34 PARK ST - BUILDING INSPECTION lit
The Coil) nomveaIIh of Massachusclis
/ Board of building Regulations and Standards CITY OF
�r u, Massachusetts State Building Code, 780 C'MR SALEM
'Lr,✓ /1N1'ISNd i loll'201/
Building Permit Application 'ro Construct, Repair, Renovate Or Demolish a
(Mv-or rwu-Famill Di tilling
This Section For Official Use Onl
Building Permit Number: �/� K
ate AAspp/lied: )
Building 011icial(Print None) 3 giryiatu D
a C
SECTION I:SITE INFORMATION
1.2 Assessors M1lap& reel Numbers
I.la Is this an accepted street?yes no Map Nunlh r Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Prn,poscd Use Lilt Area(sy It) Frontage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.qd,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check iY ros0 Municipal❑ On sire disposal system ❑
2.1 Ownert of R �/ SECTION2: PROPERTYOWNERSHIPt
e
:a-e ✓ S,/Ni-, /1W-
N;une(Prang, Caty,Smtc.Z.IP
No.and Street Telephone Email Address
SECTION): DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ I Other ❑ Spcciiy:
Brief Description of Proposed Wo�rk'
SECTION J: ESTIMATED CONSTRUCTION COSTS
I1e11t Estimated Costs:
(Labor and\laterials) 0111e)al Use Only
I. building S I. Building Permit fee: S Indicate how fee is determined:
ctrical S ❑Standard City/Town Application Fee
I ?. Plumbing S Cl Total Project Cwtt(Itet 6)x multiplier -
2. Other Fees: S
a. Mechanical III1'.1(') S List:-_
3 \Icch;mic;d tFirc -
Cu,lre5slonl S Toad .%It Fees:
s_
I, Total Project Cost: S���( v Check No. _('heck Anwunt: _ -- C,Ish \nw n l;
❑ Paid in Full 0 Outstanding baLmce Due
SECTION 5: CONS"1'RUC'rION SERVICES
5.1 Construction Supervisor License(C'SI.)
I.icensu Nuwhcr P\piradou Uate
Namaol'l'SLIIoIJer
No, aid Slrcet --
,� U Unreslndcd I Iluilditlgs Ii to i 000 cu. 11
_ R Restricted LC2Pumil Dtwllin
l'il\i full n,.hate.LlN �i Alusun
RC Root n Corerin
WS Window;uld Sidin
SF 3Ulld LLI Ilurning Appliances
I hlsulalion
Talc hone Finail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 'W'
AQ9Pz A / �Pn104 ii✓c/N w/� /LT✓r I IIC Registration Number Expiration Dale
I Com m pal Nae or IIIC'Ito Istran Nunle
��U ,�
No. Ild I"'9/ /A� Email address
O5- �-N A// O 2J o 9 (>/9- 7�3 -S7/ 7
City/Town. State,ZIP Tcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e. 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...........Cl
SECTION 7a: OWNER AUTHORIZATION TO BE CONIPLETED W HEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all platters relative to work authorized by this building permit application.
Pr111I D\iI1Cf 9 Name(Electronic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering Illy name below, I hereby attest under the pains and penalties of perjury that all of the information
ation is true and accurate to the best of my contained it he Y
knowledge and understanding.
