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7 PYBURN AVE - BUILDING INSPECTION (2) 1 The Commonwealth of Massachusetts Q Board of Building Regulations and Stand RECEIVEDCITY OF Stand sALEM dMar Massachusetts State Building Code,780 Al SER li�n�edMar2011 Building Permit Application To Construct,Repair, Renovat�.Or Demolish a One- or Two-Family Dwelling [[00 )) AUG-3 All: This Section For Official Use Only Building Permit Number: Dat plied: , n Building Official(Print Name) Signature Date U ' SECTION 1: SITE INFORMATION 1.1 Pje�e` Address: 1.2 Assessors Map&Parcel Numbers �` 4Ji -r �t �rr1 Axle ry I l.la Is�n accepted street?yes_ no Map Number Parcel Number I1- 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: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ Public 0 rrivate 13 L 1 Z A CTION 2: PROPERTY OWNERSHIP' 2.1 Owner of ec p9 , 1 y l. n S Qit 0 Q sS ame City,State,ZIP �1 No.and StreA Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other X Specify. _ Brief Des do of Proposed Work'. r SECTI 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ _7 <3,5 C) 1. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (I VAC) $ List: 5. Mechanical (Fire Su ssion $ Total All Fees: $ ce Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ , SQ Ob ❑paid in Full ❑ Outstanding Balance Due: 9-7 0981 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Uqq (o 2Z 19 r-Mw\\ 0 f License Number ExpirVition loate Name of CSL Holder 2-g , � List CSL Type(see below) _ _ suf No.and Street Type Description S o l QZ U Unrestricted2Family (Buildings u el in 000 cu.ft. R Restricted l&2 Famil Dwelling Cityfrown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding q�1p o V\ SF I Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition ^5.2 Registered Home Im�eJroveme(nt�Contractor(HIC) 1 Z-T tog V \l ( �pr110 T(St,[l��n HIC Registration Nu i mber pv ion ate r HIC 2.S p lF 4 V�CCoiName 0\)9-f— \-r and Street `Y`/lasSOI��3 9'lSc9'l) Email address City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. C. 152.g 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 .........-3d, No........... ❑ SECTION 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,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. Print Owner's Name(Electronic Signature) 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 is true and accurate to the best of my knowledge and understanding. (:p 11 'W14 r X � Print Owner's or Authonzed Agent's Namotlectronic i nature) 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 3nny.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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 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" CITY OF S.UENI, NLkSSACHUSETTS • BUUMLNG DEPARTMENT + 120 WASHNGTON STREET, 3'10 FLOOR TFL (978) 745-9595 FAX(978) 740-98" KINfBERLEY DRISCOLL MAYORT1i0A41S ST.PtHRRs DIRECTOR OF PIBLIC PROPERTY/B(:mmr.COND USSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in : II \ s1 YQ Oaf ,V-� b� Q OS`�v r'\ (name of facility) (addresslof facility) signatur of permit applicant date dcbrivlLdw I Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialtv --^---. License: CSSL-099622 t PETER MILLER 281 AIVDOVER STREET e Danvers MA 01923 �. _ � P"F Ilk Commissioner Expiration 09/O6/2015 License or registration valid for iddividul use only Office of Consumer Affairs&Business Regulation before the expiration date. If found return to: 1"�V'HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation I'Reg+straUon :p 126891 Type: 10 Park Plaza-Suite 5170 �Expuat+on 51512017_ - _ DBA Boston,MA 02116 NORTH SHORE ROOFINGS - PETER MILLER _ i 281 ANDOVER ST "� DANVERS, MA 01923 '"" Undersecretary / Not va td without sign~atWre L 1\I (i' NORTH SHORE ROOFING 281 Andover St. Danvers, MA 01923 (978)977-3816 Mr.&Mrs. Galvan 07/21/15 7 Pybum Ave. Salem, MA. The following is a proposal to install a new asphalt shingle roof on the main roof as well as the window roofs at the above address , excluding the carport roof. 1)Remove the existing asphalt roof shingles down to the bare roof decking and legally dispose of the debris 2) Check for any deteriorated and /or damaged roof decking and replace if and where needed . 3) Apply 6 -ft. of ice and water barrier along the entire perimeter of the roofs as well as around all penetrations and flashings . 4)Remaining exposed roof decking will be covered with Rhino roofing underlayment . 5) Cut in and install a ridge vent on the main roof peak . 6) Install new aluminum pipe flanges on all vent pipes . 7) Install 8-in. aluminum drip edge flashing along the entire perimeter of the roofs . 8)Remove the existing tar from the base of the chimney as best as possible , grind out new joints on the base of the chimney and install new lead flashing which will be set in with mortar . 9)Install a Lifetime High Definition architectural asphalt roof shingle , color to be chosen by the home owner . 10)All roof related debris is picked up on a daily basis and will be legally disposed of by North Shore Roofing . 11) Five year warranty on labor, manufacturers limited lifetime shingle warranty . 12) Exterior siding and shrubbery will be protected as best as possible with tarps during construction . 