132 NORTH ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts I (>K
o !- Board of Building Regulations and Standards
Nll'Nll'IP.\I-I'll
Massachusetts State Building Code. 780 CMR. 7°i edition til:
}d
Building Permit Application To Construct. Repair. Renosate Or Demolish it R, ocd Aon",rr
\e One- or Tiro-Funuhv Duelling 1. 100S
This Section For Of` u Use 41y
\ Building Permit Number / _ a Applied: _--
Signature: Ar"16 3 -------
Building Commissioner/ Ins ertor of Buildings Date
SECTION 1: SITE INFORMATION
LI Properly :lddress: 1.2 .Assessors Nlap & Parcel Numbers
ie
L la Is this an accepted street? yes � mr Map Number Par:el Miniher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq to Fruntuge(1i) ---
1.5 Building Setbacks(ft)
Front Yard Side Yards Rcar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Zone: _ Outside Flood Zone'' Municipal ❑ On site disposal s stem ElPuhlic ❑ Private❑ Check if yes❑ P l y
SECTION 2: PROPERTY OWNERSHIP'
}J
2.1 wner of Record.e/j.�l,.t t ; f
Name(Print) Address for Service:
9 >S - CAD - vo�i �
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building I91-- Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Dernulition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WOrk':_ 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
L Building $ G 6O� I. Building Permit Fee: $ Indicate haw fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cosh (Item 6) x multiplier x
i
3. Plumbing $ 2. Other Fees: S
4. Mechanical (HVAC) $ List:
I
5. Mechanical (Fire $
Suppression) Total All Fees: $
eD Check No. Check ,\mount: Cash .Amount: _
1 6. Total Project Cost: $ 6 06, ❑ Paid in Full ❑ Outstanding Balance Due:__..__
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) C' S 9 G z
License Number Ispiration Date
Name of CSL- holder
/S Z S/ �� ��, LT U
CSI_'fcpc es helosrl _
Wdress T c O Desrri Ilion
L Unresincted(tip to 35.01)0 Cu. I-L)
R Restricted IBC_ Fajml D\%elline,
Sigitrc i .N .Stasonry Only
I RC Residential Rooline Cos erutg
�frlrphonr \\'S I Krsidrntiul \V mduo ;md Snling _
SF Resideulial Solid Biel llumme :\ >>hafl, Ins(.Jl:uu.n
D Residential Demolition
5.2 Registered home In ovemen[ Contractor (HIC)
t4Q,�/l�t .r ate,;
Hlg_CompaQy Name or IIC Registrant Name Registration Nuutbec
fL-�
Address�
f-«-k5 d 1411 S/ 1�8$'S/ ` 45—%G'O Ezpi ation Date
Signawrc,--,�
SEC'rION,5.�W6RKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. I! § 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted writh this application. Failure to pros tde l
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No . O
SECTION 7a: OWNER AUTHORIZATION'.O BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , as Owner of the subject property hereby
authorize to act on my behalf. in all matters
relative to work authorized by this bt:i!ding permit application.
Si nature of Owner --- Date __----- �—
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I. Gci /Z t li < < / ��! i , as Owner or Aulhcrized Agent hereby declare
— application true an accurate, to the best of m knowledge and
that the statements and information on th„ foregoing upplicatt n are t u d c y
behalf.
4avet u e _s-7—
g i —
Pri t Name>
Signature of Owns, Authonzed. gent Date
(Si ned under thecpains and penalties of perjury)
NOTES:
1. 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 :recess to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 C•MR Regulations I IO.R6 and I IO.RS, iespectivelly
_'. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished base men Uattics, decks of porrly
Gross living area tSq. Ft.) Habitable room count
Number of fireplaces Number of hedrooms _
Number of bathrooms Number of hall/balhs
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"
dour ful'131 .c9Uf fto aoal ao
HOME IMPROVEMENT CONTRACT�p `.`".
Registration: 103185
Expiration; 7/62008
Type:.Supplement Card -
NEW ENGLAND BRICKMASTER
LARRY CARGILL -
0,51 East St. .,
Tewksbury, MA 01876- �—
Admim—�
CITY OF SALEM
r
PUBLIC PROPRERTY
DEPARTMENT -
orkers' Compensation Insurance Af idacit: Builders/ContractatniElect Please nsiPl l.ebers
ie my
t the ant llttormation / j ✓mo—A /1
\„Illlc I llnaac.. I h'ean v,l ll,m Inh. \l.lue/l I:
yerw / K< /rLk / jS11 r CA t
Address
-e�, k L;,,- /llu S S Phone:
City State.Zip: _.
tire you an employ-er:' Check the appropriate box:
Type of project(required):
I.[ '1 am a empluyzr is ith ��— 4. ❑ I ant a general contractor and 1 ll ❑ New construction
employees(full antbor part-time).' have hired the sub-contractors 2 [g-'modeling
listed on the attached sheet.
