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11 PICKMAN ST - BUILDING INSPECTION 3 s- 29 The Commonwealth of Massachusetts ° Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a ^I One--or,T-wo-Fanuly Dwelling_ tw This Section For Official Use Only ( Building Permit Number: Date Applied: -9 1I-6CAl•0C./ to zo Iv 1 Building Official(Print Name) Signature U G Dat SECTION 1:SITE INFORMATION 1.1 Property,Address, 1.2 Assessors Map&Parcel Numbers �/ r�i ,/�✓ 1'firee� JAM M�- L l a Is 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 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.),Owner[of Record: e Maine(Print) City,State,ZIP// �d<1M1� .rlreef J 9 'K-AM- 69f.)- 4�4yec�i�Q091*L (fff^l No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building ZI- Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee: $ Indicate how fee.is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5. Mechanical (Fire S Suppression) Total All Fees:$ 6. Total Project Cost: $ / (`�!, Check No. Check Amount: Cash Amount: ❑Paid in Full ❑ Outstanding Balance Due: �tAlc � I C> Zy SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �ekr /e License Number Expiration Date Name of CSL Hold f 3-7 / L/ oW e // p 7-- List CSL Type(see below) No. and Street { d ADDemolition Description wil-ke I (J P 0 I r&-L) tricted(Buildin s u [0 35,000 cu.ft.)Gty/Fo State,ZIP Y"I` l cted 1&2 Famil Dwellin„ T�1 Coverinw and SidinFuel Burning AppliancestionTele hone Email address lition 5.2 Registered Home Improvement Contractor(HIC) c _R&r- il/Qni r¢�D f C���i�y �` / 70 7 HIC Company Name or/HIC Registrant Name / HIC Registration Number Expiration Date �77 L.Otnifl/ t �tcr3'�'�OJbaf��I7e.C()/�') Now -e,�e,V 0� o/�J J Email address Cit /Town, State,ZIP 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 ..........A- No .a........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize to act toon�my behalf,in all VS' nature) ve to work authorized'by this buildmg permit application. Print Owner's Name(Electro I Date 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 i e a d accurate to the best of my knowledge and understanding e� . 7P a^� /¢ A.Print Owner's r Autho zed Agent's Name(E - is Signature) Date 1. 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 can be found at www.mass.jzov/oca Information on the Construction Supervisor License can be found at www.mass.aov/dps 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. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halfibaths 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" " The Commonwealth of 11lassachusetts l Department of Lidu.s'trial_4ccidents 7,1 �(lb Once of Investigations !, 1 Congress .Street, Suite 100 z_ Boston, 314 02114-2017 WIFIV.III(IS S.govldia Workers' Compensation Insurance Affidavit: Buildeu'slContractors/Electricians/Plumbers Applicant Information Please Print Legibly tiame (Business)Organization'lildiviammal): Peer Ryan and Son Roofing, Inc. Address: 377 Lowell Street Cain-/State%Zip: Wakefield, MA 01880 Phone 4: 781-245-4900 Are con an employer'? Check the appropriate box: Type of project (required): 1.❑ lain a enlployet .with 4. ❑■ I and a general contractor and I employees (filil and,or part-time)."' have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed oil the anached sheet. ElRe iiodehri2 slmip and have no enlploi-ees These sub-contractors have S. ❑Denrolitioi king for use illa ly capacity. eny)loyees and have �vorkers' wor 9. ❑ Building addition [\o w'orkers' comp. n13urmice connp. instil:ance.- required.] � ❑ We are a coP 5 t oration and its 10.❑ Electrical repairs or additions i.❑ I min a holneotvtmer douse all evork officer's have exercised theil" 11.❑ Phtnb ag repairs or additions rin-self. : ' . lialrt of exemption per MGL [�o workeis comp 12.❑ Foofrepaus illsill'alnce required. ' c. 152, ,�10). and the have no ellyrloyces. [Nonorkers• II.yother comp. nlstirance required] *aim applicant that checks box=l must also fill out the section below showing their workers compensation policy"information. Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must.submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet sl+owiue the name of the sub-contractors and state whether or not those entities have emplol-ees. If the sub-contractors have employees.they must provide their ;corkers'comp.policy number. I nin air employer that is providing workers'compensation insurance for nrr enrployee5. Below is the police and job Site information. hlslunnce Compally'Nante: N/A II am not required to carry W.C.as I have no employees) Please see the Sub-Contractor's W.C. Policy-or Self-ills. Lic. N/A/ Expiration Date: N/A Jab Site Address 1., 1 1,.-P/CJ n f-._.. .__ __...__ . _ .____---. -_.,.__..C ih State Zip: �9�'✓1 O/�7 Attach a copy of the workers' compensation policy declaration page(showing the polieN number and expiration date). Failure to secil e coverage is required tinder Section_'SA of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1.500.00 alit or one-year unprisolmlent, as ut"ell as civil penalties in the form of a STOP WORK ORDER and a file of up to S250.00 a clay against the violator. Be advised that it copy of this statement nlay be forn<arded to the Office of Iivestigations of the DIA for ulstuance coverage verification. I do hereby certify ander the pains mid penalties ofperjirrr that the information provided above is true and correct. x/-, I r7'� Date_._ — --- — -- Phone 81 245-4900 or 617 571 90 1.56 Official nse only. Do not)trite in this area, to be completed by ci{r or town official. Citv or Town: Permit/License Issuing Authorih (circle one): 1. Board of Health 2. Building Department 3. Citi%Tost u Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other C'outact Person: Phone._.: The Commonwealth of Massachusetts Department of Industrial Accidents 1 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 Leeibly Business/Organization Name:Santos Carpentry Address: 73 Chestnut Street-#2 City/State/Zip: Lynn, MA 01904 Phone#: Are you an employer?Check the appropriate box: Business Type(required): _ 1.❑✓ I am a employer with 2 employees(full and/ 5. ❑Retail orpart-time).* 6. ❑RestatuantBar/EatingEstablishment 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 Care4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp. insurance req.] 12.0 Other *Any applicant that checks box 41 must 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 41. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: Rapo&Jepsen Financial and Insurance Services Insurer's Address: 1103 Commonwealth Avenue City/State/Zip: Boston, MA 02215 Policy#or Self-ins.Lie.# 1053610 Expiration Date: 02-24-2017 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 certify, under the pains and penalties of perjury that the information provided above is true and correct / Sienature: >/VL ) ' ll� � n t17i Date: - J Phone#: 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.mass.gov/dia CERTIFICATE OF LIABILITY INSURANCE DATEIMMIDDff" ACORD, 03/01/2016 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 WANED,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 CONTACT NAME: Rapo & Jepsen Financial and Insurance Services ac°NIuoE : 617.783.1160 617.783.2062 1103 Commonwealth Ave ADDRESS: Boston, MA 02215 INSURER(S)AFFORDING COVERAGE NAIC9 INSURERA: Essex Insurance Company INSURED SANTOS CARPENTRY INC INSURERS: AIM Mutual Insurance Co. 73 CHESTNUT 5T APT 2 INSURERC LYNN, MA 01904 INSURERD: NSURERE: INSURER F: COVERAGES CERTIFICATE NUMBER: 03/01 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. LTR TYPE OF INSURANCE INSR yyyp POLICYNUMBER aepp MMIDD XP LIMITS GENERALLIABILITY 3ED7464 0212312016 02123/2017 EACH OCCURRENCE $ 1,000,000 COMMERCIAL GENERAL LIABILITY PREMISES Ca occurrence) $ 50,DD CLAIMS-MADE171 OCCUR MED EXP(Any one person) $ 5,000 A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER. PRODUCTS-COMP/OP AGG $ 2,000,000 POLICY F PEb LOG $ AUTOMOBILE LIABILITY COMBINED SINGLE UMI I E.accident) $ ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Per accidem) $ AUTOS AUTOS NON-OWNED HIREDAUTOS AUTOS (Per accident) $ UMBRELLA LAB OCCUR EACH OCCURRENCE $ EXCESS LAB CLAIMS-MADE AGGREGATE $ DED RETENTION $ 1 $ WORKERS COMPENSATION 10536100212412016 02/24/2017 AND EMPLOYERSHUABILRY TORY LIMITS OR ANY PROPRIETOR/PARTNEWEXECU-PNE YIN E.L.EACH ACCIDENT $ 1,000,000 B