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29 RAYMOND AVE - BUILDING INSPECTION CX z514-0 The Commamvealth oC Vtassach}{ ),CFI+ ""' SER"" CITY OF Board of Building Regulations and 9lTf &atifs SALEM Sit / Massachusetts State Building Code, 780 CMR vtsed,tlur 2011 jj�Aga P 4. . Building Permit Application To Construct, Repair, Re t emo tsh a a One-or Two-Family Dwelling 1 This Section For Official Use Only 1 Building Permit Number: Date Appliedl - Si+ alure�. ` Date Building 011icud(Print Name). bn SECTION t:SITE INFORMATION' I.I Property Add ess: 1.2 Assessom binp Sc Parcel Numbers 1.I 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 0) Frontage(B) 1.5 Building Setbacks 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 ❑ Public❑ Private❑ — Check if es❑ P y SECTION2: PROPERTY0IVNERSHIPI' 2.1 Own"' fR or(,Iv 21 1 � I— a le k o ti&- 54-If n l s5me(P�nt) p n City,State,ZIP h're� al A-a- `�7a''7tfS DYoj 1 �� 1 �rlovt C V e-dod-C V^ No.and Street Telephone Email AdL SECTION 3:DESCRIPTION OF PROPOSED WORKS(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 : e l ce SECTION a: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Ofllcial Use Only Item Labor and Materials I. Building $ r o a 1. Building Permit Fee:5 Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing S 2`?Qther Fees: .S d. XIcchanical (fIVAC) S List: 5. Mechm:ic it (Fire S Total All Fees:S Su ression) Check No._Check Amount: Cash Amount:_ 6.Tottl Project Cost: 'S ❑Paid in Full ❑Outstanding Balance Due: + ( Q•v . ?91 - ZZ3-^ 2923 Cry—��D L z Z . SECTION 5: CONSTRUCTION SERVICES 5.1 ConstructionSupervisoybi case(CSL) og2y43 /I "16 y 1 ( e License Number Expiration Date Name of CSL Holder L f List CSL Type(see below) a60 X tS r/Z Type . Description . No.,md Street L pv� �� M� Q190 U UnresRestri tel 1 2Fami a Dwellito ng 00cu. ttJ f � 7�. R Restricted I&2F;unil Dwellin City/Town,Stat ,ZIP M Masonry RC Rooling Covering WS Window and Siding SF Solid Fuel Burning Appliances 7V Z 2 3 2223 wo 7 I Insulan Telephone Email address D Demolititioon 5.2 Registered Home Improvement Contractor(HIC) > 7 e '' —� bd 4 �, (�D7 0— _ HIC Registration er Expiration Date HIC C any Name or HIC Registmnl Name No.and Street Email address Alto- 91/a -7Sl ZO s 2 Ci /-Ibvvn,State ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L:c.152.1 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 Isluance of the building permit. Signed Affidavit Attached? Yes .......... No........... ❑ SECTION 7a,OWNER AUTHORIZATION TO BE COMPLETED WHEN. :;' OWNER'S AGENT OR CONTRACT ORAPPLIES FOR BUILDING PERNI1T- I,as Owner of the subject property,hereby authorize � t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) - Dale 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 in this application is true andpc9rate to the est of my knowledge and understanding. V- Zco- S Print Owner's or Authorized Age s Nano(Ekc6onic Signature) Date NOTES: I. 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 nut have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at www mass cov;'oca Information on the Construction Supervisor License can be found at w11w.1ass.e2yL1M 2. When substantial work is planned,provide the information below: 'total fluor area(sq. R.) '� (including garage,finished basement/attics,decks or porch) Gross living area(sq. R.) 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 i. "Total Project Square Footage"may be substituted fur"Total Project Cost" ��� CERTIFICATE OF LIABILITY INSURANCE 4/14/20 5Y"' 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 WAIVED,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 endomement(s). PRODUCER CONTACT Michael Conlon NAME: 01Vlrgill0 Insurance Agency, Inc. PNONE (781)592-5220 F� .(781)598-5957 270 Broadway MRIL INSURE S AFFORDING COVERAGE NAIC9 Lynn HA 01904 INSURERA:Providence Mutual Insurance 15040 INSURED INSURER 8-.LibertyMutual Agency Todd Protz dba Cornerstone Construction INSURER C: PO BOX 692 INSURER D: INSURER E: Lynnfield MA 01940 INSURER F: COVERAGES CERTIFICATE NUMBER:GL and WC 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. INSR TYPE OF INSURANCE POLICYN NUMBER POLICY MM1DCYEXP L LIMITS GENERAL LIABILITY rPERSONA!L& ENCE $ 500000 r 50000 X COMMERCIAL GENERAL LIABILITY occurrence E A CLAIMS-MADE OCCUR PP0057739 09 1/18/2014 1/18/2015one person) $ 5000 DV INJURY $ 500000 REGATE $ 1000000 GEN'LAGGREGATE LIMITAPPLIES PER: OMP/OPAGG $ 1000000 POLICY PRO- LOC $ AUTOMOBILE LIABILITY MINED SINGLE LIMIT Ea aaitlent ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(ParaaitleM) $ AUTOS UTOS NON-0WNED PROPERTY DAMAGE $ HIRED AUTOS gUTOS Per acdtlent E UMBRELLA UPS OCCUR EACH OCCURRENCE $ EXCESS LIAR CLAIMS-MADE AGGREGATE $ DEC) I I RETENTIONS $ B WORKERS COMPENSATION X WCSTATU- DTH- AND EMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE YIN MIA (Mandatory In NH)H) LU E.L.EACH ACCIDENT $ 100000 OFFICE(Mandatory In EXCDEDT C5-31S-387476-014 /11/2014 /11/2015 E.L DISEASE-EA EMPLOYEE S 100000 U yes,desaibe under DESCRIPTION OF OPERATIONS ba. E.L.DISEASE-POLICY LIMIT $ 500000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(Alraeh ACORD 101,Additional Remarks Schedule,U more space Is required) Carpentry Contractor - 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. Mary Furlong 29 Raymond Ave Salem, MA 07970 AUTHORIZED REPRESENTATIVE Michael Conlon ACORD 25(2010106) ©1988-2010 ACORD CORPORATION. All rights reserved. INS025/>mnnsl m Th.Ar.npn nnm¢and Innn¢ro roni¢1¢rod m¢dr¢of Arno T The Commonwealth of Massachusetts Department oflndustrialAccidents 1 Congress Street, Suite 100 tl Boston,MA 02114-2017 www.mass.gov/dia Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers. TO BE RILED WITH THE PERMITTING AUTHORITY. Applicant Information Please Print LelZibly Name Business/Or attization/Individual : O ( E ) Address: ?O 44k� u -62eZ City/State/Zip: L 1,< �,PhOne#: 7 2 3 3 Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with Z. employees(full and/or part-time).* 7. ❑New construction 2.❑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 doing all work myself[No workers'comp.insurance required.]t 9. ❑ Demolition ❑4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Building addition ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs These sub-contractors have employees and have workers'comp.insurance.= 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other 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. tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: 97 /��✓'t4,gl Policy#or Self-ins.Lic.#: q(Al Cv�,k�^'3 ( �3 p 71/'74—&&Expiration Date: �9"" Job Site Address: Z/ F�tc// tO(/� �1/e City/State/Zip: y/�l!'� /f�� f?�G Attach a copy of the workers'compen ation policy declaration page(showing the policy number and expiration 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 verification. I do hereby certify under the pains and penalties oftreirlury that the information provided above is true and correct. Si ature: Date: Phone#: 2 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.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: 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." 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 confirmation of 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/icense 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 bum 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 1 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 L QTY OF SALEM, MASSAC HUSE M 1: BLUDjNG DEPAR7WNT L 120 WAsmNGTON STREET,3AD FLOOR TtL.(978)745-9595 KIMERLEYDRISCX)LL FAX(978)740-9846 MAYOR THOMnS STYIERRE DIRECTOR OF PUBLICPROPERTY/BUR DING ODINSOSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CIVIR, Section 111.5 Debris, and the provisions of MGL c40, 5 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, 5150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature o a icant Date t' f Lynnfield,Ma.01940 P.0 Box 692 781-223-2923 todd.protz@yahoo.com Proposal Submitted To: Mary Furlong Address: 29 Raymond ave PROPOSAL Salem,Ma.01970 Phone Number: 978 317 6537 We hereby submit the following specifications and estimates for: Removal of three bay windows and one casment window and replace with double hung windows.lnstall vinyl siding on entire house. Remove and replace windows as specified above. Install 1/4" insulation on body of House,Wrap trim in pvc coated aluminm . Install vertical trim at all corners.lnstall J channel at all termination points. Install white vinyl sofitt.Replace gable vents with square vinyl vents. Removal of all debris. Install 14 pair of shutters. Stockand Labor $18,700.00 We-propose hereby.to furnish material and labor-.complete in accordance with the above specifications for the sum of: 4�; � "I .. Eighteen thousand seven hundred----------------------------------------------00/100 Dollars Payment Terms: 1/3 down 1/3 windows installed 1/3 upon completion Any alteration or deviation from above specifications involving extra-costs will be Respectfully Submitted: Fexecuted only upon written order and will become an extra charge over and above ?/ nd Ahe estimate.All agreemeri£s contingent upon strikes,accidents,'.or delays beyond control. *All Checks are made payable to Todd V. Protz Acceptance of Proposal Signature The above specifications and conditions are hereby accepted.You are authorized to do the work as specified.The payments will be made as outlined above. I Signature °i �re tpa�uo�aooemeall�-o�P/f�nmac�uwalb Office of Consumer Affairs&Business Regulafion UOM,.tI:R VEMENT CONTRACTOR eglstration �137243 Type: xpiration =102 016 Individual TODD V. PROTZ N� =G 7 � TODD PROTZ - �A) 3 RICHARDS RD ?: °'� LYNNFIELD,MA 01940 Undersecretary Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor License: GS482443 . TODD V PROTZ PO BOX 692 LYNNFIELD 111 k 019'40 Expiration Commi@sioner 01104/2016