26 RAYMOND RD - BUILDING INSPECTION (2) t !1-T a�
!ILI The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
%)
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar1011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: DateLA lied:
Building Official(Print ame) Signa. Date
SECTION 1:SITE IN _ RMATION'
1.1 PropertyAAddress: 1.2 Assessors Map&Parcel Numbers _
l.la is this an abeepted 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(it)
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 Rfie ord:
l�? /c lri lzK 1 r eT Z/? W,28 El Qd . Q5;L Leiyj
Name(Print) City,State,ZNJ
N�nd Str 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 Work': AZd(, 51n/AJe, .4y4 711w- TjZAri .
SECTION 4:ESTIMATED CONSTRUCTION COSTS '
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ oe I. 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 $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:_
6.Total Project Cost: $ �� Zj10 0 Paid in Full 11 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 11 �
VGVHe r TLr.C(/.i s License Number Ex Illation Date
Name of CSL Holder
St
/� II List CSL Type(see below)
3 J t areet.,,� w ,( sr T Description
No.and -
L 1 State, 1� U Unrestricted2 Family
(Buildings u el ing cu.ft.
&� jyI-1—[` ' D Restricted I&2 Famil Dwelling
Cityll'own, Z P M Masonry
RC Roofing Covering
WS Window and Siding
b// a SF Solid Fuel Burning Appliances
�"n 3r'f- 3 �� _ iJVY)GG.c�zS,/' �„�/1!t 1 Insulation
Telephone E ad addre 7 D Demolition
5.2^Registered Home Improvement Contractor(HIC) -7 S/3
--JCL1i'1e$ 64 4 p� S HI Registratio N�r Expiration Date
HIC Company Name or HIC RegiZzt Na�F" y-y�/l ..y
No.a'n�Street _ Egii d a ess
City/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.AUTHORIZATIONTO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR AP�P—LIKES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize��`-tidts`t
to act on my behalf,in all matters relative to work authorized by this building permit application.
CfcalL(nrf✓ q'q'�J'l�
Pnn 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
contai d in this application is true and accurate to the best of my knowledge and understanding.
q 'CJ' ZOJ Z
Print 0 ner's 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. oe v/oca Information on the Construction Supervisor License can be found at www.mass.eov/des
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"
i CITY OF SM.E.N. I, UA SSACHUSETTS
• BUILDL\G DEPARTMENT
130 WASHINGTON STREET,3' FLOOR
TEL (978) 745-9595
FAX(978) 740-9W
KIJtBE tL.EY DRISCOLL
MAYOR T3 omm ST.PrERRa
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMaSSIONER
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:
60c_ It t7)sl�v5aL
(name of hauler)
The debris will be disposed of in :
�Q+L =g� U>15ti70.5r 1,�
(name of facility)
(address of facility)
siknatard of permit applicant
date
Jcbriu0'.Joc
t
�. CITY OF Sa71.0 MI I LkSSACHUSETTS
BUILDLNIG DEPARTMENT
120 WASHINGTON STREET,Sao FLOOR
TEL (978)745-9595
FAX(978)740-9846
KIJ[BERLEY DRISCOLL
MAYOR THob w ST.PmRRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Busin svOrganizatiorvindividual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box:
Type or project(required):
1.❑ 1 am a employer with 4. ❑ [am a general contractor and i 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 sub-contractors have g. Demolition
working for mein any capacity, workers'comp,insurance. 9. Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its !0.❑Electrical repairs or additions
required.] officers have exercised then
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 LQ Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' ME]Other,
comp.insurance required.]
•Any applicant thus chttW box 91 moot also fill out the section below showing their worker'txmtpt n ottion policy infutmarion.
'I Inrneuwrrvmt who submit this affidavit indicating they am doing all work and then hire outside contractors must submk a new alRdavit indicating such
-Contractors,that check this box must anachad an additional sheet showing the name of the sub•comracbts and their wotkrn'comp,Pat icy infamtagwn.
I am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy and fob Sim
information.
