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72A PROCTOR ST - BUILDING INSPECTION (3) i 1 The Commonwealth of Massachusetts RECEIVED n Board of Building Regulations and Sta d EC T I�)1A� $EIS !�(`F$FOR QC^f ( rVTl7NICIPALITY e Massachusetts State Building Code,780 CM edition USE - Building Permit Application To Construct, Repair, Renoy{��sOrrldetpe�is}� :101sed January One- or Two-Family Dwelling (( JJCCYY GG 1, 2008 (� This Section For Official Use Only Building Permit Number: Date Applied: Signature: Building Commissioner/Inspector of Buildings .Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes_ no Map Number " I `Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq tl) Frontage In) 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 O err of Record/• JJ A✓I God �p1 an f?3✓ S� Name(Print) Address for Service: 47 qud Signature Telephone 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 Other ❑ Specify: Brief Description of Proposed Work`: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: - Official Use Only - Labor and Materials I.Building $ L Building Permit Fee:$ Indicate how fee is determined: 2.Electrical g - ❑Standard City/Town Application Fee ❑Total Project Cost"(Item 6)x multiplier x 3.Plumbing S 2. Other Fees: $ • 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount_ 6.Total Project Cost: $3 s'�� _❑Paid in'Full ❑Outstanding Balance Due: L Tb T SECTION 5: GONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) /��t� 0�. oZ0I� �4�dGl / 6�j G� License Number Expiration Date Name of CSL-Holder .ffff-------�� / en 4'/A List CSL Type(see below) Add es , Type Description U Unrestricted(up to 35,000 Cu.Ft.) Signature R Restricted 1&2 Family Dwelling N1 Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 is red a Itltpri eme'�nt/Contr�gfor(HIC) /z✓�'`� tWYbkgYJ<// ! J HIC Company Name or H C Regi ra Name Registration Number 1 Addre Expiration Date tgnature Telephone SECTION 6:WORKERS'COiVIBENSA•TION INSURANCE AFRIDXWT 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 Iss tce of the building permit Signed Affidavit Attached? Yes .......... No__.....00 , S 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APRLIES FOR BUILDING AR & Y. I, as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authorized by this building permit application. Signature of Owner Date .SECTION 76:OWNER" OR AUTHORIZED A GENT=DE ON as Owner or Authorized Agent hereby declare that the statements and informatiog on"the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signamre clf Owner or Authorized Agent Date (Signed under the paills and penalties of au - 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 110_R6 and 1 IO.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" Y The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www,tnassgov/dfa Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Businecs/Orgmi/'rat /,ioonilndividual): tom' 1 ' Address: (—otwK2g17�0e -� City/State/Zip:,�jt/et'S / /d a/9a3 Phone#: 77��Lt�� Are you."employer?Check the appropriate box: Type of project(required): 1.❑I am a employer with 4. ❑ I.am a general contractor and 1 6. ❑'New construction employees(full and/or part-time).• have hired the subcontractors 2.V?f am ship a sole wproprietor mp o partner- Iisted'onTheattached sheet:t 7. ❑Remodeling. ship and have no employees These subcontractors have 8. ❑Demolition working for mein any capacity. workers'tromp.insurance. 9. [-]Building addition [No workers'comp.insurance 5. ❑ We are acorporation and its 10.❑Electrical repairs or additions required] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 1 LC]Plumbing repairs or additions myself.[No workers'comp. c.152,.§1(4),and we have❑o 12.Q Roof repairs insurance required.]t employees.[No workers' 13.❑Other comp.insurance required] - •Any applicant niztchucks bat gl mosi also rill out the suction below cimwin8.thcir workus'cowl+msaaon l+uliq ivfarvunort t Hom..m who submitthiseM&At inlicating they arcthing ell wort sod than hit-ouaide-,m um,most submit a new affidavit iWicatingeach. :Conrtactva that check this box must mmched an additional sheer showing the name ofau'eubcontradon oust theirworkm`comp,policy informmion, tam an employer th it is providing varkers'compensation huuronce for my employees. Bdoro b 4o policy and job site informadam Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Atmch a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). ailum to seems,coverage w required under Section 25Aof 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 todhe Office of Investigations of the DIA for insurance coverage verification. I do hereby ceni j vender the p- O s and ndt that the information provided aabov is true dud correct. S t e�� Dale: 42 /��.! �S /0.?