54 PROCTOR ST - BUILDING INSPECTION q 8 oa Ck< t 30 3
D
The Commonwealth otll �li�l � S
Board of Building Regulations and Standards CITY OF
Q ALEM
Massachusetts State Building1Cod�j#� C,MI},, 1 S Revised Mar
Q O�I CC 1011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
- -' This Section For Official Use Only
Building Permit Number. - -Date Applied:.
31 �
Building Official(Print Name) ,_Signature I k.V �r << Da
:a SECTION 1: SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers
S J?ru 6�raf Z)T•
L la 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`
2.1 Owner of Record:
i3uE t y1+IE b�Dpt)X 7►4Lf�1 �A•1.ut ®t°l`ZD
Name(Print) City,State,ZIP
S A'or—I'o2 S C . lr/7•3 2--4 —0J (�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed World: D S OD .B/1'
ocrr To 4"44XI Ors &u»4=�
ukr--3
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 $ Total All Fees:$ -
Suppression)
� Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ / !/ Voo ❑paid in Full e ❑Outstanding Balance Due:
�-�- 01 142-3 - 6-1 1 S
'_• SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
/�/ ak4 t�,z � ShaOisP� License Num er Expiration Date
Name of CSL Holder
3 3 t_.,0. T&oa 37f- List CST Type(see below)
No.and Street -- T Description,
O P Y � ®,�� U Unrestricted(Buildings s u to Ring
cu. R.
,fir/Zy �//Z R Restricted 1&2 Famil Dwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7/�•��i2 d /�d NST C%///UZOM I I Insulation
Telephone Email address A' D Demolition
5.2 Regis/tered Home Improvement Contractor(HIC) /4,2 ,7f�y
eonotor HIC Registration Number xpuation Date
HIC Company Name or HI Registr nt Name
33 ct yr - r N.761V:i key.
No.aad,S[r �� ,, 1pin f 1p oA gle$ Email a ress
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 .......... No...........❑
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 J� / 1) 1-4 C"rS-F .
to act on my behalf,in all matters relative to work authorized by this building permit application.
3_ .� ^ 1 (_
Pr wner''s amN a(Electro c Signat e) Date
SECTION 7b:OWNEW 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 ' this applicau is true ccurate to the best of my knowledge and understandin .
3 3� b
Print Owner's or Authorized Agent's N e(Electronic Signature) I I Date
.., 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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
1
1
1
i 1
1
' ' 1
V6N)ry
!
0000000
1
1 1 1 1
i
1 1 1 ' Y •
` I
1 ,
I �
, 1 �
,
_
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organization/Individual): '-}-
Address:
City/State/Zip: z' Phone#: (_ g l og
Are you an employer?Check the appropria box:
[14.
of project(required):
I.MJ am a employer with_employees(full and/or part-time).• New construction
2.0 I am a sole proprietor or partnership and have no employees working for me in Remodeling
any capacity.[No workers'comp.insurance required.]
3. I am a homeowner doin all work m self. ] Demolition8 y [No workers'comp.insurance required. t4.❑I am a homeowner and will be hiring contractors to conduct all work on my properly..I will Building additionensure that all contractors either have workers'compensation insurance or are sole Electrical repairs or additionsproprietors with no employees.
lumbing repairs or additions5.�I am a genera]contractor and I have hired the sub-contractors listed on the attached sheet.These sub-contractors have employees and have workers'comp.insoranc,l oof repairs6. We are a corporafion and its officers have exercised then right of exemption per MGL c ther
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 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.
:Contactors that check this box must attached an additional sheet showing the time of the subcontractors and state whether or not those entities have
employees. If the sub=contactors have employees,they must provide their workers'comp.policy number.
lam an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_ 5691
Policy#or Self-ins.
.Liicc..#: �I�, ^ p 9q"r297-D �^O So Expiration Date: ,i�' '^'tj ^•,� [A.�
Job Site Address: ,5 O I��Z�jC i ' (Z S`� City/State/Zip: �yt Lyt�v` Ut/II,Q- d 1'7D
Attach a copy of the workers'compensation policy declaration page(showing the policy number and Aspiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a 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 verific 'on.
