8 NAPLES RD - BUILDING INSPECTION (3) 'PG3 CK In-16
The Commonwealth of Massachus_e�,ttgg(f�''TION�� SCR CITY OF
Board of Building Regulations and s �j SALEM
%Y1H
Massachusetts State Building Code, 780 CM�R( 5 �) 3: Revised.6lur?011
Building Permit Application To Construct, Repair, Re1%k%t r Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number DattiA pliedr
7c;. 5 �S
Building racial(Print Name). - Signatpre Da
SECTION 1:SITE INFORMATION'
1.1 Property Addre s: 1.2 Assessors Map&Parcel Numbers
I.I a Is this an acc pted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Luning District Proposed Use Lot Area(sy d) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if ycsE3
SECTION2. PROPERTY OWNERSHIP,`
2.1 Ownerl of Record: / rr
�6A) _i. are (^IaeVese SAitfln Mc- 6 (r76
Ntme(Print) zkCity,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all at apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description ot'Proposed Work': ffP J a6 a +-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building $ �00. W 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing S k Qther Fees: S
y. Mechanical (IIVAC) S List:
5.Mechanical (Fire S Total A Fces:S
Suppression)
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S �/otso 0 ❑Paid in Full 13 Outstanding Balance Due:
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Cl S O,90S'7p
CS ®SG 5-7t7 License Number Expiration Date
N:une of CSL Holder
List CSL'fype(see below)
No.:md Street TYPe _ Description
J U Unrt'slricted Duildin a to 35,000 cu. Il.
�. !"��TP� �� R Restricted l&2 F:unil Dwellin
Cityfrown,Slate,ZIP M Mason—
RC
!yA /ems M CT 019 7 d Roolin Cuverin
( ! WS Window and Siding
SF Solid Fuel Burning Appliances
�7Lj�fz3- y)/� 4 Q �� o/Ma,1 1 Insulation
Telephone. Email address D Demolition
5.2Jlte e rel Home
o mempovement Contractor(HIC) 63 a
1,r.4O1Kh //"h
C`e2 HIC Registration Number Expiration Date
HIC Coffin{AaY Name r HICJta is}rand Name / , /
/ ImilW ( ) tie / (A—MCr.t/ d i .
No.ygl Stryt tU C P C 1 (�A/ M A 0/!�JD Email address
City/Town,State ZIP / J ~ Tele honeq
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G,L.c.ISL§25.C(6)y.
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 .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED.W HEM
OWNER'S AGENT OR CONTRACT�OR,,AFPLIE9FOR BUILDING PEPMIT''
1,as Owner of the subject property,hereby authorize ti�C/U
t9 act on my IIbehalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED 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 and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
.FrNOTES:
An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
IF
(not registered in the Home,Improvement Contractor(HIC) Program),will LLoj have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program can be found at
wwW maSs cov'oca Information on the Construction Supervisor License can be found at wwvr.mass.gov'dos _
2. When substantial work3'�p,jla�nned,provide the information below:
'rota) tloor area(sq. ft.) Jd '� (including garage,finished basemenNattics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces `lumber of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
rypeofcoolingsystem Enclosed Open
1. "Total Project Square Footage"may be substituted 1'or,,Yogi Project Cost"
=�
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02I14-2017
www mass.govldia
Wilworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / p Please Print Le ibl
Name (Business/Organizafion/Individual): �o�t'l j lJ✓ e t`P(�
Address: a k6 34 r 2 C f
City/State/Zip: :74 f em M a Of 1 7 0 Phone#: g7g-fYa 3- y7/1
Are you an employer?Check the appropriate box:
Type of project(required):
l f�I am a employer with employees(full and/or part-time).* 7. Fj New construction
m a.sole proprietor or partnership and have no employees working for me in g. Remodeling
any capacity.[No workers'comp.insurance required.]
3.Q I am a homeowner doing all work myself[No workers'comp.insurance required.]t 9. El Demolition
4.F]I am a homeowner and will be hiring contractors to conduct all work on my property. =will 10 Q Building addition
ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.F-1 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.<
6.EJ We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(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 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. ff
Insurance Company Name: d
�a hOPcAS u e, Ca.
