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16 OLIVER ST - BUILDING INSPECTION (2) cv, The Commonwealth ofMassachuseti'sECEIVED U� r^-n '^ ' AL Sr-WICES CITY OF M }� Board of Building Regulations SritYS'tandards r SALEIvI qYt / Massachusetts State Building Code, 730 CMR Revised Alar 2011 Building Permit Application To Construct, Repaiir7Iet�at2&DOhtoUa� One-or Tivo-Family Divelling This Section For Official Use Only Building Permit Number: Date. pplieds io /l/,.5 Building Olticial(Print Name). Signatpnc . . ' Date SECTION L SITE INFORiN(ATION` 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 146 B1%d�r 5� 1.1 a Is this an accepted street?yes_ 110 M1lap Number Parcel Number 1.3 'Lotting Information: 1.4 Properly Dimensions: Zoning District Proposed Use Lot Area(sy R) Frontage(Il) 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.d11,§SJ) 1.7 Flood Zone information: 1.8 Sewage Disposal System: Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yesE3 SECT[ON1: PROPERTYOWNERSHIP,1` 2.1 Owner of Record: .J"I/ems All time(Pont City,Slate,ZIP - No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building® Owner-Occupied P r Repairs(s) 0, Altention(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Nuniberof Units Other ❑ Specify: Brief De cri tion of Proposed Work': C//1 Lr r i✓2 G1G �y1 /1QzJ / ba /J7D 06®U23 Oki -ea1 SO /Ztr�'1 . i /'/OF V — SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials) I. BuilJing $ I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S 3L Qi 2> O ❑Total Project Cost?(Item 6)s multiplier s 3. Plumbing $ 2'r Qther Fees: .$ d.blcchanical (hiV;\C) S List: �(/ i. Mechanical (Fire rota)All fees:$ Su ression) Check No._Check Amount: Cash Amount:_ 6.T _sotal Project Cost-Ts ❑Paid in Full ❑Outstanding Balance Due: SECTION5: CONSTRUCfIONSERVICES 5.1 Construct/ion Supervisor License(CSL) /O6 yto�/ V-6 ✓j p'�['�'� License Number Expiration Dale Name of CSL HuIJe (� G List CSL'fype(see below) U � f 6� 9 O ` Type � �� --.:, � Description . No. and Strect U Unrestricted(Buildings Lip to 35,000 cu. 11. 5' a of /�eCeLS's �l� Restricted 1&2 Family Dwelling Cityrrown,State,ZIP M Masonry RC Routing Covering WS Window and Siding S I Solid Fuel Burning Appliances Insulation Telephone Enmil address D Demolition 5.2 7 Registered Home Improvement Contractor(HIC) a,/ y-ical 64 e `li HIC Registration Number Expiration Date IIIC Cmnp:u,y Nmn�r ur HIC gtstrunl .•one Gf/�CQ•-�G)G�v✓ Si No. and Sree 4�$' ,.� �r �J✓3 L f� Email address s L /� City/Town, State ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.152.§2SC(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 ..........❑ No........... ❑ SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN, OWNER'S AGENT OR CONTRACTOR APPLIES FOgR BUILLDDING PERMIT I, as Owner of the subject property,hereby authorizes e /K L t9 act on my behalf, in all matters relative to work authorized by this building ermit application. Trr'tiit Ow er's Name(Elect Vic is Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,) hereby attest under the pains and penalties of perjury that all of the information contain d in this application is true and accurate to the best of my knowledge and understanding. Print Owner' or A di irized Ageno Namc(Electronic Signature) Date NOTES: I. An Owner who obtains a building permit to do his/her own work,or aft owner who hires an unregistered contralat (not registered in the Home Improvement Contractor(HIC) Program);will not have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be foun Supervisor License can be found at wwtv.nuass.��ov:'d n _ •• Information on the Construction n �eww.mass. ov'oed t P 2. When substantial work is planned,provide the information below: 'total tloor area(sq. R.) .