Insurance Company Name:'T/li4"h� . err S _
Policy#or Self-ins.Lic.#: !O 5�,T'b —L/ Y-ZA P- — Expiration Date: �7—
Job Site Adtin;sa:— Zl0 W42h 1.I/ )eeJ - CitylState/Zip: SG,I�ZU ; AL, aJ 7
Attach a copy of the workers'coluileasatiou 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 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.
Ida hereby certify ugdeetheaains and penalties of perjury that the information provided
�above is true and correct
Si mat ue: I LL11�� Dau /
• % ZO/
OKirW use only. Do not write in this area,to be completed by city or town oJrcial
City or Towne-.._ PcrmtfR.ieenve a
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.CityfTown Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other.
Contact Person: Phone#:
• •.
ACORD. CERTIFICATE OF LIABILITY INSURANCE DATE(MMA)DIYYVY)
OB 31 2012
PRODUCER - (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
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:TRAVELERS INSURANCE
Gaddis, James WSURERB.Essex Insurance
381 Lafayette Street NSURER C:
INSURER O:
Salem MA 01970- INSURER 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 ADD'L TYPE OF INSURANCE POLICY NUMBER POLICY
MWDD/YYE PDATE MMPDDIYYN LIMITS
IM S D
B GENERAL LIABILITY ED313123 11/22/2011 11/22/2012 EACH OCCURRENCE $ 500000
COMMERCIAL GENERAL LIABILITY DAMAGE To Ea6om�irrence $ 50000
CLAIMS MADE F OCCUR / / / / MED EXP one $ 5000
PERSONAL B ADV INJURY 8 500000
GENERAL AGGREGATE 8 1000000
GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG 8 1000000
POLICY JEC 7 LOC
AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT b
ANY AUTO (Ea accident)
ALL OWNED AUTOS / / / / BODILY INJURY $
SCHEDULED AUTOS (Per Person)
HIRED AUTOS / / / / BODILY INJURY
8
(Per accident)
NON-OWNED AUTOS
PROPERTY DAMAGE
(Per accident) $
GARAGE LABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / / OTHER THAN EA ACC a
AUTO ONLY: AGG $
EXCESSA)MBRELLA LIABILITY / / / / EACH OCCURRENCE 8
OCCUR CLAIMS MADE AGGREGATE b
b _
DEDUCTIBLE
RETENTION $
A WORKERS COMPENSATION AND 6S62UB-4728P 07/06/2012 07/06/2013 X TORV IMRB ER
EMPLOYERS'UABILRY
ANY PROPRIETORIPARTNERIEXECUTNE E.L.EACH ACCIDENT a 100000
OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE $ 100000
a yea,describe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMIT $ 500000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLESIEXCLUSIONS 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 WALL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERnFK;ATE HOLDER NAMED TO THE LEFT,BUT
City of Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
INSURER.1114 4GENTS OR REPRESENTATIVES.
AUTOO PRESENTATIVE,
Cy �, 0oQ
ACORD 26(2001108) o ACORD CORPORATION 1988
INS026(alwpo Page 1 of 2
1
J.M. Gaddis Fine 26 Raymond gauthier
Homebuilding and
Construction 11
PROJECT NAM[Siding-Trim DATE: 8/24/2012
Labor Hourly Material
Description of change in work hours rate Labor total Subcontract/unit cost costs Item Total
55 -
Based on 25 Square of Siding 55 -
55 - -
Remove exisiting Siding 55 - 16,200.00 16,200.00
1/4 insulation -vapor board 55 - INC -
Hardi-board installation 55 - T&M -
new water-table 55 - T&M -
new Corner boards 55 - T&M -
55 - -
Dum ster and disposal fees 55 - INC -
55 - -
55 - -
All window trim, corner boards, and water Totals: 16,200.00
table will be billed on a Time and materials Paid to date Deposit 4,050.00
addition to this contract
Total Due 12,150.00
o ra torsi nature
w er sioature
This Change Order modifies our Agreement as above. All other terms and conditions remain the same.
Kehn Fine Homebuilding Change Order Page: 1