17 PALMER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
W
Board of Building Regulations and Standards CITY
SALEM
Massachusetts State Building Code, 780 CMR, 71h edition R OFed January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
`` \V Building Permit N ber: Date Applied:
v Signature: Z147,-yy0i-.-v y /0
Building Commissioner/I pector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1 ; x ye
Lla Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: - - •'r.=,
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
✓
Name(Print) pss for eAd reu iV ��
9-52- - 1 y�-
Sigr Telephone
SECTION 3:DESCRH'TION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2:
4
SECTION 4: ES IMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ /;L i 0. Io 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ 3
❑Total Project Cost (item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ �a I b f Q, 00 ❑Paid in Full ❑ Outstanding Balance Due:
ZJQL
0 3cl
Ia 70 ps� � lcl �t o1983
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ( ! D 210 I 1
U��/�die ✓ /�� � License Number Expiation D to
Name of -Holder L.)P t � List CSL Type(see below)
'� T��6'�il—y`� Type Des ri tion
Address
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature _ M Mason Only
Q ���" ��� RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
52 Registered Home Improvement Contractor(HIC) ye�
hln� n ?t-t �-6-�
IC C mpany Name o 1 R is[ran Name Registm[ion Number
Ile-AA C>Aaa ZIZ� I � 1
ress ee
_I'��•S9�' S4�o Expitation Nte
S' atu a Telephone
SECTION 6: WORKERS' 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ...........O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, - 1g✓L !?uehn on - Ai as Owner of the subject property hereby
authorize (ICI pt�iv k r SVC to act on my behalf,in all matters
relative to work auth rized by this buildi ermit application.
Signature of Date
(� SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
1, !+ Itl2. - � 1 >.'.YU,as Owner or Authorized Agent hereby declare
that the statements and information o�he foregoing application are true and accurate,to the best of my knowledge and
behalf.
t �
Print N e
natukof Owner or Authorized gent Date
A under the pains 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 access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I I O.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
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"
• 1
CITY OF S.3 .& �'LaSS.�CHL'SETTS
BU1LDl2NG DEP iRT�tEVT
�`` 130 W ASHNGTON STREET. 3tO FLOOR
TEL (978) 745 9595
FA%(978) 740-9846
KINtBERLEY DRISCOLL
MAYOR THOMAS S .PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUMDQVG COMMISSIONER
iER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debriswill be transported by:
name of hAler)
The debris will be disposed of in :
"rd J-)Jm)Q
fame of facility)
,. �ad" M/r
(addr ss of facility)
s' aWpermiplicant
�/ �5-/ IQ
dat
dcbrlvlTJia
CITY OF S.U-Fabvl, ANWSACHUSE=
• BUILDLNG DEPARTI &N-T
• 120 W.ALSHINGTON STREET,3'"FLOOR
\ TEL (978)74S-9595
FAx(978)740,98"
KIMBERLEY DRISCOLL
MAYOR THomu ST.PI> RRe
DIRECTOR OF PUBLIC PROPERTY/Bl.'tIDVG COMQSSIONER
Yorkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busim-ss Organimtiord[ndividwi): dyt; r- R WE1/4 � C� &I
Address: o239 00n, A S:L.
City/Statc/Zip: 1T&I4L ✓YJWORSC3 Phone#:
Are you an employer?Check the appropriate box: Type orproject(required):
I.( t am a employer with_� 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time).
• have hired the sub-contractors 6. ❑New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached shcet,t 7. ❑Remodeling
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 S. ❑ We are a corporation and its 10.❑Electrical repairs or additions
officers have exercised thew
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additk.
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.)t employee&[No workers' I3.0 Other
comp.insurance required.]
•Any applicant tha chain tnx 01 must also fin out the section holes,showing theirweakms c:ompenarioo policy iorurmaioa
'I le,twosvtaxa who submit this ai ,wit indicating they are doing a0 work and then hue outside contract,,aunt subutn a new affidavit indicating such
:Cuntracwn that chat this box anti anached an additional shot showing the emote,of the sub-contract,,and their wotkera'eamep.policy infmtutiae
I am an employer that Is providing workers'compensation insurance for my employers. Below Is the policy and Jab site
informatiolL
Insurance Company Name:
Policy#or Self-ins.Lic.#:ty 1/U �� (7 Expiration Date- 1
Job Site Address: 17 A JMGY c5 t . City/State/Zip. ,�A 1 f A, MA-- 491 9--�e
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date}
Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fore
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the OIl ice of
Investigations of the DIA for insurance coverage verification.
