Workmanship warranted for a period of 1 year, (excludes spider cracks in plaster, abuse,
paint and existing conditions)
7. Excludes landscape damage
8. Excludes paving damage
9. Price is good for 30 days
3 Page
Signature Print name Date
Sincerely,
John Downie
4 Page
�+✓ CERTIFICATE OF LIABILITY INSURANCE 313012015m
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW.' THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(Sb AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER
IMPORTANT: N tlro eartiflcate holder is all ADIN710NAL INSURED,the Poliey(res)must he endorsed. H SUBROGA710N IS WAIVED,subject to
the terms and conditions of the PoOcy,certain policies may require an endorsement A statement on this cerfificats does Trot center rights t0 the
CwNcate holder in lieu of such endorsement(s). CONTACT
FROWCER tlA Robin McAfee
FIAI/Cross Insurance
�� (603)669-3218 F (w3)ss5-a331
1100 Elm street zmCafee@Croesa2NTCy.Cam
AFFORDING COVERAGE NAIC e
NH 03101 asesERA. securi Ins Co 4082
Manchester 4198
INSURED BSIIra�tB:Peerless Ins Co
Busy Bee Construction LLC ff=RERC:
125 WedgeuoOd Lu OmDmm D:
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Manchester NB 03109 INSURER F:
COVERAGES CERTIFICATE NUIMBER 5-16 GL c WC REMI(MNUMBERC
THIS IS TO CERTIFY THAT 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 ALL
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 CONDIHONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED raDOCLAIMS'
unRTs
OL92 TYPE OF INSURANCE POLICY NU1®Br 1,000,000
EACH OCCURRENCE S
GENERAL LABILITY $ 300,000
X COMMERCIAL GENERAL UMUTV /18/2015 /19/2016 ��( eAMa P ) $ 15,000
A CWMs4IADE ®oCCUR SSS82574 1,000,000
PERSONALAAM INIURY s
GENERAL AGGREGATE $ 2,000,000
PROMCTS-COMP/OPAGG $ 2,000,000
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AUTOMOBILE7)OJiY BOOLLV RR.ARRY(PerPgsm) S
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OFMCERIMEMBER DXCLUOEIr NIA /18/202.5 /18/2016
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(MyMeeH,tl Y M MR) EL DISEASE_POLICY LINO S 500,000
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CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION 1117E THEREOF, NOTICE WILL 9E DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISION&
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ACORD 25(2010(05)
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Board of Building Regulations and Standards
Construction .-uperl'i"r
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MANCHESTKKflH
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Ot6ce of Coammer Affairs&Bes®®s RM-1sfioe
HOME IMPROVEMENT CONTRACTOR
Registration: 164647 Type:
Expiration- --:10f3012017 LLC
BUSY BEE coNsTRUCTIPM,LLC
John.Dowry -
125 Wedgewood Lane .-...�—
Manchester,NH 03109 Undersecretary
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125 WttiaWOOD LANE
fH€STEIL NH 03109
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