23 OLIVER ST - BUILDING INSPECTION RECE
The Commonwealth of Massachusetts AL SERVICES
Board of Building Regulations and Standards � �CITY AOF
O / Massachusetts State Building Code, 780 CMR �]7ev'%rid7rr120� b 0 9
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Us Only
(s" Building Permit Number: Date Ap ted:
Building Official(Print Name). - Sigpatur VDa e
L� SECTION 1:SITE INFORMATION'
1.1 Property Address: 1.1 Assessors blop&Parcel Numbers
a o 1 �t1 e r s >`- Parcel Number
—
I.I a Is this an accepted street?yes no Map Number
1.3 'Zoning Information: 1.4 Properly Dimensions:
"Zoning District Proposed Use Lot Area(sy It) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Reyuircd Provided Required Provided Required Provided
1.6 Water Supply:(h1.G.L c.40,§Sd) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if es❑
SECTION2: PROPERTY OWNERSHIP!`
2.1 Owner'of Record:
LpM M r CC
i7nhme(Print) City,State,ZIP
n-z c�� ,,a,( Sf 4ysr��cl-47tJ7
No and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building j L Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: (its (nUa r / / C
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing S P Pther Fees:
3,Mechanical (NV;\C) S List:
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No._Check Amount: Cash Amount:_
G. Total Project Cost; $ J yl� oa ❑Paid in Full ❑Outstanding Balance Due:
M(al l,t� Sit
SECTION5: CONSTRUCTION SERVICES
5..11 ^Construction Supervisor License(CSL) eS-
0 is I U oke License Number Expiration Date
Name ofC E folder List CSL Type(see bclow)—Al-
5 —
7 e14 GA^A_(./J� 1v Ty Description
No. and Street "
U J I Unrestricted(Buildings iiii to 35,000 cu. 11.
Me,55 n Ici 3F- Restricted 1&2 Family Dwelling
Clty/town,Stale,LIP Ivt Maso
RC Roolina Covering
WS Window andSiJin
SF Solid Fuel Doming Appliances
97ff *h7-070 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 77S i�6 3 /6
�( LA ftaSn fieoN. s d K'�"li/�5 HIC Registration Number Expiration Date
HIC Cumgg;my Name or HIC Registrant Name
Q r5++A. > G`(L)are
Nu.and Street Email address
,b Y.v nJ IA c„S T c ISaS' 7& tffr7— a 70
City/Town, State ZIP Telephone
SECTION 6:WORKER$'COMPENSATION 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 Istuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........O
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED.WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES f FOR BUILDING PERMIT'
\ / I, Owner of the subject property,hereby authorize f S, Ori I r(it -
V t ac on my behal t i all matters relative to work authorized by this building permit application.
Pant ner's Name( lectronic Signature) Dale jJ
SECTION 7b:OWNER'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 and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic 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 rror have access to the arbitration
program or guaranty fund under 1d.G.L.c. 142A.Other important information on the HIC Program can be found at
www mass eov'oca Information on the Construction Supervisor License can be found at wivw.nmss.eov%'dn5
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) '� .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
type of heating system Number of decks/porches
TYPeofcoolingsystem Enclosed Open
3. `Total Project Syuare Fomag�'may be.substituted f'or"Total Project Cost"
ac oe CERTIFICATE OF LIABILITY INSURANCE
7123/15
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 POLICES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), At1fHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the Policy(es)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 endorsemenq .
PRODUCER GOPITACT
Circle Business Ins. Agcy, Inc NAME:
247 Newbury Street 978 777-5619 FAx NO: (978) 777-4898
M uL
Danvers, MA 01923 XG ESS:
INSURE S AFFORDING COVERAGE NAICN
INSURED
INSURERA:Hartford Underwriters Ins. Co.
INSURERB:Main Street America
National Management Team Inc.
INsuRERc:Torus National Insurance Co.
2 Austin Square Lynn, MA 01905 INSURER D:Merrimack Mutual Insurance
INSURERS:Travelers Insurance
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.LMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I R
LTR TYPEOFINSURIWCE O EF 0 CCyy
1M WVD POLICY NUMBER Mm01V MMIDO'YYYY LIMTS
B GENERALLVIBILITY Y Y MPT7965M 2/24/15 2/24/16 EACHOCCURRENCE Is 1.000.0
X COMMERGALGENERALUABIUTY DAMAGE TO RENTED $ $OO OOO
CLAIMSMADE a OCCUR MED H7W(Anyo perem) $ 10 000
PERSONALSADVINAIRY $ 1,000,000
GENERAL AGGREGATE $ 21000,000
GEN'LAGGREGATELIMITAPPLIESPER PRODUCrS-C MPIOP AGO $ 2 00O 000
POLICY X FRO-
LOC $
B AUTOMOBILE LIABILITY Y Y MPT7965M 2/24/15 2/24/16
Deets aen " $ 1,000,000
ALLOWNENYAUTO BODILY INJURY(Per person) $
AUTOS SCHEDULED
AUTOS AUTOS BODILY INJURY(Per a Ide $
X HIRED AUTOS _2L
NON-OWNED
AUTOS P ROePE.Ig DAMAGEPar $
C X U68RELLALIAB oocuR Y Y 85824I190ALI z/26/15 2/26/16
EACH OCCURRENCE $ 5,000,000
EXCFSSuae CLAIMS-MADE AGGREGATE s 5,000,000
DED RETENTION$
A WORKERS COMPENSATION $
AND EMPLOYERS'LIABILITY UB-2EO4199-3-15 2/21/15 2/21/16 ]( we STATU- OTK
OFFICEORMMEMBER�EXCLN EXCLUXECUTIVE YIN
DED? 7 NIA EL.EACHACOCEM I S 1,000.000
(v1en0doryin NH) -describe under EL.DISEASE-EA EMPLOYE $ 1.000.000
(yyes
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICYLIMIT I$ 1,000,000
D Rental Equipment cover IMC8-454-711 5/21/14 5/21/15 Limit 100,000
REPLACEMENT COST Deductible 5,000
E ICrime 1 1106102524 5/15/14 5/15/15 dead. 2500 100,000
DESCPIPTION OF OPERATIONS I LOCATIONS/VEHICLES (Attach ACORD 101,A44Nonal Renmrb SchetlWe,N more apace Is mgdmd)