I do hereb Ar�un i �ps jRerjury that the information provided above is true and correct.
Si en Date: rwl,
Phone M r"
FAuthority
only. Do not write in this area,to be completed by city or town official.
n: Permit/License#
hority(circle one):Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
son- 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."
i
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 confirmationof 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)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 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
I 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
1
CONSTRUCTIQN
33 Central Street,Peabody; MAC 01960
(978)532-8188-FAX(978)532-7477
www.tnydandhconstruction.com
Construction Contract
This agreement made this__?,-Kday of , 2016 by and between LeAnne
and Blake Maddux of 58 Proctor Street, Salem, MA herein referred to as "Owner", and D
& H Construction Company, Inc., of 33 Central Street, Peabody, Massachusetts, 01960,
Mass. Contractor Registration No. 102798, herein referred to as "Contractor". Owner and
Contractor in consideration of the mutual covenants hereinafter set forth agree as follows:
Contractor shall furnish all labor and materials necessary to perform and complete the
work described below upon the following described property, which owner warrants he
owns, free and clear of liens and encumbrances: 58 Proctor Street, Salem,MA.
The work, which shall include all of the labor and materials necessary for the completion
thereof, shall consist of the following:
BATHROOM
Remove and discard all existing tile and wallboard/tile base in tub and shower area as
specified.
Remove and discard existing tile on remaining walls and floor.
Remove and discard existing tub/shower mixing valve and water supply from floor up.
Frame existing window opening as specified to close height approx. in half of existing
size.
Supply and install one new all vinyl premium venting awning/hopper or equal.
Install new fiberglass insulation on exterior wall.
Supply and install new Symmons valve, spout and shower head or equal.
Supply and install one new Panasonic exhaust fan and vent with light.
Install Owner supplied 30"x 60"tub.
Install all rough plumbing for new shower valve and water supply lines.
Install all rough plumbing for new vanity/sink and toilet. .
Install all rough electrical as needed for ceiling light/exhaust fan, two lights over sink and
GFI safety outlet.
Supply and install duro roc/14ardie or equal water resistant wallboard to make walls of
tub/shower and floor ready for tile.
Frame out recessed niche in shower wall as specified.
Remove existing shower soffit prior to new blue board.
Install new '/2" blue board to walls and ceiling not getting tile and make ready for plaster.
Skim coat walls and ceiling with plaster finish excluding tub/shower walls getting new
tile installed.
Install Owner supplied tile,bull nose, and grout to walls of tub/shower area and floor.
Remove and discard existing medicine cabinet and wall light above cabinet.
Remove and discard existing toilet and sink.
Install new Owner supplied vanity with new sink and Owner supplied faucet.
Install Owner supplied toilet.
Install Owner supplied medicine cabinet and light.
No tile installed on shower ceiling.
No tile on walls except for shower area.
No new venting or sewer lines included.
No painting included.
Clean and remove debris generated from work performed.
Contractor shall perform the work in conformance with such plans and specifications, if
any, as have been provided by the owner or the contractor,which plans and specifications
shall be deemed incorporated into this contract by reference, and will do so in a
workmanlike manner. Contractor is not responsible for performing any work not
specifically referred to in this contract.
Owner shall pay contractor the sum of Fourteen thousand dollars,
($14,000.00), in installments as follows: } lb 3 3 l b
($4,667.00),upon signing this contract. 9 l
($4,667.00), upon 50%completion
($4,666.00), upon completion of the remainder of the work called for under this contract.
In the event any installment is not paid when due, contractor may stop work without
breach until payment is made and for five (5) days thereafter. In the event any installment
is not paid within ten(10) days after it is due, Contractor may, at its option deem this
contract terminated by the owner and may take such action as may be necessary,
including initiating legal proceedings,to enforce its rights hereunder.
At all times during construction, Owner shall provide and maintain free and unobstructed
access to all areas of the site where the work will be performed and shall provide, at
Owner's sole expense, water and electrical service.
Due to the nature of construction there may be some damage to the landscaping.