].❑ 1 am a sole pntpriRor or pointer Ihese sub-contractors have N. ❑ Demolition
shlp and have no employees %Wrkers' comp insurance. y. ❑ Building addition
working for me in any capacity. 5 ❑ We are a corporation and its
INo workers' cornp. insurance 10.❑ Electrical repairs or additions
I equired I othcers have exercised their 11.0 Plumbing repairs.
n ,ht of exemption per MGL
;.Elmyself. [Nu workers' comp. or additions
I am a homeowner doing all work c 515� $1(4) and we have no 12.0 Roof repairs
'
insurance required.] t employees. [No workers, 13.0 Other
comp. Insurance required.]
• ing their workers'compensation policy infurmation.
Any.Ipplieam that checks box pl must also lilt out th e section below show
' I lomeowners who submit Ihis affidavit Indicating they are doing all wUrk and then hae outside contractors mnYt fllhmlt a new ilfhllaVlt indicating such.�( pinf:IC tors,hal check this box must AN,hed an additional Sheet sho"'ng the name of the subcontractors and their workers'comp. policy mfofmarlOn.
/ tion insurance for my employees. Below is the policy and job site
ant an employer that is providing u•orkerr'compen.ru
information. L
cLVvt c < < Tcrr /Ct' n < lnsu✓ru << /�
Insurance (�ompany Name:_ /
// Expiration Date: S
Policy 4 or Self-ins. Lic. a: P /
Job Site AJdres's: /? City,State/Zip: SCr�✓.� //1GlS (J/9J6
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coserage as required under Section 25A of bIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S I.ifo oo and'or one-year imprisonment, as well :is civil penalties inthe form of a STOP WORK ORDER and a tine
of op )Io 250 a.u0 day against the t Iolator. lie advised that a copy of Ibis statement may be fornvarded to the Office of
,In a,n cations of Ilse DI:\ li,r insurance cocrrage tenficanoll.
l do hereby rerfl.i-under the pains hind peuahies of perjury that the information provided above A rote and correct
i„yn_Itnr
t 1//irio/toe on/r. no not mite in this area, to he.miopleted by Lily or town official
( its ur Iltw it: - . -_-... . . —. -
Issuing \ulhoritr (circle one):
I. Board of lleallh 2. Building Departntcot A. City/I'oivn Clerk J. Electrical Inspector S. Plumbing Inspector
6. O(her -- ------ --
Contact 11cram: ------
Phoned:___ —.—
Information and Instructions
\I,t,ailtu,cns llc tic r.tI I an, :hap Ier I i' Icqunrs sill cnlplo%I,l:, to Prot the %%orkcrs' congn•ns.n mn for Ihcir cinplo%ces.
I'm,u.uil to (his ,I.uute, -in empi'm ee i, dctuncd .is e%cn pcnon in the sett tic ,It.Moiler ender sort :ontract of hire.
tl+I c,s or inplicd. oral or \%nl le I],
\^ emplmer is dclined .Is "slit indn:d ua I. parincr,hi p. A"'Icianon. corporation or of her Iced) cm nn-. or sun nto or more
,a the for _tnnp cn_aged in a loin( :ntwprse. and ulcluduig die Ir_al Icprescn(ati%c, ot.1 dece,,ed empl,!yer, or the
reds cr or trust cc of in utdit ideal, p:ut n cr,lu p. .J.soCl.nion or other Icgal entity. c III n lo)Ind cnlp lot cc., Ilo%t c%er the
,,•.%ncr of a ,tit ellrig house hating not More (han three apartincnts and �%lit) res tile s therein, or the occupant of the
d tt ci!mg house of another oho cl upl o" persons (o do Ina(n tenancc. :onstrucuon or repair stork tin such duelling house
.rant file ,•rounds or bun lit III g .IPpu etc ndnt the reel ,hall not hccausc of site It cnlp lot men be deemed to he an cniployer."
M I. :hapter I>_1, �_1JcList also states (hat "C%ery state or loca
l licensing agency shaII u'u hhuld the issuance or
rene%sal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant oho has not produced acceptable e%idence of compliance with the insurance coverage required."