CERTIFICATE HOLDER CANCELLATION
. SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOR1l REPRESENTATIVE
. ..... 4bb�gsemem
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mtmisuzmxmemm
01988.2010 ACORD CORPORATION.All rights reserved.
ACORD 25(2010106) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E-Mail'
k
IT
l•.
Massachusetts_Department df puhiic Safety !
Board dfBuityng Regulatidns and Standards Con'strucdon_Superrisbr I
i License:CS bOO145 1 i
srrrca(rtw,ty
' Commissioner Expiration
� L
Office o onsumer A airs 4 usmess egu a ion
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
r r Registration: 178186
7 Z i Type: Supplement Card
NATIONAL MANAGEMENT TEA Expiration: 3/24/2018
MING � G,;1
EDWARDS RICHARDS ni r t -a _
2 AUSTIN SQUARE
LYNN, MA 01905 sae;8CA1 Co 20M-05/11 p
`+j" .r„ U date Address and return card.Mark reason for change.
y_'-'✓
Address Ej Renewal Employment Lost Card
1 y
The Commonwealth of Massachusetts
- Department oflndustrialAccidents
= I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Orgaiuzzlation/Individual): A,uA JC^ut)A c,, k&r.%ItA t.�y L� CG+C
/�Itl /l l
Address: E'I -S{�`YL � � u a to I-,
City/State/Zip: Phone#: !i 7 C- <-&l - 1,V70
Are yo n employer?Check the appropriate box:
Type of project(required):
I. I am a employer with employees(full and/or part-time).' 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
4.F11 am a homeowner and will be hiring contractors to conduct all work on my property. twill 10 ❑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.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Ro repairs
These sub-contractors have employees and have workers'comp.insurance.=
b.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14. ther % L4)4l.0 W
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
-Any applicant that checks box#I 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.
tConnuctors 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.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 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 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 undq the pains and penalties ofperjuty that the information provided above is true and correct.
Signature: �ir't l'��� Date:
Phone#: 151' T1S=3&5
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#:
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 permi0icense 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
r
7". eting Group HIC#178186
s
Roofing • Siding • Painting •Masonry National Management Team Inc.
John Henkelman
23 Oliver SL
Salem,MA 01970
(978)74444-4747
(978)744-2475
January 23,2015
Dear John, Revised: May 5,2015
The following estimate is for the roof installation for the property located at the above address. The following paragraphs describe the
work that will be performed.
Installation Procedure
• Go over existing roof on the entire house
• Install new vent pipe flanges
• install 8 inch drip edge '
• Install new GAF Timberline Lifetime High Definition Architectural shingles
• OPTION: Go over(2)Flat roofs with Flintlastic rolled roofing
Additional s Oct*nations -
• Home owner to choose color of shingles COLOR: -
• All work will be done in a professional manner,and timely basis
• We are not responsible for any of the cracks that may arise in any walls or ceilings
• Please cover all your floors in your attic to protect from dust and debris
• We will remove all of the job related debris
• Permit costs vary from town to town and are not included in this bid
• This estimate price is good for six(6)months
Please initial all onttans you are choosingbelow:
Cost for Labor&Material for Shingle Roof Go Over: $3,600.00�
Cost for Labor&Material for Flat Roof Go Over: $1,800.00
Pavment Terms:
1/3 deposit due upon signing contract: $
113 payment due upon start of job: $
113 payment due upon completion of job: $ Total Amount Agreed To Be Paid: $ �/
Please sign & date. Remit to: National Management Team Inc. -P.O. Box 365, Topsfield,MA 01983
The following schedule wail-1�bb dhered t !s beyond National's control arise:
Work Scheduled to Begin.///, TgD / j Job expected to be completed within 60 days of actual start date.
Warranty: National Management Team Inc.guarantees all work performed for a period of one year. If any problems occur we will cover the
cost of all labor to correct the problem and meet the customer's satisfaction.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BL K SPACES
Edcni .-crds-Project Manager ll
National Management Team Inc. Date J ho H ikelma - ..
omeowner Date
Tel: (800)535-4312•Fax: (978) 887-5875 •P.O. Box 365 -Topsfield,MA 01983
1-RRR-5-OT YMPTC • viruntr nlvmn:rr fi