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2 PETER RD - BUILDING INSPECTION 5(P CCA< Z4-3 1 $1 33/ Rf¢t?'1�.41 The Commonwealth of Massachusetts � 1i1tit ( jf t' ITY OF Board of Building Regulations and Standards SALEM / Massachusetts State Building Code,780 g0fFNOV _6 A 10 sed Alur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dtvelling This Section For O�cial Use Onl Building Permit Number: Date Applied: ( Building 0111cial(Print Name). - Signature- '. - Date SECTION i SITEINFORiVIATIOW 1 Lla-ropef kT"er: (ZoA-D 1.1 Assessors Map&Parcel Numbers 1.1 a 1s this an accepted street?yes no Map Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: "Zoning District Proposed Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(R) Front Yard Side Yams Rear Yard Required Provide) Required= Provided Required Provided 1.6 VVnter Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ — Check if es❑ P P y 7ty1'J�Y7 10 SECTIONI: PROPERTY OWNERSHIP!': 1 ort OYc- J FE I th P t hme(Print) City, ,ZIP en f�>4 b �jZS7�1�F s No.:md Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED VVORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:, 7'1Z)J3+Pe-GkY-NLy Brief Description of Proposed Work-: SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Offlcial Use Only Item Labor and Materials 1. Building S J'p 0, do 1• Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost}(item 6)x multiplier x 3. Plumbing S 2. Other Fees: S y.Mcchmtical (HVAC) S List: a U 5. Mechanical (Fire $ 'total All Fces:S Su ression) Check No._Check Amount: Cash Amount: 6.Total Project Cost: S j 0 0 r�4 ❑Paid in Full ❑Outstanding Balance Due: � iLt� D rJ C'3GLJ kli� I 1 (q mast L_1--P l•D . SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ' d 1 a.9�0 �11 License Number Expiration Date Nance of� F,RC/SLL[[polder List CSL'rype(see below) F _ 2-1S t/ (L 57 Type - - Description Nro.`;mQd Street 1� �"d' D/to ! U UnrescrictedU OuilJin s u -to 35,000 cu. il. r� L�` `� R Restricted I&2 F;unil Dwellin City/rown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding apry SF Solid Fuel Burning Appliances I I Insulation Telephone - Email address I D Demolition 5�.2qRegistered Home Improvement Contractor(HIC) [ 7 D f 1/ � �✓ ¢ W 'CE.F J�./I� dre-rl-/Ii7 -J)L coA-T )� HIC/Registration Number Expiration Date I I I CtrtpV N ILUort I I gi�uoptName No.and Street Email address - +x� �, rn�- ©[goy �J�[—�1T-,ILL Ci /fo vn State ZIP Tele hone 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 Is§uance of the building permit. Signed Affidavit Attached? Yes ..........19 No......:....❑ SECTION 7a:OWNER AUTHORIZATION:TO HKCOMPLETED.W HEN: OWNER'S AGENT OR CONTRA,C-T/ORAPPLIES FOR RR-BUILDING PERMIT 1,as Owner of the subject property,hereby authorize W� �}M 11ZA44213- t9 act on my behalf,in all matters relative to work authorized by this building permit application. 209 NO V - n IQ) _ i f-oc Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,[ 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 eol have access to the arbitration program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at wvww.mass.!ov'oca Information on the Construction Supervisor License can be found at w\vw.mass.aov!dos 2. When substantial work is planned,provide the information below: Total floor area(sq. R.) (including garage,finished basementlattics,decks or porch) Gross living area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Nuntbcr of bathrooms Number of half/baths rype onccating system Number of decks/porches rype orcooling system Enclosed Open 1. "focal Project Square Footage"may be substituted for"rut:d Project Cost" The Commonwealth of Massachusetts UflDepartment of Industrial Accidents I Congress Street,Suite 100 Boston,MA 02114-2017 www mass.gov/dia Workers'Compensation Insurance Affidavit:General Businesses. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print Legibly m Business/Organization Nae: AyIlk� x A-^ J RA- Con 1.41 T^-t Address: VE fk7 NA S]- nA City/State/Zip: U//t/A.- AA e[TOY Phone#: /7�'511' 12-) 1 Are you an employer?Check th appropriate box: Business Type(required): 1.to I am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/Eating Establishment 2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.) employees working for me in any capacity. [No workers' comp. insurance required] 8. ❑Non-profit 3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment their right of exemption per c. 152,§1(4),and we have 10.❑ Manufacturing no employees. [No workers'comp. insurance required]* 11.❑ Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] L 12.