Policy#or Self-ins.Liic..#: bJ 4 6 0s �PQ 7N�7'—I—� � Expiration Date: I o�—c7i O—I
Job Site Address: U VQ e f'P 5 q�
- �'( o a S City/State/Zip: S x Ke *1 /V Ck--
Attach a copy of the workers'c mpensation 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 verification.
I do hereby under th_e pa' s a d penalties ofperjury that the information provided above is true and correct.
Signat : � G 1`� Date:
Phone#: '7g' �a3- 7 ? / -
Official 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#:
r
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
I 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, MASSAQiusms
i BUILDING DEPARTb1ENr
120 WASHNGTONSTREET,YOD.00R
nL(978)745-9595
KBEERLEYDRISODLL 'FAX(978)740-9846
MAYOR THomm ST.PIERu
DIRECTOR OF FmucpROPERTY/Bu[LDING ODMIvIISSIOmR
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 c4q 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
bJ k.e--ere
(name of hauler)
The debris will be disposed of in:
(name of facility)
/�TT"5�12- C4—
(address of facility)
Signature of applicant
Date
NOTICE VIZINOTICE
TO u
A
0 TO
EMPLOYEES EMPLOYEES
y �W
� V
O,qM Sv0
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street; Boston, Massachusetts 02111
617-727-4900 — http://www.mass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21,22&30, this will give you notice that
I(we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
HARTFORD UNDERWRITERS INSURANCE COMPANY
NAME OF INSURANCE COMPANY
P.O. BOX 1450
MIDDLEBORO, MA 02344-1450
ADDRESS OF INSURANCE COMPANY
(GSGOUB-0197N77-1 -14) 12-20-14 TO 12-20-15
POLICY NUMBER EFFECTIVE DATES
JOHN J DOYLE INSURANCE 85 CONSTITUTION LANE RM 2-H
DANVERS MA 01923
NAME OF INSURANCE AGENT ADDRESS PHONE#
o� WHEELER, TIMOTHY DBA 2 FOSTER CT
o�
WHEELER REMODELING
o SALEM
MA 01970
EMPLOYER ADDRESS
m
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
— The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and reasonably
'= connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
004869 W20P1G02 TO BE POSTED BY EMPLOYER
c t premal
ALL-PHASE CARPENTRY
FCf'CT=o OURT MA HIC REG. 138630 j
SALEM, MA 01970 MA LIC. CS 80570
978-423-4712 —
PROPOSAL SUBMITTED TO: DATE
Don and Laurie Hoover May 3, 2015
STREET JOB NAME
8 Naples Road Hoover
CITY,STATE AND ZIP CODE JOB LOCATION
Salem,MA 01970 Salem,MA
PHONE JOB PHONE
978-745_9290
We hereby submit specifications and estimates for:
Front porch:
Remove all decking, replace joists as needed and add any support posts as needed.
Remove ceiling and replace.
Replace or repair railings as needed.
Remove and replace all stair treads. j
Install new tight weave lattice on right side of porch and under stairs.
Total cost of materials and labor $9,400.00
J II
II
We PHIPOS O hereby to fumish labor—complete in accordance with above specifications, for the sum of:
Nine thousand and four hundred dollars ($ 9,400.00
Payment to be made as follows:
$4,000.00 at start and $5,400.00 upon completion. _
I
j
All material is guaranteed to be as specified.Ali work to be completed in a workmanlike manner
according to standard practices.Any alteration or deviation from above specifications involving Authorized
extra costs will be executed only upon written orders,and will become an extra charge over Signature 'L
a carry
our control.Owner to fire,tornado and other necessary insurance. We carry liability Note: This Proposal may he
ntl above the estimate.Ali agreements contingent upon strikes,accidents or delays beyond thirty (30)
insurance. withdrawn by us if not accepted within thirty
days.
Acceptance of Proposal -The above prices, specifications and /�� �// f
conditions are satisfactory and are hereby accepted.You are authorized to Signature 1 "'^^^^^^^^^"' ��Vlll..."`----
do the work as specified.Payment will be made as outlined above.
Signature_ j
> q
Date of Acceptance: r I ✓
J