(including garage, finished basement/attics,decks or porch) Gross living area(sq. 11.) Habitable room coot Number of fireplaces Number of bedrooms Number of bathrooms Number of half%ballts Type of healing system Number of decks/porches Type of cooling system Enclosed _—Open 3. "foul Project Square Footage"may be substituted for"Total Project Cost, _ LILIA-1 ._ OP ID: OH CERTIFICATE OF LIABILITY INSURANCE °A'�`M"°°°A"YY' 03/12/2015 THIS CERTIFICATE IS ISSUED.AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS 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(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsements . CONTAPRODUCER NAME: John J. Doyle Insurance - John J Doyle Insurance Aggency PHONE g78-777-6344 AX No): 978-777-9804 85 Constitution Lane Ste 2H AIC No Ezt Danvers,MA 01923 _ ADDRESS: kevin@doyleinsurance.com Kevin C Lawrence INSURER(St AFFORDING COVERAGE NAIC k INSURERA:Safety Insurance 39454 INSURED L:iliana Mendez INSURERS: Mendez Home Improvement INSURER c: 16 Walden Street Lynn, MA 01905 INSURER D: INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. EFF EXP INSR TYPE OF INSURANCE ADOL SUB POLICY NUMBER MMIDDYIYYYV MMIDDY/YYYY LIMITS LTR GENERAL LIABILITY - EACH OCCURRENCE $ 1,000,000 A X COMMERCIAL GENERAL LIABILITY BMA0019296 03126/2014 03126/2015 PREMISESOEa ccu ante $ 100,000 CLAIMS-MADE I-XI OCCUR MED EXP(Any one person) $ 10,000 PERSONAL B ADV INJURY $ GENERAL AGGREGATE $ GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGE $ —XI POLICY PRO LOC $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT Ea accident III ANY AUTO BODILY I NJURV(Per person) $ ALLOWNED SCHEDULED BODILY INJURY accident) $ AUTOS AUTOS NON-OWNED _ PROPERTY DAMAGE $ HIRED AUTOS AUTOS PERACCIDENT UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DED I I RETENTION$ Is WORKERS COMPENSATION I WCSTATU- OTH- AND EMPLOYERS'LIABILITY RY LI I ANY PROPRIETOR/PARTNER/EXECUTIVE YIN NIA 6HUB-5B91341-9-14 03112/2015 03/1212016 E.L.EACH ACCIDENT $ OFFICERIMEMMandatory ER H)EXCLUDED'! 6HUB-5B91341.9-14 03/12/2014 03/1212015 E.L.DISEASE-EA EMPLOYEE $ (Mandatory in NH) Ifyes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $ DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPMEA Kevin La ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD The Commonwealth ofMassachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,M-4 02114-2017 www.massgov/dia NVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Le 'bl Name(13usiness/Org2m'ation/h,dividual): Q1� 7i Address: � City/State/Zip: 0- Phone M Are you an employer?Cheek the appropriate box: Type of project(required): 1. am 1 a employer with employees(full and/or part-time).' 7. ❑New construction 2.Tama,wlepmprielormparmmhipmdhavenoemployeesworlmtg lormein g- ❑R=odehng any capacity.[No workers'comp:ini mane required] - 3.❑I m a homeowner doing all work myself.[No workers'wmp.insurance required.]t 9. El Demolition 4.❑ an 1 am a homeowner d will be hiring contracton to conduct all work on my property. ]will 10❑Building 8tlditlon. ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions proprietors with m mployees. 12.❑Plumbing repairs or additions 5.❑I m a general wmactoi and I have hired the sub-tontactors listed on the attached sheet. These subu tmctors have employees and have workers'wmp.msum.ee t 13.❑Roof repairs 6.❑We are a corporation mid its officers have exercised their right of exemption per MOL c. 14.❑Other 152,§1(4),and we have no employees.[No wmkers'comp.brsuran care quired.] - 1. *Any applicant that checlo box#1 must also fill out the section below showing their workers'Eompeosation polity mformatron: .. - t Homeowners who submit this affidavit indicating they are doing all work and then hire outside commetors must submit a new affidavit indicating such iContracton that check this box must attached an additional sheet showing the name of are sub-cobuacton and state whether or not those entities have employees Ifthe sub-contractors have employees,they,must provide their workms'.wmp policy moaber. - I am an employer that isproviding workers'compensation insurancefor my employees. Below is-the policy andjob site information. //!