��flP
Print(loner's or:\uthuriied Agent's N;unu Ililectrunte.Slgn;uura) Date
NOTES:
I. An Owner who obtains a building permit to do his her o\vn work,or an owner who hires in unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program).will no have access to the arbitration
program or guaranty fund under M.G.L.c. IJ_'A.Othcr important information on the HIC Program can be found at
iota % o,..l Information on the Construction Supervisor License can be found at it%%%% nm- g_,\ alp,
\Then substantial work is planned,provide the inf'orlmation below:
Total floor area Isy. a.) _ ____""_I including garage, finished basement attics,decks or parch)
Cross li\ing area(sq. it.) ..___ - Habitable room count
Number of lircplaces.__ .\umher of bedrooms
iNumber of bathrooms _ Number offialf hoths
I\pc of heating s)stem _ . _ Vunlhcr of decks, porches . . . .. _
i
ItPCof,:oolllltti\ilelll 1'.11closed _ _.tlpoll
i. "f,u;d Project Square Foomgc..nsq he substitlncd li r-folal Project Cost'
46
CITY OF S.UZ%f, Akss,ICHC'SETTS
BCIIDNG DMUMNONT
120 W.1.iHNGTON STRE"I JWFLOOR
TEL (978) 745-9595
KI SERI Y ORLSCOLL FAX(978) 740.9&g
MAYOII THO.�W ST.FtFRRti
DIRECTOR OP PCBUC PROPFR7V/8CQ.ONG CO\OlISSfONER
Construction Debris Disposal AftIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 180 CMR section I !I.S
Debris, and the provisions of MOL a 40, S 54;
Building permit #I is issued with the condition that the debris resulting from
1 11, S 1 SOA.I work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name o— f faullay) '
Wdrets of 7C+ ++y
+lynalure ofpermrt�pplu�nr
:ale -�
c o r v rr VC Jivr.Emj lY kssi lCH US.ET S
B1:ILDLNG DEPART\(E.NT
j+a�' ` iru 120 �s ASHLNGTON STREET, 3"'FLOOR
\?�\\c T EL (979) 745-9595
F.+x(979) 740-9W
KI\IBERLEY DRISCOLL
A-kyox T Ho%As ST.PiEwts
DIRECTOR OF PUBLIC PROPERTY/BUMD3NG CONMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriefans/Piumbers
ALplicant Information Please Print Lepibly
V;IIr3C(Ousitxss,Orgrniraniomdndividual): M/n1r,.q„/ O�U/c >< „� /r/cz�s�T i✓C
Address: 3c D L uM17 �,V/ .5-0, L,-
City/State/Zip y1� ✓ /� Phone hl: 1 /-
\rc you in employer?Check the appropriate box: 'typo of project(requ(red):
1.0 1 am a employer with 4. 0 I am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time).' have hired the sub-contractors
2.0 lam a sole proprietor or partner- listed on the attached.shcet. t 7• ❑ Remodeling
ship and have no employees These sub-contractors havo 8. 0 Demolition
working tier me in any capacity. workers'comp. insurance. 9, Ouildiug addition
(No workers'comp. insurance S. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'Gump. C. 152,¢1(4),and we have no 12.Cl Roof repairs
insurance required.) t - dmployees.[No workers' IJ,❑Other
cum.. insurance required.)
;env applieun dot Owka but 01 must also fill oul the suction hulow yhawiny their woken'compensation policy iniumtution.
I('xnaown na who,uhmii this affidavit indicating they an doing all wok and then hire outride canttactsxs mtut submit a new afltdavil indicating such.
Klnnm non than churk this bus mum atlwhud an additional+horn showing the nwnc of the subtionlractun and their woken'wmp.policy infommtion.
I uns an employer that br providing workers'c onipetrsadan insurance for my employees. Below is du polhy and Job site
infonnutinm
I aaurunce Company Natne: y �r�A N� �„s/<, /dry e-s-e y
Policy 4 or Self-ins. Lic. d: /V�rV f 5�3 6 S Expiration Date: aD
Job Silt:Address: :F G /�//fin r lP• CityiStatcaip: 5]Z,)„e j1 e& t>'Zr7 7
Attach a copy of the workers' compensation policy declaration pike(showing the policy nombar and expiration date).
F`diluru to secure cuverdge as required under Section 25A ut'%IGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 andlur one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and it line.
of up to S250.(10 d day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Invesligalions of the DIA fur insurance coverage veriticatiun.
Ida hereby certify under the pubes and peualries of per%eery that the brfunnurlua provided ubuve Ir rue air currrrG
Chone,i: `/� 7 - 3dFS-�f/G(�
Ol)iciul use only. Oo nor write bit flus•area, m be completed by city or town nJJiciai
City car Tuscan: _
-- _-. Permit/Lkcnsep--_
Issuing,\u iurily (circle one):- i
I. Hoard of Itealth 2. Ruildim;Deparl"ellt .3.CiWfown Clerk 4. Eleetrica( Inspector 5. Plumbing Iospector
b. Other
Contact Person: _ _ Phone;J:
I
Information and Instructions y
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 ajoint 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
uwncr 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."
