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5 RAVENNA AVE - BUILDING INSPECTION (3) \s The Commonwealth of Massachusetts J Board of Building Regulations and Standards CITY OF Massachusetts State Budding Code,780 CMR SALEM Revised Mar 2011 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: BuildmgOfficial(Print Name) '•.s Signature , " s, Date `. SECTION 1: SITE INFORMATION r, 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number 13 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? Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record• mom �1�tcHe o � Name(Print) l� City,State,ZIp y 9 S IC.0.UP_h Nq A0P--h11L �_l •�7�K- No.and Street • Telephone Email Address ,,`,SECTION 3:DESCRIPTION OF PROPOSED WORle(check all that apply) New Construction❑ Existing Building%, Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work : Q$_uv1 e v o r_n (0,( z g Ar l S 41 u 0 r, ,` SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Lab or and Materials 1 -- fi 1.Building $ a I. Building Permit Fee: $ Indicate how fee is determined 2.Electrical $ ❑Standard•City/Town Application Fee ❑Total Project Costa;(Item 6)x multiplier x ` n r'• 3.Plumbing $ 2 `Other Fees $ " 4.Mechanical (HVAC) $ List 5.Mechanical (Fire Suppression) $ Total`All Fees: $ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $6, 00 ❑Paid in Full ❑Outstanding Balance Due CAL(- WgEJ RED`; b I - ,TS 3 • vLiyc" - D . SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) ��g I H I �'.�M � -�a License Number Expira lion Date N e of CSL Holder List CSL Type(see below) Type Description No.and Strcel t U Unrestricted(Buildings up to 35,000 cu.ft. Restricted 1&2 Family Dwelling t�.l-A City/I'own,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances ��(•�S�•®Lttl.b Ar�c1uC 1Q� a�( Cr un I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 14,5 A3 1 12-A &adk C-r Pw D HIC Registration Number Expiration Date HIC CompatV Name or HIC Registrant Name No. and Street Emai dresdl�s 1w n h . lhkh Cl l �l�1 1 �l• �53.o" Crown,State,ZIP T— 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 PER\MIfTn I,as Owner of the subject property,hereby authorize AWcW & V.A h P Ro C FC V�'\Gb%4T R= to act on my behalf,in all all'l matters relative b ork authorized �by/this building permit application. X A/� �yl�[- ( ,//mil �0/.U,f S� l �j • Z 0 ( `� Print Owner's Name(Electronic SignatmW — �� Date . . SECTION 7b: 6wNrnL0FAUTHOR1IZED 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. JR;Ana1 Cov,Ai S- (5- Zo ( 1-1 or Authorized Agent's Name(Electronic Signature) 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.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"maybe substituted for"Total Project Cost" Proposal (y� Bay State Weatherization & Construction LLC. DATE:April 30,2014 89 Newbury Rd. Rowley MA 01969 Project Manager Phone 508-330-6646 Randy Comito kelly.goodhue@yahoo.com 781-953-0446 NSCAP For: Pam Shute Attn: 5 Ravenna Avenue Chuck Salem,MA Main Roof: 1. Strip 2 layers of shingles on unfinished section of roof 2. Apply Ice and water around perimeter of the roof 3.Apply tar paper covering the rest of the roof 4. Install 150 feet of white drip edge metal 5. Apply approximately 1200square feet of CertainTeed 30 year architectural roof shingles 6. Install flashing along with tar to secure chimney 7.WII use new pipe boots for any waste pipes 8.Will dispose of all Debris 9..Rear section of roof needs new plywood go over Cost asphalt roof$6200.00 Rubber roof 1. Strip all rolled roofing 2. Apply 1 inch insulation board covering entire area of roof 3. Fasten with disks and screws all insulation board 4.Apply white 3 inch bald cleat metal around perimeter of roof 5. Apply approximately 300 Square feet of.060 rubber membrane to insulation board gluing entire area 7. Seal .060 rubber membrane to 3 inch bald cleat metal using black glue and 6 inch neoprene flashing 8. Caulk all seams 9. Dispose of all debris related to this work Cost$1500.00 Total cost $6,700 Res&ctfully s