\dditionally. SIGL chapter 152. j?a'I-, ,(dies "Neither the conunon%%calth nor any of Its political subdivisions shall
enter into any contract for the performance oYpLlbliC cork until acceptable et idence of collipliallce with the insurance
rcgillfCnlCnts of this chapter ha%'e 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-contruclor(s) nante(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 dues have
employees, a policy is required. Be advised that this affidavit may he 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 he 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 he 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
tow n)." A copy of the affidavit that has been officially stamped or marked by(he city or town may be provided to the
Applicant is proof that a valid affidavit is on tile for future permits or licenses. A new affidavit must be tilled out each
tear. W here a hoine owner or citizen is obtaining a license or permit not related to any business or commercial venture
(ix. a dug license or permit to burn leaves ere.)said person is NOT required to complete this affidavit.
I he I Mice of Im estigations %could like to thank you in advance for tour cooperation and should you hate ;my questions,
(+Ie.I,e do not hesitate to give us d :all.
the UrP,utnnem'; address, lelephonc and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021 1 1
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 61772777
tie% ,ed �-_(I-u; - - 49
www.mass.gov/dia
'.01 , CITY OF SALEM
^^ R , PUBLIC PROPRERTY
DEPAR"I'MENT
Itli❑ cl P1 ' 1:h. �':I
l�\SII<1-1T • SAI I'M. \l.\ii.\\ It M I
`)'8-'4n');'6 4 1 \Y: 7i 8 74�,')14f,
Construction Debris Disposal Affidavit
(required lix 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by: J
/.c.r/ l�/�v� /-Gf\ �ls.�f�2
- - (1"ame of hauler)
I he debris will be disposed of in
(name ut laelhty)
(address ut racll v)
Signature Of Ile❑ It all leant
ate
IrinI I1!0�
MASS REG. TEL:978-851.5100
103185 FAX:978-851-9269
CELL:508-958-4048
NEW ENGL•AND BRICKMASTER
www.brickmaster.com
LARRY CARGILL 951 East Street
Production Manager Tewksbury,MA 01876 '
ACORD,,, CERTIFICATE OF LIABILITY INSURANCE DATE(MMCI,D/l 08
PRODUCER THIS CERTIFICATE IS ISSUED ASA MATTER OF INFORMATION
Wayne C. Jenkins insurance Agy ONLY AND CONFERS NO RIGHTS UPON THECERTIFICATE
HOLDER.THIS CERTIFICATEDOES NOi AMEND,EXTEND OR
100 Coxpora"r? Place ALTER THE COVERAGE AFFORDED 13YTHLPOLICIES BELOW.
STE 206
Peabody, MA 01960 INSURERS AFFORDING COVERAGE NAIC#
.___._.................__—
INSUREDSa£etV
INSURER tl XnBUY'anCE Comprin
New England Brickmaeter Window _: American Home Assurance Compa. ..
and Mxteziors, INC, INSURERC:Arbella Protectio951 East Street n
INSURER D•
_......... ........... ........ ........... .. . ...
I
Tewksbury, MA 0187E __.._. ..._... .
INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE FOLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT, TERM OR CON0171ON OP ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN, THE INSURANCE AFFORDED BY THE POIJGrS DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSION$AND CONDITIONS OF SUCH
POLICIES, AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
IN9R D _. �...__........—._ ._._
a POLICY% T POLICY EXPIRATONL LIMITS
GENERAL LIABILITY EACH OCCURRENCE S l O�OOO _
X COMMERCIALGENER_ALLIABILITY SP00008400 4/1S/08 4/15/09 -
A X CLAMS OCCUR MEDEXP(An 'nz+) $ lO„,000
_._
PERSONAL&P.DVINJURY $ 1 00,0 -0.00
_GENERAL AGrREOA?E ._.....$'.....2_I.00_Ot_00.0 ._.
GEN'LAGGRE G_X ATELIMT}ITAPPUU0ER: PRODUCTS-COMPIOP,AGG L $ 2,QOOiOOO._
POLICY JELQT IAC ...._I__.... ,
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
_ ANY AUTO (Ep axIde-Q $ 500,000
ALLOMEDAVTOS 042034000000 7/8/07 7/8/09 BODILY INJURYV� $
C X X SCHEDULEDAUT09 .._..---- --
X HIRED AUTOS 90DIIZ I�JURY
X NCN•OINNEDAUTOS ( recd enU __ $....•--- —
PROPERTY DAMAGE S
(PerecddenQ
GARP8E LIABILITY AUTO ONLY_EA ACCIDF NT $
ANY AUTO - EA ACC
6--._ OTHER THAN _ .._.._........ .. _....