bIGL 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,MOIL 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 cenificate(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 till in the permitilicense 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 Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
the Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMce of Investigations
600 Washington Strcet
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05
www.mass.gov/din
Office of Consumer Affairs and 2UIS2
iness Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 135991
Type: Private Corporation
Expiration: 5/30/2012 Tr# 296062
AMERICAN EXTERIOR AND WINDOW IN-C
JEFFREY NADLER _
r -
300 Commercal Street suite 2 x „
BOSTON, MA 02109
�
-=,y-s„_�`_ :,,, Update Address and return card. Mark reason Tor change.
--
DPS-CAI G 5OM-04/04-0101216 Address Renewal El Employment LostCard
DEC-27-2011 (TUE) 11 : 15 MALCOLM N PARSONS INSURANCE (PAX) 17813441425 P. 001/001
ACORQN CERTIFICATE OF LIABILITY INSURANCE NODoIYi1
12/27/2011
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: time certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed. IFSUBROGATION 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 endorsement(s).
PRODUCER UUNIAUF
NAME:
Malcolm & Parsons Ins. Agcy. Inc. PHONE 781.344.3200 FAu 781.344.1425
AIC No Ezl: AIC No'
6 Freeman $t. E-MAIL
P.O. BOX 527 ADDRESS:
INSURER(S)AFFORDING COVERAGE NAICq
Stoughton, MA 02072 INSURER A: Nautilus Insurance Company
INSURED American Exterior & Window, Inc INSURER B: Associated Employers Insurance
300 Commercial Street Suite 2 INSURER C'.
Boston, MA 02110-1192
INSURER❑
INSURER E:
INSURER F
COVERAGES CERTIFICATE NUMBER: Master 104/2511 REVISION NUMBER;
THIS IS CERT /0Y T THE OLICIES O INSUR , E S ED FLOW HAVE 6 ISSUED TO THE INSURED NAMED ABOVE FOR HE POLICY PERIOD _INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THISED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORD
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AODL SUBR
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MMI�D,YYY MMItlC1YYVY LIMITS
GENERAL LIABILITY NN-158365 10/0112011 10/01/2012 1,000,00 0
EACH OCCURRENCE 5
X COMMERCIAL GENERAL LIABILITY
PREMISES(Ea occurrence) 5 100,QQQ
A CLAIMS-MADE TOCCUR MED EXP(Any one person) S 5,000
PERSONAL&ADV INJURY S 1,000,000
GENERAL AGGREGATE S 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-C..RIEFAGG 5 1,000,00
LIABILI
X POLICY PERO.
OC
5
AUTOMOBILE T CTY �
Ea accident S
ANY AUTO BODILY INJURY(Per Parson) S
AUTOS A OS SCHEDULED
S AUTOS BODILY INJURY(Pat accident) S
HIRED AUTOS AUTOS
UN-OWNED
AUTOS PROPERTY DAMAGE S
(Peracctdenp
UMBRELLA LIAB OCCUR
EXCESS LIAB CLAIMS-MADE EACH OCCURRENCE 5
AGGREGATE 5
DED RETENTION Y
WORKERS COMPENSATION 5
ANO EMPLOYERS LIABILITY W1-05QQ7257Q12Q11 O6/08/2011 O6/0$/2012 X TORYLIMRS ER
B OFFICERIME BER EXCLUDED?ECUTIVE� NIA E.L.EACHACCIDENT S 500,000
It(Mandatory In NH) 500,DOC
f yes,describe OFF E.L.DISEASE EAEMPLOYE S
DESCRIPTION OF OPERATIONS below
E.L.DISEASE-POLICY LIMIT S SQQ,QQQ
DESCH IPTION OF OPERATIONS I LOCATIONS I VEHICLES (ARach ACORD 101,Add lDonal Remarks Sched We,It more Space is redo lredl
Siding & Window Operations.