-7 Official ase only. Do not write in this area,to be completed by city or rotor,official City or Town: Permit/Liceme# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Fdectrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: `l. 4 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 hive, 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¢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;.constfudion or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because ofsuchemployment be deemed to be an employer." MGL chapter 152,§25C(6):aiso states that"every slate or beat liceopdngiaggncy aludl withhold the issuance or renewal of a license or permit to operate a business or to routine[build ngs in-the commottwealth for any applicant who has not prudirced-acceptable evidence of'compllance widutha.brsuratte coverage required." Additionally,MGL chapter 152;:§25C(7)slates"Neither dratcoimnonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work unliIacceptab)e evidence of compliance with the insurance requirements of this chapter have been presented to the contracling;authority." Applicants Please fill out the workers'compensation affidavit completely,by clieeckih$-the.boxes that apply to your situation and,if necessary,supply sub-contractor(s)mante(s),addresses)andpbone.n irntaQs).along with their certificate(s)of insurance. Limited Liability t'.ompanies(LLC)or Limited Liability�Pertnerships(LLP)with no employees other.than the members or partners,arnracit required to tarty workers'compensation insurance. If an LLC in LLP does have employees,a policy issequiied. Ile advisedthat this affida inaptansuhmitteal igthe Department of Industrial Accidents for confiriivtioa of iiisurance.covemge. Also'be silyd to sfgb`anit-datette affidavit The affidavirshould be returned to the city o6towa'that the application forthe permitorliceirm is,being regtrested,not-the Department of Industrial Accidents. Should you have any questions regarding the law:orifyou 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 provideda space at the bottom of the affidavit for you to.fill out in the event the Office of lnvestigationsfias to contact yourregarding the applicant. Please be sure to fill in the pemtiWceme number which will be used as a refemmst number. In addition,an applicant that most submit multiple peranit/license applications in any givenyear,ueard.only.submit one affidavit indicating current policy information(if necessary),and under"Job Site Address"the applicaneshould 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{o 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 obtamingaaicense m permit nohmlated.to any business occommercial venture (t.c.a dog license or perinit to burnleaves etc.)said person is NOT requited 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 Office of Investigations 600 Washington Street Boston,MA 02111 Tel.4 617-727-4900 ext 406 or 1=877-MASSAFE Revised 5-26-05 Fax N 617-727-7749 www.mass.gov/dia -Office of Consumer Affairs & Business Regulation- Mass.Gov - - Page 1 of 1 The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) '/�`•• t 1 Consumer Affairs and Business Regulation A, vF Home Consumer Rights and Resources Home Improvement Contracting HIC Registration Complaints JJILi Registration# 150758 Home Improvement Contractor Registrant Registration Home Page Name MICHAEL FITZPATRICK Address 7 LAWRENCE ST. City, State Zip DANVERS, MA 01923 Expiration Date 04/25/2016 Complaints Details No complaints found for this registrant. You can also view arbitration and Guaranty Fund history. Back To Search ©2012 Commonwealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. https:Hservices.oca.state.ma.us/hic/licdetails.aspx?txtSearchLN=51828 9/22/2015 Massachusetts-Department of Public Safety Board of Building_Regulations and Standards• k Construction Supervisor Specialty License: CSSL-104158 aJSgTT.c O n r I F_ Michael T Fitzpat�jc�k 7 Lawrence StreeC 3 Danvers MA 01913 z � y J� `1 JI'19n Expiration _r COrrenissioner 06125/2017 .", ` ' Olfc2s b"' r{C'lf�'r �`l�s 1 1 ' HOME IMPROVEMENT CONTRACTj't' r Registrat�on, t50758F r ,Types "� .Expiration 4f25 dividual .. . l /�.�;LET l � t i�q�•.= NVE ,MA`t11923'° ,e < 4,-!nm sc: FI- sx w� MICHAEL FITZPATRICK 781-983-1027 Goddard 72a Proctor St. Salem, Ma. Estimate: • Install drip edge along rake edges on main roof area. • Re shingle with 30 year shingles of customers choice. • Install new lead around chimney. • Install new vent pipe boots and louver vents. PRICE INCLUDES ALL MATERIAL, LABOR AND CLEAN UP $3,500.00 $2000.00 Down Payment�r4GtGio� O�{al IIS 00S $1500.00 Upon Job Completion Michael Fitzpatrick stomer Signature