AUTO ONLY'. AGG�S
ERCESSIUMBRELLA LIABILITY EA.OHOCCURRENCE $
OCCUR CI.AIMS MADE _AGGf'CGATE
DEDucrIBIB $
RETENTION $ -- -- —_---
Wc:1A1U- DI'H-
WORK ERS COMPENSATION AND EEL_
EMR-OYERO•LIAMLITY
ANYPRORiIETORIPARTNERIEXECUTIME WC 6835704 3/26/08 3/26/09 F,I-_r;AcH ncclDeNT _ $
B OFFICER/MENBEREXCLUDEM E.L.DISEASE-EA EMPLOYEE $ 500.,000_
9PCIALPPROVI9WSbebW E.L.DISEASE-POLICY LIMIT $ 100,000
— OTHER
❑ESCRIPTIONOF OPERATIONS I LOCAMON9I VEH CLESI EXCLUSIONS ADDED BYEND ORSEMENT I SPECIAL PROVISIONS
ContraCti.nq Opor&tions:
E'ax#978-B51-9269
CERTIFICATE HOLDER CANCELLATION
SHOULD PNY OF TOP ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
TO Whom it May Concern DATE THEREOF.THE ISSUING INSURER WIL L ENDEAVOR TO MAIL 30 DAYSWRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO D 0$0 SHALL
IM°OSENQ OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES. . . •.•.•.
AUTHORIZED REPRES
ACORD 25(2001108) (P ACORD CORPORATION 19B8
etZ
` ) e Bear o` uil -w lat+�ons an tan ar s
One Ashburton Place - Room 1301
Boston, Massachusetts 02108
Construction Supervisor License
License C5: 97262
Restriction: 00
Birthdate: 9/22/1958
Expiration: 9/22/2010 Tr# 97262
STEVEN WOLPE ------ -- ------
158 ASH STREET
HOPKINTON, MA 01748
Update Address and return card.Mark reason for change.
Address Renewal [] Lost Card
DPS-CAI as SeM-OS/O6-PC84d0
Construction Supervisor License
License: CS 97262
t v..
Budhdate:\9/22/1958
fsf Expnahon.:.9/22/2010 Tr# 97262
Restrl¢hon: OO�y%�
STEVEN WOLPE -
158ASH STREET'.:.-\'�'r' �--�--
HOPKINTON,MA01748 i'`- Commissioner
8oa1`of YYu°i'� Ong egu �Ti�mi�in"d'$`i"nns" License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration:. 103185 Expiration:Type: Supplement
08 ement Card One Ashburton Place Ran1301
lug �
Boston,Ma.02108
NEW ENGLAND BRICKM ASTER
STEVE WOLPE
951 East St. _`„-- u�
Tewksbury, MA 01876 .- - Administrator `l'iVot Valid wi ut-5fg9tu re
NEW, EnGLAnD BRICKMASTER Salesman: Ct� G��
i Date: ..
951 EAST STREET•TEWKSBURY,MA 01876.97$-851-5100
Registration#: 103185
THIS AGREEMENT,between NEW ENGLAND BRICKMASTER WINDOWS&EXTERIORS,INC.,OF TEWKSBURY,MA herein referred to as"Contractor',and
herein referred to as"Customer"
(CUSTOMER
NAME)
` •� (STATE) (ZIP)jl )/-1
(ADDRESS) t � 2--
(CUSTOMER
TEL.#a) )k I y Z >==r—
VATNESSETH in consideration of the undertakings herein expressed.Contractor and Customer do hereby agree as follows:
JOB NAME:
JOB ADDRESS:
TRUCK DIRECTIONS:
YES NO PROJECT SPECIFICATIONS
ERECT SCAFFOLDING WHERE CONTRACTOR DEEMS NECESSARY
APPLY VAPOR BARRIER WHERE CONTRACTOR DEEMS NECESSARY
. . APPLY 3.4 DIAMOND MESH GALVANIZED STEEL LATH TO SPECIFIED WORK AREAS -
APPLY FORMULA SCRATCH COAT OF CEMENT TO SPECIFICIFIED WORK AREAS �l ` )
APPLY NEW ENGLAND BRICKMASTER WINDOWS&EXTERIORS SPECIFICATION NUMBERS: ��CIA 1 / ^y.. C_ M C''1�
1ai � Cn— �1C_ �J �CCu
ELEVATIONS =„-k� t; WORKAREA DESCR T10NS
IC g - --
�p n
S ` R A�J J cl PJ _ ,. Anc^ Li A
s L J 1
cc,
/J J