I do hereby certify t pe ! perjury that the iaformadoa provided above is true and correct
n t i err
Phunc_i;,
OJfu:ial use only. Do not write in this area,to be completed by city or towns oJfichd
City or Town: PermitJUcense#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other_
Contact Person: _ ___ Phone M
�- - Restricted to: 00
f ... 00- Unrestricted
IG-1 2 Family Homes
1. Massachusetts- Department of Public Sitfety
Board of Buildim„ Regulations and Standards :Construction Supervisor License Failure to possess a current edition of the
License: CS 80145 Massachusetts State Building Code
Is cause for revocation of this license.
Reslricted:toi; 00
' '' W Refer to: W W.Mass.Gov/DPS
GEORGE'`gU,ASILIA�S
5 PITCAIRNj1YVAY
IPSW]CH. NP4':01938'• s,. • ..
Expiration: 10f262011
0ummisn6mer Tr#: 6238
J Bo r Build�lat ons/an�S'tan
One Ashburton Place - Room 1301
lug Boston. Massachusetts 02108
Home Improvement'Contractor Registration
_ - Registration: 154326
Type: Supplement Card
Expiration: 2/27/2011
ALPINE PROPERTY SERVICESb;sl�J ; --
GEORGE VASILIADES -
11 WILSON STREET
SALEM, MA 01970 Update Address and return card.Mark reason for change
Address C Renewal Ej Employment Lost Card
OPSCAI 0 4oM4 Ma-0ab•LIF0RMCAfea21200a
_ _ -� _�ie 1Sarwman�+ea�-o�✓�amac�weed2_.. — -- - - - - -
Banrd of6gllding Regulations nnd.Standards License or registration valid for individul use only
HOME IMP.FjOVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registrdtfont 15432E
-ra sc: One Ashburton Place Rm 1301
E Cp1Fa0ort:'.21272011 Boston,Ma.02108
; Stu(iplement or
ALPINE PROPEkiYZERO,CES C
8E!6WGE VASILIAD
11 WILSON STREEI•+;_�`,p;^✓ ������,_,_` ____ __ _ _ _ __
SALEM,MA 01970 - Administrator Not valid withdut'signnture
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f AGGRO. mill
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Yvuz- e TXIB.CERTIFICATE 1919E OR,}NFCYLAATTON
ONLY AND CONFERS NO RIGHTS UPON YS/E GEi47]FICATIe'.. ••,
H.1. Knight lntcmaliunal)nsurancc Agencies, Inc. HOLDER. THIS CERTIFICATE DOES NOT AMENDA•k7C{ENp OR. _
500 Victory Road-Marins Hay ALTCR YNE CC WRACE AFFORDED BY THEPOUCIES i§f c7 .
North Quincy.MA 02121 MPIummsAF'•FURODFGCOyERACE.
'COWART •�'
A AllhutiL-ChbrLerInsumnceCompany VDAC
aDW tp COWANT
Alpine Property Scrviccs Co.,Inc. B
CONIFANT
PO Box 365 C
.. -Topsfield,MA'- 01983. . ._ .coMPAN ---
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THIS ar TO CERTIFY TNAT TME►aLN.7E9 Of INSYMNC6 LISTED BELOW NAVE BIiFN BBLIEO TO TNe ugVRED NaMEOADOYEFORTHEPOLIGYPEIBDD •'
INDICATED. NOTWIT16TANONGINIT CONORIONOF ANY CONTRACFOROTttIR OpCYMEnT rJIiN REEPEGT TO YIIBCX 7Nta
CERTIFICATE MAY OR,BEUEDgr MAY PENTADI THE URRIPAPCE APCORDED BY THE POLICIES DUMBED NFAEIN U BUVJXCTTOKI TKTERMB.:• '
Excumom AND comamoNS OF SUCH POLICIES.LIMIiB 590'NM WT WTE eEEN pE000E0 BY PAID CWMe- '
CO TrPe Cw Pa• A"m FOLILT"KR TYIUCTrBTECTITE POWir pFpiwTlelp •uN11$•;
Lm MilF wc,mrm mwtmwwrm IMi lAwimF.j
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CONTACTUAL PERSONALUL!LWADO 1 -
WpEPENOENTCOMRACIORS '
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PFASONY.NJYAY
AYTGNOD uA911TY ' " T.WNM _••
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AILOUpIEO AVTDDPA.""pol BODILY WDRY~,'I
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+A ownMO ,�r.0 WCV0075490 1/52010 1/5/2011 STATuro"huNrB
r401ACODENr t •1 '500.000
olr+O.LE-POUC(LDBr' •s. 500,000
opeve•E:eipwlPlaTs•1 s '500.000
omLR '
DETCRVngI DI DPTAAnDFMLxanmwnpctbvlFlOALnpra �- t'
..t _ �� 5w'Y''t�.3�0�biTp+.dil`.'•- : IF'.c.T:.
'SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CArILj:LLFD INHIPRBTME
EXPIRATION DATE TXEREOF,THE ISSUING COMPANY 1Mli ENDEAVOR 7D MIL
DAYS VAMEN NOTIC£TOTNE CERTIFICATE MOLDER?LM1E0 T0',TME LEFT.
BUT FAILURE TO MAIL SUCH NOTICE SHALL IAIPOSIS NO OSLIC,ATW N OR UABILIT
OF ANY KIND UPON THE CAMP AOEII T(AYNES.
• AUMIYRAD RPlKIENTATIVE
cury
ti
flPR-29-2010(THU) 13: 35 Office (FRX)9788875870 P. 001/001
,✓ IIIC#154326 -
EIN1f 56-2618812
OLYMPIC Job#:
Roofing Siding- Painting Office: 978-887-5870
239 Boston Street-Topsficld MA 01983 Fax: 978-887-5875
Steve Gagnon
Gagnon Rcall.y
P.O.Rum 431
Topslichl,MA 01983
(979)852-6142(cell)
978-887-7692(fax)
Job 1.,oyation:
17 Palmer St.-Salem.MA
April I,2010
Dear Steve,
The[following estimate is for the roof installation for Ihr•properly located at the above address. The following panigraphs describe the
work that will be performed.
Installation procedure
4. Rcrnove rmistiug shingle roof oa the entire house
,& Install nil 8 inch drip edge on all leading edges
+1. Instill 3 lent of ice&water shlcld on front leading edges&valleys -
J. Install 15 pound felt paper Dan all areas not covered by ice&water shield
4- Tnsinil new ridge vent
4: Install new vent pipe flanges
3 Replace any rotten or danagcd roof decking plywood(we allow 32SP(o)no charge,$65.00/sheet thereafter)
,4 Rcpbrce troy mtleu or d:mnaged roofdecking ledger board(we allow 30n.at no charge,$5.00111. thereafter)
y, Repluix any rotten or damaged fascia or rake boards @$10.50/11
.* Install new CAP 30-yr Arcbitectural shingles
4 Remove existing lead flashing on(2)chimneys,install ice&water abield,ship Bashing,and grind new lead flashing into
chimney(included in price)
.. _; ., -•, ... Alkfitiunul S eel ., _. ,.Homeownd ui choose culor M'shinglas COLOR[ -
4• Our dumpshss ale sett(to it rcoycling liacilil.y;Ilaereliere no additional trash may be placed in Thom. Tlac lraasler station will
charge us a fee which will be passed on lA the homeowner.
rot- T'nmsitiun walls two an option,and i 1'llie existing[lashing is in good shape,usually do not rcquirc rrpltu:ement
-4: We arc not rospuns;ble for ally of O e cracks that may arise in any walls or cciiings
* Please cover all your floors in your Attie to protect Fran dust and debris
4 we will remove all of thrjob retried debris
Cost for Labor&Material rnr New Shingle Roof: $12,610.00
Payment Terms: 1/3 deposit upon signing contract $ - - ,113-work in progress 5 —- and t/3 upon completion F
Recoil in., Alpine property Services Company.Ina.,P.O.Bax 365, Topaft h4 MA 07983
Total Amount Agreed To Be Paid: $ -„
'file following schedule will br.-udliomd to little$$cireumsuinces heyond Alpine's control arise:
Work Scheduled to Begin:, TRD - 1{xpected Datc ofConnpletion: TBb
Wermnly; Alpi ar.Properly Services Company Inc.guarantees all work performed for a period of three(3)years. If troy pruhlrms uccur
we will cover .le coat o' I lalmr and material to correct the problem and meet the custbmer's satisfaction
mi Maniatis Pn.cet Manager S(vve ragnun
Alpinc Property Svcs.Co.,Inc..d/b/a Olympic by(Name) - Oa{nun Rarity