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5 MOFFATT RD - BUILDING INSPECTION (2) What is the current use of the Buildi ? Material of Building? G.. o o If dwelling.how many units?_ Wit the Building Conform to Law? - Asbestos? Architect's Name Address and Phone ( ) Mechanic's Name Address and Phone Consiruction Supervisors License 0 a SYa 6 y HIC Registration# l 7 U Estimated Coot Project S O n Permit Fee CakwWW p ,Permit Fee Estimated Cost X S7/$1000 Residential --- -- -- - - _. - - Estimated CostX S41/51000 fommeralai—An Additional $5.00 Is added as an Administrative charge. Make sure that all fields are properly and legibly written to avoid delays in processing. The undersigned does hereby apply for a Building Permit to build to the above Stated specifications. Signed under penalty of perjury X z Date a 7 i 30 s N ts,- EITy`oF-- -- -- PUBLIC PROPERTY DEPARTMENT �Q� M�vae 12O WMWW--WM b%MEW• Sum WsuaHcsk-rrs 01970 TEu VWUSAS9S•FNC 97{.740.9so APPLICATION FOR THE REPAIR RENOVATION CONSTRUCTION DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING STRUCTURE OR BUILDING 1.0 SITE INFORMATION Location Name: R o 4 Zn ✓ - o Building: Property Address: Property Is located in a;Conaarvatlon Arse YIN P D Historic District YIN 11 0 2.0 OWNERSHIP INFORMATION 2.1 Owner of Land Name: Address: Telephone: 7 S G 3.0 COMPLETE THIS SECTION FOR WORK IN E7CIS M BUILDINGS ONLY Addition Existing Renovation pa 'Q° umber of Stories Renovated Change in Use New Demolition Existing Approximate year of Area per floor (sf) Renovated construction or renovation of existing building New Brief Description o PTposed Work: 1 /` C/N�o�( C - /0/\ 13a�7 1 T�c � —Mail Permit to: Patti eoffitractm" ' 28 BAY ROAD f EVERE, MA 02151 (617) 567-6436 LIC.#108370 MR and MRS Robert Indresano June 21, 2007 9 Moffatt RD. Salem, MA 01970 Remodel a portion of bathroom • Remove the exiting bathtub, wall board and tiles in the bathtub area only (approximate 60 sq feet). a Remove the exiting floor tiles (approximate 40 sq feet). • Install one new American standard 5'tub(Princeton recess white bath tub) • Install one trip lever • Install water proof sheetrock and ceramic tiles around the tub area. • Install 1/4" plywood and ceramic tiles on floor. • Apply two coats of latex paint on the walls and ceiling. • Clean and remove all debris. • Owner will supply the ceramic tiles. All work will be completed in a workmanlike manner. Payments should be made in two installments. All work and material is guaranteed as specified above. Any alteration or deviation from the above specifications involving additional costs will be written up separately and will become an extra cost over and above this estimate. Total Labor and Materials: $ 4800.00 ------------------------------------------------------------------------------------------- Acceptance of Proposal: The signature below authorizes the price and conditions of this proposal. Accepted by: c Date: ti 7 [ , Contractor: �� ` ! y lie � _. �ife f'aazvrzom��eal// o�.�aaxsa�i -, . Board of Bmldiog Regal BOARD OP BUILDING REGULATI a 1 use only ' +License: CONSTRUCTbN.SUPERV'SOR a ro to - HOME IMPROVEMEN Bards ++�� Number^ CS 058204 Registration ,1,a083, Expvation EV /2 Birtbdets 01/211,,1956 ' 1 Type OBA'6 'dcB(r' i QTf2'{/f 108 Tr tro. k"303 PATTL CONSTRU IONvO0 � 3 •. .` .a ,, P &EPH A Pf?TT � ,xn.. ..n, t .s R Jos h Pattl28 BAY RD , 8 Bay Rd! , REVERE, MA 021.51 = - Re�V.ere MA 02151 -Commissioner. �Q6D. CERTIFICATE OF LIABILITY INSURANCE 06/20/20o PRODUCER (978)744-7110 FAX (978)741-2059 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Soucy Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR P. 0. Box 44§7 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 201 Washington St. Salem, MA 01970 INSURERS AFFORDING COVERAGE NAIC# INSURED Joseph Patti INSURERA: Safety Insurance Co. 39454 14 Pleasant Street INSURER B: Salem, MA 01970 NSURERC: INSURER D: INSURER E: 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. I NSR D' TYPE OFINSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS DATE IMMIDDAPQ DATE I GENERAL LIABILITY - BP00006201 11/26/2006 11/26/2007 EACH OCCURRENCE $ 1,000,00C X COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,OOO CLAIMS MADE D OCCUR MED EXP(Any one Person) $ 10,000 A PERSONAL B ADV INJURY $ 1,000,00 GENERAL AGGREGATE $ 2,000,00 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2.000,00 POLICY JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EAACC $ AUTO ONLY: AGO S EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ OTH WORKERS COMPENSATION AND WC STLIMATU- - EMPLOYERS'LIABILITY E.L. ANY PROPRIETOR/PARTNER/EXECUTIVE EACH ACCIDENT $ OFFICEWMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE $ If yes,describe under SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMB $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS _ CERTIFICATE HOLDER CANCELI ATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITSEN.NOTICE TO'Td1EC RjI CAjf HQ4DfRMA_Nq&CL{�I� E T• Mr. & Mrs. Robert Indresano BUT FAILURE TO MAIL SUCH NCWICF$HALL IMPOSE NO OBLIGATION OR LIABILITY 9 Moffatt Road OF ANY KIND UPON THE tNSVAERjITS AGENTS OR REPRESPgATIVES. Salem MA 01970 AUTHORIZED REPRESENTATWIE Paul Soucy ACORD 25(2001/08) ©ACORD CO P&ATION 1988 J American Standard 2391.202 Princeton Recess Bath RHO, White - PlumberSurplus.com Page 1 of 3 16 PlumberSurplusxom (951) 58 Point. Click. Plumb." KITCHEN BATHROOM I WATER HEATERS LIGHTING PUMPS TOOLS ACCESS DOORS VALVES I `C Search GQ! Shop_by-Brand, Home > Bathroom > Shower &Tub > Bathtubs & Whirlpool Tubs > Bathtubs FREE' S . HfPPISNGfi -­W O."