13) Quote includes a roof permit . . TOTAL PRICE HOUSE ROOF: $7,850.00 PAYMENT TERMS 1/3 DEPOSIT REQUIRED: $2,600.00 PAYMENT DUE UPON COMPLETION: $5,250.00 CARPORT ROOF 1) Remove the existing asphalt roof shingles down to the bare roof decking and legally dispose of the debris . 2) Check for any deteriorated and/or damaged roof decking and replace if and where needed . 3) Install 6-ft. of ice and water barrier along the entire perimeter of the roof as well as along any penetrations and flashings . 4)Remaining exposed roof decking will be covered with Rhino roofing underlayment . 5) Install 8 in. aluminum drip edge flashing along the entire perimeter of the roof. 6) Install a Lifetime High Definition architectural asphalt roof shingle ,color to be chosen by the home owner . 7) All roof related debris will be legally disposed of by North Shore Roofing . 8) Five year warranty on labor, manufacturers-limited lifetime warranty on asphalt roof shingles . TOTAL PRICE CARPORT ROOF : $1,950.00 *NOTE-Deduct $200.00 if both roofs are done at the same time .* Acceptance of Proposal - By signing this proposal you have accepted all of the to a stated above . Date of Acceptance m• i 7uff Home owner r-- 1 o- N.S.R. Peter ill *Member of the Better Business Bureau* *Voted" BEST OF BOSTON -NORTH 2O10 " by Boston Home Magazine* *North Shore Roofing carries liability insurance as well as workmen compensation* *Mass. Construction Supervisor License#99622* *Mass. Reg. #128691* CITY OF S.U.EiN1, iNv'LkSSACHUSETTS • BUILDING DEPAR-MENiT 120 WASHINGTON STREET,Sao FLOOR \ TV1_ (978)745-9595 FAX(978)740-9846 KIN(BFRi EY DRISCOLL MAYOR IHoMAs ST.P>F1tR6 DIRECTOR OF PUBLIC PROPERTY/Bt1IDLNG CO%5aSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information CPlease Print Le¢ibly Name(Busines Organisation/Individual): Address: 2g 1 to via O y S2r S / City/State/Zip.? �\JQ Cam. M A O 1 q 7�_ Phone#:a-<j '21 Ito Are you an employee7 Check the appropriate box: Type of project(required): I. _g am a employer with—( 4. D t am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7. ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. 0 Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.) officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have no 12.❑Roof re airs insurance required.]t employees.[No workers' 13.V1 Odder — comp. insurance rrequired.] Any applicant that checks boat#1 must also fill out the section below showing their worker'tompensauen policy infermsdom *1 ftsmgwxts who submit this affidavit indicating they are doing all work and then hire outside contractor most submit a stew affidavit indicating such :Commton that check this box most attached an additional shest showing the name of the subeoatmctgs and their wodxre'comp,policy infwmatim 1 am an employer that Is providing workers'compensation insurance for my employees. Below Is the pollty and Job sire informwion. Insurance Company dame: '� r� TV\ C Policy#or Self-ins. Lic.#: �4)c C Expiration Date: —1 Job Site Address: l rT)t t )A1 t Vrr\ A t) 0 City/State/Zip: � 1�C) S S Attack a copy of the worker 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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 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. [do/eereby c !fy on litepaitts and penaltler of perjury that the information provided above is true and correct. ' G D te: i Phone �11 q 1,— O 1 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): I. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person• Phone#: ACORD CERTIFICATE OF LIABILITY INSURANCE 08/03/20' PRODUCER (g78) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Rose Insurance HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 958 Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A:Western World North Shore Roofing INSURER B:Hartford INSURER C: NSURER D: NSURER E: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADO'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICY NUMBER DATE MWDD/YY DATE MM/DD/YY LIMITS A GENERAL LIABILITY / / / / EACH OCCURRENCE 5 500,000 DAMAE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) 5 300,000 CLAIMS MADE ❑X OCCUR NPP8290377 06/20/2015 06/20/2016 MED EXP(Any one person) 5 5,000 PERSONAL&ADV INJURY $ 500,000 GENERAL AGGREGATE $ 1,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 POLICY PRO LOC / / fir / AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS / / / / BODILY INJURY SCHEDULED AUTOS (Per person) 5 HIREDAUTOS / / / / BODILY INJURY (Per accident) $ NON-OWNED AUTOS PROPERTVDAMAGE (Per accident) $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHERTHAN EAACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE 5 5 DEDUCTIBLE / / / / $ RETENTION $ $ B WORKERS COMPENSATION AND WCC-500615412 04/09/2015 04/09/2016 X TORV LIMITS OTH ER EMPLOYERS'LIABILITY ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICEWMEMBER EXCLUDED? 100,000 E.L.DISEASE-EA EMPLOYEE 5 If Yes, a antler S 500,000 SPECIALAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ OTHER DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE MR. 6 MRS. GALVAN INSURER,ITS AGENTS OR REPRESENTATIVES. 7 PYBURN AVENUE UTHORIZED REPRESENTATI SALEM MA 01970- . ACORD 25(2001108) ©ACORD CORPORATION 1988 INS025(ome)oe Page 1 of 2