Dumpsters and heavy equipment may be necessary and may cause damage to the
driveway blacktop and lawn. As long as Contractor shall exercise reasonable care, it shall
not be liable for any damage to the above-mentioned landscaping, lawn, or driveway.
NOTE: Hammering to walls, roofing, and around windows may cause dust in attics,
plaster cracks, and things falling.
Contractor shall not be responsible for claims for damages to persons or property
occasioned by Owner or his agents,third parties, acts of God or other causes beyond
contractor's control. Owner shall hold contractor completely harmless from, and shall
indemnify contractor for, all costs, damages, losses, and expenses, including judgments
and attorneys fees, resulting from claims arising from causes enumerated in this
paragraph.
1. All work shall be completed in a workmanlike manner and in compliance with all building codes and
other applicable laws.
2.To the extent required by law all work shall be performed by individuals duly licensed and authorized by
law to perform said work.
3. Contractor may at its discretion engage subcontractors to perform work hereunder,provided Contractor
shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this
Contract.
4. All change orders shall be in writing and signed by both Owner and Contractor. Contractor shall be
responsible to provide only the work described in this contract and in such change orders as may from time
to time be agreed to between Contractor and Owner. All change orders shall specify in detail any
additional work called for and the price for such labor and materials as shall be necessary to complete such
additional work.
5.Contractor warrants it is adequately insured for injury to its employees and any others incurring loss or
injury as a result of the acts of Contractor or its employees and subcontractors.
6.Contractor shall at Owner's expense obtain all permits necessary for the work to be performed.
Contractor shall not,however,be responsiblefor obtaining any variances or other zoning relief,or for the
cost thereof,as may be required to enable the Contractor to obtain a building permit.
7. Contractor shall not be liable for removal,recalibration,or replacement of alarm systems,satellite
dishes,wall or window air conditioning units or faulty cable, electrical,and telephone connections.
8. Contractor shall not be liable for any delay due to circumstances beyond its control including strikes,
casualty or general unavailability of materials or the discovery of the conditions or defects upon the site or
in the structure(s)thereon not known to the Contractor at the time of execution of this contract and which
may be discovered during the course of the Contractor's completion of the work. In addition,the Owner
acknowledges and agrees that in certain remodeling work the demolition of portions of the pre-existing
structure may reveal additional defects,conditions or the need for additional work which must be repaired,
altered or carried out in order to commence or complete the work called for in this contract. In such case,
the Owner agrees that the duration of the work and any scheduled date of completion may vary from that
which has may be set forth herein and Owner agrees execute a change order detailing the cost and scope of
the additional work necessary to repair,correct or alter such additional defects and conditions.
9. Contractor warrants all work for a period of 36 months following completion.This warranty is void if
payments have not been made to Company Agent or Foreman when due and in the full amount specified.
10. Owner agrees that in the event it becomes necessary for Contractor to collect any payments called for
hereunder or to enforce any provision of this agreement,Owner shall be responsible for the costs of such
ent including reasonable attome 's fees.
collection or enforcement, g y
You may cancel this agreement if it has been signed by a party thereto at a place
other than an address of the seller,which may be his main office or branch thereof,
provided you notify the seller in writing at his main office or branch by ordinary
mail posted, by telegram sent or by delivery, not later than midnight of the third
business day following the signing of this agreement.
Signed this "/ day of-�V, 2016.
Company Representative
wner Owner
L7JOdd
pa3'° 096LO HW',(pogead� is Iellua0 C£k aide4S Iae93iW;G µ ONI OO NOIlOfRi1SN00 H 9.0 9L(fLIZ/L- uo4Wldz _OYN1NO0 1N3W3AOW _sauuvV114N Jamnsuo03o aag}p.�no/TJvamrtoarrauv�zr� a
v Massachusetts -Cepzrtment of Public Safely
Board of Building Regu'ations and Stan:nrd!s
Construction Supenisor
License: CS-068059
MICHAEL M SIWHtO
i 33 CEP VTRALST' 4
4 PEABODY MA ff1960
Expiration
Commissione, 06/17/2016