�R L}D ° „I. M P O R` T- 5 L It=G, Hu' American Standard 2391.202 Princeton Recess Bath RHO, White a 00 r;. o- h F $r Of" 5 4'- ° ..r. eati- s.w�vaGar Description American Standard 2391.202 Princeton Recess Bath RHO, White American Standard 2391.202 Princeton Recess Bath RHO, White Features: • Durable Americast material with glossy porcelain finish • Acid resistant porcelain finish • Recess bath with integral apron and tiling flange • Integral lumbar support • Beveled headrest • Full slip-resistant coverage • Nominal Dimensions: 60" x 30" x 14" (1524 x 762 x 356mm) • Bathing Well Dimensions: 56" x 25" x 13-1/4" (1423 x 635 x 337mm) • Right hand drain outlet * Image shown may vary by color, finish and or material Details and Features Manufacturer and Model: American Standard 2391.202 Color: White Oversize: No Ground Shipping Only http://www.pltimbersurpluS.com/Prod/American-S tandard-2391-202-Princeton-Recess-Bat... 6/21/2007 CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT 81\Illi(R LIiY UR11(:UI.L MAYOR 120 WASldlNGTON STREET 4 SAtr.m,MASSACI itil[Tll OIM9 . Tla_978-745-9595 4 Fax:978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A i licant Information Please Print Le ibly Name (13ucincss/Oreanization/Individual): r Address: 2 � ! a / 97� �773- P5�� �� << R� n 0 / Phone Pr: D l 7 4 / ` G 7 6 Are you an employer'.' Check the appropriate box: 'Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and I 6 ❑ New,construction t Flo ces full and/or art-time).' have hired the sub-contractors El' �1 Y ( p listed on the attached sheet. : 7• L�J Retttodeling 2 1 am a sole proprietor or partner- ship and have no employees These sub-contractors have 8. ❑ 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.❑ Electrical repairs or additions required] officers have exercised their on exem ti right of per MGL I I.❑ Plumbing repairs or additions 3.El am a homeowner doing all work. g P P myself. [No workers' comp. c. 152, §1.(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.❑ Other comp. insurance required.] •Any applicant that checks box N must also Jill out the section bulow showing their workers'cumpenmtion policy inloonatiun. 'I Wmeuwm;rs who submil this affidavit indicating they arc doing all work and then himm outside cwttrnetom must submit a new affidavit indicating such. �Comrac un that check this box must attached on additional xha:l showing the name of the subtontracturs and their workers'comp.policy information. I ant tot employer t/tat is providing workers'compensation itrsurmtce for uty employees. Below is the policy and job sire information. Insurance Company Name: �G. .-/ __ —fin-�Al.. P ..✓�#? C-�-- ��. Policy a or Self-ins. Lic.to:: p �'O d /O d.2 C) Expiration Date: �y Job Site & d .address: 00 7 lN. � City/StateiZip: :kttach a copy of lite 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 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$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 DIA for insurance sewerage verification. l do hereby certify outer the pains and It* of perjury that the infortnation provided above is(rue«ut correct. Si malure: Date: O Phone:.! 2 7 - cP 5--iQ Ofjicial use only. Do not write in this area, to be completed by city or town official. 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 emp[uvee 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 Bien 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 nuruber(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 continuation 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 i1'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. ln addition,an applicant that must submit multiple ennidlicense applications lications in any given year,need only submit one affidavit indicating current p p 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 tilled 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. it dog license or permit to bun 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 Fax #617-727-7749 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM 3 , ' ► PUBLIC PROPRERTY DEPARTMENT .'AM,NI.ar \l.%wx I20 WAit f(NG:JAt5tREET SAL!:%1,StAS5ACM IL IS:01C Tn.:97S.745-1595 *FA-x:978J4C-,)m Construction Debris Disposal affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 ChIR section 111.5 Debris, and the provisions of vtGL c 40, S 54; Building Permit M _ _ 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 I I. S 150A. The debris will be transported by: (flame of hauler) the debris will be disposed of in pc�S-I -@ , - G/�t/ f (name of utility) "'51 it ,wjm.:aat-----