mitted, Ra y Co o, roject Manager CITY OF S.U.EMs TNLA SSACHusETTS • BuummiG DEPARTMEINT 120 WASHINGTON STREET,3"a FLOOR 0 TEL (978)745-9595 FAX(978)740-9846 KI\BERLEY DRISCOLL MAYOR T HomAs ST.PiERRB DIRECTOR OF PUBLIC PROPERTY/BUII.DING CO%L%USSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Name(Business,Organization/individual): (StIt In ( (i Address: 2 Ulu. City/State/Zip: dZoz\ di Dlgt Phone Are you an employer?Check the appropriate box: Type of project(required): 1.ta 1 am a employer with -17 _ 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2_❑ 1 am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These subcontractors have 8. Demolition working for me in any capacity, workers'comp.insurance. 9. Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.0Electrical repairs or additions required.] officers have exercised then 3.❑ I am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions myself.[No workers comp. c. 152,§1(4),and we have no 12.0 hoof repairs insurance required.] t employees. [No workers' 13 [J Other comp. insurance required.] *Any applicant that chocks box#1 must also till out the section below showing their worker'wmpenation policy information. I I inmeowms who submit this affidavit indicating they am doing all work and then hire outside contractor must submit a rmv alydavil indicating such :Contracmn that check this box must attached an. lWilional sheet showing the name of the subcontractor and their workers'comp,policy infonnation. l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site information. insurance Company Name: AC-10,1 A Policy#ur Self-ins. Lie.#:pper e Z%2 n n R a'1 Lin— a 1 Expiration Date: S I l y Job Site Address: S I�QL' nno QVZ Ciry/State/Zip: (MIA 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 ofa fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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. l do hereby ce fy alder/ sins and penalties of perjury than the information provided above is true and correct S', :n Ire Q IgA.. Date: Phnn #: p OJficiad use only. Do not write in this area,to be completed by city or town offciaL City or Town: Permit/lAcense# __ Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: __ Phone#: 0511912014 12:19 Lauranzano Insurance Agency ffW0 P.0021002 ACO P CERTIFICATE OF LIABILITY INSURANCE F DTE(M 5119/2014 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DO ES N OT AF FIRMATIVELY 0 R N EGATIVELY AM END, E XTEND 0 R AL TER T HE C OVERAGE AF FORDED 8 Y T HE P OLIC1eS BELOW,T HIS C ERTIFICATE 0 F I NSURANCE D DES N OT C ONSTITUTE A C ONTRACT B ETW EEN THE I SSUING I NSU RE R(S), A UTHORt2ED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the POIICY(IeS) must be endorsed.If SUBROGATION IS WAIVED, subject to the terms and Conditions Of the policy, certain 'Policies may require an endorsement. A statement On this Certificate does not confer flights to the Cartificate holder in lieu Of Such endorsemenC s . PRODUCER Lauranzano Insurance Agency " Berkte Asai ned Risk Sami 107 Dodge St .Na,E 80 4.4689 .wa,. OKI 215-81IS ADOREBSI POII Services berkIe risk.DOm Beverly.MA 01916 INSURE AFMR01 OOOVEAAC NNCP INSURER A INSURED Bay State Weatherization and Construction LLC INSURER S: INSURERC 89 Newbury Road INSURER 0, weUReR e' Rowley MA 01969 INSURERF: COVERAGES CERTIFICATE 8 R: REVISION NU B THIS IS TO CERTIFY THAT THE POLICES 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, EXCLUSIDINS AND CONDITIONS OF SUCH POLICIES, AMITS SHOWN MAY HAVE BE N REDUCED BY PAID CLAIMS, T TYPE OF INSURANCE INSR MO POLICY NUMBER NNIOD vVY Mur Drvrry LIMITS GENSRAL LIABILITY EACH OCCURRENCE $ COMMERCIAL CENE4AL MAPRITY 0 MADE O RENT O $ PReMI ES Ea m nw ❑CLAIMS-MAOE ❑OCCUR ❑ ❑ MED e P(my One ere n $ PERSONAL a AOV INJURY $ NE AL AGGREGATE $ CENT,AOOREOATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGO $ POLICY El PEG ❑LOC g AUTOMOBILE LIABILITY ❑ ❑ E xcl ent 1 is ANY AUTO BODILY INdURYALL O Pet ercon g AUTO$"ED ❑8CHEOULED AUTOS SO ILY NJURY Per accWon $ HIRED AUTOS ❑NOAUTOSNAW"Eo PROPSRTV DAMAGE per accMAnl $ ❑ $ UMBRELLA 5AB OCCUR EACH OCCURRENCE $ EXCESSLIAB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION C 5 A U. AND EMPLOYERS'LIABILITY YIN TORS LIMIT 0 Eft ANY PROPRISTORIPARTNERIEXEOUTIVE © ❑ El EACH ACCIDENT $ 100000.00 E/A OFFICMEMSER EXCLUDED? Am WC-20-20-004738-01 6/14/2014 6/1412015 4y0 n,,40,y 0y In"HJ O E. .DISEASE-EA EMPLOYEE $ 100000.00 I! neunder DESCRIPTION OF OPERATIONS WW. .DIB ASE-POLICYLIMIT $ 5000 0.QQ ❑ ❑ DESCRIPTION OF OPERATIONS I LOCATIONS I V HIC ES(ALIEee ACOR3 ItT,Addilionel anNAa ehede a,i mote aPAaIs mwiodl Election Category Election Status Name All EntifieaMsuneft Other Exclude Mark Goodhue Say State Weatherization and Construction LLC CERTIFICATE HOL09A CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE City of Salem EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN 120 Washinglon Street ACCORDANCE WITH THE POLICY PROVISION$. AUTHORIZED EPRES 1 E Salem MA 01970 0511912014 12:19 Lauranzano Insurance Agency (F4 P.0011002 AC CERTIFICATE OF LIABILITY INSURANCE DA7a o101•YYI L� 0 119 5�194 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE D098 NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED REPRESENTATIVE OR PRODUCER AND THE CERTIFICATE HOLDER. IMPORTANT: If the cert)ficate holder Is an ADDITIONAL INSURED,the polioy(ies)must be endorsed. If SUBROGATION IS WAIVED,subject to the terns 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 endorsemen s. PRODUCER AC Lauranzano Insurance Agency F"o" (978) 921-8420 1F AIC NA,I9,81 9E1-919A 107 Dodge Street ApDRESS,Oi11°' LL@Lauranaaao.com INSURE INSUREWS1 AFFORDING COVERAGE NAIC9 Beverly M 01915- fNWMRAAtlantic CaItualty Insurance Cc INSURED Bay State Weatherization 6 INSURER a: Construction LLC INNAERC: 19 Newbury Road 1 uREA . IN RER RE _ Rowley MA, 01969- INSWARRF, COVERAGES CERTIFICATE NUMBER: 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 ISSUEO OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM$, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. AVok TR TYPE OF INSURANCE R Y NUMaE M D EFF FOLK: IA1ffS A GENERALUAS1IJW L143003849 9/31/2014 8/31/2015 EACHOCCURRENCE S 1 000,000 X COMMERCIAL GENERAL LIABILITY / / / / EMISE Ea caVnn E 100,000 CLAIMSWADE ©OCCUR / / / / VeD$XF Wy mv wc.I $ 5,000 PERSONAL&ADV INJURY S 1,000,000 OENERAL AGGREGATE $ 2,000,000 G NL AGOR TE LIMIT APPLIES PER: / / / / PRODUCTS•COMPIOP AGO $ 1,000,00 POUCY1ALOC / / / / NOWNO d AUTOMOBILE LIABWTY / / COMB NEO 1 L LIMIT ANY AUTO / / / / BODILY INJURY VWPerson) E ALL OWNED SCHEDULED SCHTE� LED 60 pqSNCU0HHNE{1 01LY INJURY(ib aa�denC E HIREDAUTOS AUTOS / / / / TY UPER AMA E S UMBRELLA UAB OCCUR / / / EACH OCCURRENCE $ EXCESS UAB CLAIMS•MAOE / / / / AGGREGATE E RErENnONI / / / / S WORKERS COMPENSATION 1C STATLL I IOTP- AND EMPLOYERS'LIABILm ANY PROPRISTORIPARTNERIEXECVTNE YIN / / / / E.L.EACH ACCIDENT S (Mand=My1M.NM EXCLUOFDO NIA yy@@yr. EI.DISEASE-EA EMPLOYEES OESCRIPTO Ott TONS IaN / / / / E.L.DI$EfSE•POLICY LIMIT E DESCRIPTION OF OPERATIONS I LOCATIONS I VEMCLeS(ANacn ACCRn 10i,Adtlkbnal Remarks BcheduM,i/mere APaE!le mAVlrodl CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DEUVBRED IN ACCORDANCE WITH THE POLICY PROVISIONS. City of Salem AUTHORIZED REPRESENTATIVE 120 Washington Street Salem Kk 01970- ACORD 28(2010105) 01988.2010 ACORD CORPORATION, All rights reserved. I, ---•'•INS02S•(AINS)m— .... ...The�AeORD,name•and•IGgo-are•registere&marks-of•AGORD--^-••^^- - --- --w----•-^••-- - •• f-1 Massachusetts -Department of•Public Safety s .. �' Board,of Bwlding.Regulations and Stgh4ards Construction Supen'isn>� ,+,. License: CS-075917 V is RANDEL GCOMItO 45 BOWLER ST t LYNN MA 0190f Expiration Commissioner 0 7/1 912 01 5 A ' ��e f0�nmroreeae¢(��o��1�aGtadel�ii � btyice of Cons,mer Maim&Business ftegutanon � - _` ME INIYiiv NIENTCON1rws.It1R -- egistretion: '165631 '-. TYPe xpirabon:.= 07266� - , Individual 'a RANDEL COMITO RANDEL COMITO �d - /:`.r j 45 BOWLER STREET LYNN,MA 01904 - Undersecretary