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 REPRESENTATIVE
City of Salem Amne Parsons
IS)IUBB-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
iAllassachusetts- Department of Public Safctc
Board of Building. Rc.ulations and Stanch ds
Construction Supervisor License
License: CS 102345
ANTHONY TOCCO ,`
6 ARICIA LANE
BEVERLY, MA 01915'
o—
�G- '--o, Expiration: 12/13/2012
t'...mukAmier Tr#: 12273
✓ ��� Telephone:617-723-5717
Toll Free: 1-888-744-1756
I/we the owner(s) of the premises mentioned below, hereby contract with and authorize American Exterior and Window
Corporation (hereinafter referred to as the "Contractor") to furnish all necessary materials, labor and workmanship, to install,
construct and place the improvements according to the following specifications,terms and conditions on premises below described
with reference to which I/we warrant that I/we are the record holder(s) of title:
Owner's Name J-�;/9111 e&z c^ Te!. 27E-7--aJ/2Z
Job Address -- F 4y p4zlz Sr City State
SPECIFICATIONS 2�
V o t
✓ Uc✓
/'n .��i :%ice/�,r����.h •��T' ►�'S �/�i9�dr//�
In consideration of the labor and materials furnished by the Contractor; the Owner(s) agree(s) to pay the Contractor the sum of
5e2a$ f e � Deposit not to exceed 33 1/3%$ Z-1 d Balance Due $_ate
Est. Start Zt�4E Est.Comp. zt2j4�2 Security Interest Yes ❑ No ❑
It shall be the obligation of the Home Improvement Contractor to obtain such permits as the Owner's Agent.The Owners who secure
their own construction-related permits, or deal with unregistered Contractors will be excluded from the guaranty find provisions of
MGLC, 142A.
All Home Improvement Contractors and Subcontractors shall be registered by then Director and that any inquiries about a Contractor
or SubcorAractor relating to a registration should be directed to:
Director
r Home Improvement Contractor Registr tion
UIVUI ���c� B:oa-aaAa asase Rea�+�aa1 1a f4gk P�az�y Su1�c St 1�
/ 6,7-727-8598 �u5�o>J
HE OW R SHALL PAY FOR THE WORK BY THE FOLLOWING METHOD:
CASH UPON COMPLETION ( ) BY MODERNIZATION LOAN ( )
Notwithstanding acceptance of this contract by Contractor,this contract shall be cancellable by the Contractor if the homeowner
is unable to finance the payment of this work through an established bank or other financial institution or within fifteen (15) days.
All work performed by the Contractor is fully covered by Workmen's Compensation and liability insurance.
NOTICE TO THE OWNER(S): If it will be necessary for you to obtain a bank Modernization Loan in order to enable you to pay
for said improvements.
1. You will be given a completely filled-in copy of this Agreement.
This Agreement constitutes the entire agreement of the parties and no other agreements, representations and/or warranties,
expressed or implied,shall be binding on either parry hereto unless in writing and signed by both parties.Any alteration or deviation
on the specifications listed above involving extra costs of materials or labor will be furnished and performed only upon written order
and will be in addition to the cost price of this contract.
The Owner(s) hereby certify(les) that he has (they have) read this Agreement, that the terms and conditions and the meaning
thereof have been explained to him (them)and he(they)fully understand(s) them.
The Owner(s) acknowledge(s) the receipt of an executed copy of this Agreement at the time of execution hereof,
If any provisions of this agreement are in conflict with any statute, regulation,ordinance or rule of law, then such provisions shall
be deemed null and void to the extent that they may conflict therewith, but without Invalidating he remaining provisions hereof.
COMPANY'S GUARANTEE: The Company guarantees its workmanship for � ���� years. It will replace
defective material within the period of guarantee free of charge.All requests for service must be in writing!
This agreemert may be cancelled by an officer of the Contractor, but only within three (3) business days from the date of
execution and in a similar manner of the Owner(s)'right of cancellation.
You may cancel this Agreement without any liability to you,provided that you send a written notice to the Contractor by midnight
of the third business day following your signing of thig Agreement, by ordinary mail, posted, by telegram, or sent by delivery.
WITNESS our hands and seals this J day of �/r �� — 200
AMERICAN EXTERIOR AND WINDOW CORPORATION Do n_Qt sign this Agreement efor you read it.
(SUBJECT TOHOM C
By. �—`�. `j
Representative (Owner)
Accepted By: (Owner)
Authorized Officer (Owner)