❑ Other *Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information. **If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an organization should check box#I. I am an employer that is provi//d��i.n,g..,,workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name:_ tl.N -�t'>eJ�-��"L C�,ft�l�'�`t/ Co Insurer's Address:, 6L)5- V SS7' City/State/Zip: l.X 1/Vh-- r��Qy�[Q 1 `y Policy#or Self-ins.Lic.#b53 Py D 1%Z7o 1 O M Expiration Date: 0 4- 04-17 Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerd ,�u�n/d/der the pains d penalties ofpperejury that the information provided above its true and correct. Signature• .t((i(.Y.��;9, 04 — Date: Phone#: /'()l� J 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. Licensing Board 5.Selectmen's Office 6.Other Contact Person: Phone#: www.inass.gov/dia � µ 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 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 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 your insurance company's name,address and phone number along with a certificate 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 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). 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 burn 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 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 www.mass.gov/dia Fonn Revised 02-23-15 C 1 \ /�� �)`/�/�}I�S /�/� ./J���,f�/}'�1/lam,aI i V` V Yff E+ , I>3� 7�9995. $�SRiFYXL FAX 744Xb DxKusrjwm re'RKxROkaY/istvanassecm Construction Debris Usposb/Affrdovit (required forall demolition and,-renovation work] In amordaw wfth the shah edition of the State B &Wkw Code. 780CAOX Swft 121.5 Debris, and the wvWo is of MGL do,S 54, Bufldt Permits is issuedwRh the condW=that the debris resultV from this work shag be disposed of In a pmpe*lbensed waste deem*facility as deffned by MGL c 111,S 15K The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of fadlity) C Of►1► 4,efL aL �T (address of facility) Signature of applicant Date i II all 11 Ul 5X�p r N r N Y' F, �m � � � M N N N N N N M N M N. N N M N ..NM N •� � W � P� � � m ti $ syIII flitINIg'y F � �� • Allltl �1 Pe ��� Page No. of Pages WM.•TRAH�ANT JR. CONSTRUCTION, INC. 4TH GENERATION ROOFING 2.15 Verona Street LYNN, MASSACHUSETTS 01904 CSL #101220rr ' (781)599-1.211 • (781)844-4551 • FAX: (781) 681-0855 H.I. LIC:#141778 PHONE - DATE PROPOSAL SUBMITTED TO - - ewCh� STREET - JOB NAME - _ o� Oeier 2d- CITY,STATE and ZIP CODE` - - JOB LOCATION - - We hereby submit specifications and estimates for: - - We hereby submit specifications and estimates for. SHINGLE ROOF FLAT/RUBBER ROOF S Ip entire roof ❑ Reshingle ❑ Sweep entire roof clean Re lace any bad boards upato 100 linear feet ❑ Strip entire roof I a I Ice aril aterbarner first4Wm feet up roof El Mechanically fasten down ISO board Insulation — Install is end water b tiler in all valleys-and along dormers ❑ Install 060 Rubber Roofing on entire roof stall r on remainder of roof. ❑ Install metal flashing around perimeter of building - - - - -/ -- - nstall eight inch drip edge L7White p Black O Mill q Flash chimney(s),pipe(s).and.wall(s) . ❑ Ins all ridge vent - _ ❑ Edge caulk all seams Flash or re-flash chimney(s) ❑ Install new copper center drain nstall new pipe flanges ❑ Other: stall lifetime shingle olorC' ❑ Clean up all debris ❑ Install gutters and downspouts ❑ Labor and materials guaranteed 100%fog five years D --- - -- - - - - ❑ Install trim coil ❑ Install new fascia boards Please �Q�f fifth an� ----- _.—_ _____ ---vny ❑ Install new rake boards g g -- - -- -- - 4.0 - ❑ Install sky light(s) - - - - 71 ® 4-4 . ❑ Other VCIe n up all debris abor nd materials guaranteed 100%for five years shingle roofs are nailed by hand. Me Propose hereby to furnish material and labor - complete in accordance with above specifications, for the sum of Total Price is ) **IF YOU ARE.HAVING YOUR.ROOF STRIPPED, PLEASE COVER ALL VALUABLES IN ATTIC, AS - WE. HAVE NO CONTROL OVER-DEBRISTHAT MAY FALL THROUGH ROOF BOARDS."• .` _ s: - 1 All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above specifiea- Authorized lions involving.extra hosts will be executed only upon written orders, and will become an Signature extra charge over and above the estimate. All agreements contingent upon strikes, i accidents or delays beyond our control.Owner to carry fire,tornado, and other necessary) - insurance.Our workers are fullycovered by Workyman's Compensation insurance. - - �1CCELitaure of rlTpasal—The above prices, specifications , and condditions are satisfac ory and are hereby accepted'.'You are authorized to Signature do the work as specified.Payment will be made as outlined above. Date of Acceptance - Signature - Please mail yell.copy to above address. - - -