OFFICER/MEMBER EXCLUDED? ❑ NIA (Mandatory In NH) EL.DISEASE-EA EMPLOYEE $ 1,000,000 It yes describe under DESCRIPTION OF OPERATIONS below E.L DISEASE-POLICY LIMIT $ 1,000,000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Attach ACORD 101,Additional Remarks Schedule,S 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. PETER RYAN AND SON ROOFING INC AUTHORRED REPRESENTATIVE 383 LOWELL ST AUITE 2G WA EFIELD MA 01880 JOHN RAPO ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD s Peter Ryan and Son Roofing,Inc. • r IPct�ffr:Ryan�and�Son L CENSURE HIC License #: 178871 Exp. Date: 05-28-2016 Reg License or registration valid for individul use aids •N� office of Covsomc, \rfi,rs d, 0u�meT Regulation before the expiration date. If found return to: I,t i -4OME IMPROVEMENT CONTRACTOR Type Office of Consumer Affairs and Business Regulation Registration, 178871 10 Park Plaza-Suite i170 lzpiration: 5l2812016 Corporation Boston,MA 02116 PETER RYAN&SON ROOFING,INC. PETER RYAN 3B3(REAR)LOvvELL ST SUITE 2 �i ,G ,<.�,/�- _ _ -- -" PV.4KEFIELD.MA 01080 Lndersceretarp Not valid wrt t signature Massachusetts Department of Public Safety 1 CS License #: 106054 Board of Building Regulations and Standards Exp. Date: OS-17-2019 License: CSSL-106054 Construction Supennsor Specialty � PETER RYAN 377 LOWELL STREET,'� 80g WAKEFIELD MA 018 §4V';,t ..nn CA— Expiration: ! Commissioner 05/1712019 Peter Ryan and Son Roofing,Inc. Wakefield,MA 01080 i Tel:181-245.4900 %Email:RyeNlodSonNINEeom www.RyanAndsonRoonng•eom O lces: Tel: 781-245-4900 r 377 Lowell Street,Wakefield,MA 01880 Ni• Ronn plRd S81Y Fax: 781 245-4999 IIY���1'l1Yr www.PeteiNVaMndSonRoefog.com Submitted To: lob Location: Diane Cline&Mike Hastings 11 Pickman Street 11 Plcbnion Street Salem, MA 01970 Salem,MA 01970 Phene#k 419-306-6982(Diane) 508-769-5591 (Mike) Email: dianecline(i amail.com;mikehastinesQa email.com Proposal dale: August 12,2016 Revised data: October 18,2016 �l We are pleased to hereby submit this proposal to famish materials and labor,completely in accordance with the below specifications: (Additional charges may applyfor any change's not included below in proposal either by request of owner,or if Peter Ryan and Son Rooftngfrnds unforeseen circumstances that will affect the performance,quality or integrity of this job).In the event legal action is taken to enforce any provision of this agreement, the prevailing party shall be entitled to all its reasonable costs, including reasonable in-house or outside attorney's fees. Not responsible for debris in attic. SWUM* Strip entire reef to ham wood and re-shim ile: $8,180.00 • Strip existing shingles down to bare wood • Check for rotted wood and replace(at time&material • Nail down any loose wood • Install ice&water shield to first 6-feet,and in all valleys and around any protrusions MW • Install premium synthetic underlayment(in place ofstandard 301b.felt paper) BBBa • Install all new 8"white drip edge on perimeter and step flashing,where needed • Install manufacturer suggested starter course of shingles • Install GAF Lifetime/architectural shingles in color of Pewter Gray • Cap roof with manufacturers suggested cap(GAF Timbertex®) • Properly flash any protrusions and all new pipe flanges,ifany on roof Remove holivents and hoard holes then shingle ever Knock down from chimney to Just below roof line,close hole then board and shingle over Rebuild apprmdmately 5 course of bricks from Me top down on rear chimney and point as needed Install I Rroanvent Clean up: • Cover area with tarps to minimize debris and remove debris related to work • NOTE: Please cover any belongings in the attic,as they will get dusty,if applicable ..u ... ..�,. .. .P'.L91 PC-@}£all _1_,v .. . .. t ° - I Is'payment due upon signing:-$2,680.00 Total Cost 8180.00 Total balance due upon completion: $5,500.00 Kindly remit payment to "Peter Ryan'.Thank you? Respectfully Submitted by' ✓ r Accepted by: tX.-.k(X,;q Our craftsmanship is 100%guaranteed for I =years. All rrantees are through the manufacturer.All warrantees will be null&void if job is not paid in full. Peter Ryan and S ofing,Inc.License#178871 1 Thank you for letting us serve you!!! cc: Evan