/ a Insurance Company Name: S/v 144 /ctf Policy#or Self-ins.Lic.M r,11 713 t 1" Expiration Date: Job Site Address:�ly ®/iyc� 50 ty 14�0 -City/State/Zip: O l !'20. 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 verification. I do hereby certify untie - ns allies ofperjury that the information provided above is true and correct Signature: ate. Z'a v Phone#: Official use only. Do not rile in is area,to be completed by city or town o0kial 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 writtep." 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 notbecause 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 UP 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 perrnit/license number which will be used as a reference number. In addition,an applicant that must submit multiple pemrrat/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 dqg 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. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia CITY OF SALEA MASSACHUSE TIS i BLnDnaGDEPAx7MENT 120 WAsimqGmNS7mT,3mfl ooR 7kL(978)745.9595 PAX(978)740-9846 B.IIvIBERLEYDRISODLL MAYOR THMAS ST3'FM DIRECTOR OF PmijcPROPERTY/Bu[LDm mmmmomR 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 c40, S 54; Building Permit#I 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: aC'Z (name of hauler) The debris will be disposed of.in: . . (name of facility) Cor�e�cta� �s`� (address of facility) Signa re of applicant Date 4 Licensed f.Inwred Estimate "The right hand for the job" ®n Date Estimate# 9/15/2015 372 Name/Address Project Address Mary Manning - 16 Oliver St. 16 Oliver St. Salem,MA 01970 Salem,MA 01970 Description Total The following Estimate for the property located at above address. The following paragraphs explain the work that Mendez Home Improvement will carry out. SCOPE OF WORK:EXTERIOR PAINTING&REPLACE CLAP BOARD SIDING ON FRONT SIDE OF THE HOUSE 1-REPLACING CLAP BOARD SIDING FRONT SIDE OF THE HOUSE a)Remove old clap board siding b)lnstall new Tyvek c)Install new flashing on top of window and doors d)Install new ice water shield 4"wide around window an doors e)Install new clap board siding f)All penetrations shall be properly sealed " TOTAL FOR MATERIAL AND LABOR 2,625.00 EXTERIOR PAINTING • Scrape off and light sand any loose paint with a paint scraper • Power wash the exterior • Fill in cracks and holes with a paintable caulk or putty • Re-nail any loose clapboard and trims (Note:any(rotten wood)carpentry we will do an additional charge) NOTE:the procedure described above will be done at 3 sides of the house only' Prime and paint the entire house • Apply oil base primer over surfaces • Apply 2 coat of white exterior paint on trims&grids • Apply 2 coat of exterior stain on body NOTE: Mendez Contractor will supply primer and white paint for window trims and grids only,customer will supply stain for body***** TOTAL FOR MATERIAL AND LABOR 6,400.00 Completion means satisfactory cleanup,removed of debris NOTE: Any alteration will be approve by all parties before is done Total these may result an extra charge. Page 1 K Licensed E Insured Estimate "The right hand for the Job" men Date Estimate# i 9/15/2015 372 Name/Address Project Address Mary Manning 16 Oliver St. 16 Oliver St. Salem,MA 01970 Salem,MA 01970 Description Total Payment terms: $ 3300.00 down payment $ 3900.00 upon thejob is in progress $ 1825.00 upon the job is completed PNO// end z e ' c ntractorACT Owner Walter yen z-Sale Manager www.mendez n/trtor.com i NOTE: Any alteration will be approve by all parties before is done Total these may result an extra charge. $9,025.00 Page 2