5 READ ST - BUILDING INSPECTION `O The Commonwealth of Massachusetts
OFSALEM
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 71" edition Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
,This Section For Official Use Only -
Building Perm itNu er: _.. .. &ateAp ed
Signature: G � -/0/V .-
Building Commissioner/lnspector of Building r Date
SECTION S INFORMATION 7
loperty aA�ddress; _ 1.2 Assessors Map& Parcel Numbers
l.la 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 ff) Frontage(flu
1.5 Building Setbacks(R)
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 Qw rer' f Re o•d: � Q m_tl,1A 0�(�10
N e(Print) Address for Service: `"'11
_1A_a-Wq- t a3a
Si ature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)'`
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg._❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Workz:
SECTION 4: ESTIMATED CONSTRUCTION COSTS ' i'
Estimated Costs: -
Item Official Use Only
Labor and Materials) ° -
I.Building $ 1:=Building Permit Fee: $ Indicate how fee is determined:,
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier
3.Plumbing $ 2 Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire l - ,I
Su ression
$ Total All Fees: $ t
Check No. Check Amount:e .I s" Cash Amount:
6.Total Project Cost: $ 1 �(� p Paid in Full ' ❑ Outstanding Balance Due:
33 0/J
.,SECTION 5: CONSTRUCTION SERVICES =
5.11 Licensed Construction Supervisor(CSL) �"S' S' L
\2P� (L)I(X�J a�t4 I
� \It � c)(Aw �,as License Number Expiration Date
Nam of CSL H c ist CSL T YP e(see below)
®RC
Description
Address Unrestricted(u to 35,000 Cu.Ft.)
Restricted 1&2 FamilyDwelling
S�]nampre Mason Only
Residential Roofin CoverinTelephone - Residential Window and SidinResidential Solid Fuel Burning Appliance Installation
D Residential Demolition
5 .Re istere ome I r ent Cont c[ r IC) ,G Q �Q
H pa ame r is tName Registra[wn Number
s �g— � Expiration Da[�
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 Issuange 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 PERMIT_ 2
I, cXJ11 lLzb --
as Owner of the subject property hereby
t 1 t
authorize to act on my behalf,in all matters
sellive tow t oriz by this building permit application.
Si a e of wrier Date
t � 'V'SECTION 7b:OWNEW OR'AUTHORIZED AGENT DECLARATION
I, S aw o (>,hs6}\�\Cu as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
beha
Print Name n�
Signature of Owner or Authorized Agent �at�
(Signed under the pains and penalties ofperjury)
NOTES: v
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 MC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,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"
i CITY OF S.UEM, UksSACHUSETTS
BUILDING DEP.Ja MENT
• P• 120 WASHINGTON STREET,3w FLOOR
of TEL. (978)745-9595
FAX(978) 740-9846
��tgFRt F.Y DRISCOII.
MAYOR T Homm ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDID3G COMMSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ` Please IPrint Leeibly
Name(Busires&Organizationiindividual): `� QkmLCc
Address:
CitylStatelZ p:
A e an employer?Che h f µppropriate box., Type of project(required):
). 1 m a eMy ith 11 4. D 1 am a general contractor and 1 6. ❑New construction
employd/or par-time).• have hired the sub-contractors
2. I am a stor or partner- listed on the attached sheet.t ?• ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, 0 Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.a g
1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12�R' of repairs
q I
insurance re uired. t employees. [No workers' '—'
Other
comp. insurance required.]
13.❑
the—
;Any applicant that checks box d I most also fill out the section below showing their workers'canpensadon policy mronmadon.
'I Immeawners who submit this affidavit indicating they am doing all work and then him outside contmcron must submit a now affidavit indicating such.
'Commkson that chack this box most anached an additional sh ct showing the name of the sub-contractors and their workers'comp,policy information.
I am an employer that is providing workers'compensation insrtrancefor my employees. Below Is the pollcy and fob site
information.Insurance Company Name: eav l
, I / � / ft l k
l Policy 4 or Self-ins.Lie.#: �NCV xJ�� 4 "IlJ alp Expiration Date: 1
. . q0
Job Site Adtlress.�_� City/State/Zip: O'
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 of a
fine up to S 1,500.00 andlor 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 he forwarded to the Office of
invesligatiom or the DIA for insurance coverage verification.
/do hereby certify under the pains and penahes of perjury that the informadon pro vided//above is ruee and correct
Signature' Date: ( (A J
RipPhone
Official case only. Do not write in this area,to be completed by city or town official
City or Town: Permit/i.Icense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical inspector 5.Plumbing Inspector
6,Other
Contact Person: _. Phone#:
. NLutiachusettti - Dcp:u-rnunt of Public S,rfeh .---. ..Board of Building Regul itions :md Stan,
License: CS SL 101003
Construction Supervisor Specialty License -
-(License or registration valid for individul use only
- I before-the-expiration date. If found return to:
Restricted to: RF,WS Board of Building Regulations and Standards
One Ashburton Place Rm 1301
STAVROS MOUTSOULAS iBoston
11 WILSALEM,
MA STREET
SALEM, MA 01970
i
Expiration: 12/14/2011 ! Not V. without signature
t 1nuui-asiuncr .
Tr#: 101003' � -
fi"oul ffmwg eguldonsantan
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement,6ntractor Registration
Registration: 154326
Type: Private Corporation
Expiration: 2/27/2011 Tr# 279846
ALPINE PROPERTY SERVICES,CO INC
STARROS MOUTSOULAS
11 WILSON STREET
SALEM, MA 01970 =
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
OPS-CAI t5 5OM-07107-PC8490p p -------
✓{ee 'l�m�vnem=«ea .may✓G�trddadztureti�
Board Building Regulations and Standards License or registration valid for individul use only
before the expiration date. If found return to:
HOME IMPROVEMENT CONTRACTOR
Board of Building Regulations and Standards
Registration: 154326 One Ashburton Place Rin 1301
Expiration --2127/2011 Tr# 279846 Boston,Ms.02108
Typo. Private Corporation
ALPINE PRO P2�TiESERVICE5G0,INC.
STARROS MOU1rS0.ly`d =_;",
11 WILSON Not valid without signature
SALEM,MA 01970 -- Administrator —
® .
A` CERTIFICATE l CERTIFICATE OF LIABILITY INSURANCE
PRODUCER (617)471-1220 FAX: (617)479-5147 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Amity Insurance Agency, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND EXTEND OR
500 Victory Rd. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Marina say
North Quincy MA 02171 I INSURERS AFFORDING COVERAGE I NAICI
)NSU RED IWsuRERA:F1rst Mercury Insurance Co.
pine Property Serviceso., Inc.
INSURERS:Safety Insurance I
j Atlantic Charter Ins.' Group - I- - --
A1
-OBA Olympic - - - �� �- - INSURER Oi
515 Lowell Street I NSURERD;Gxeat American
Peabody MA 01960 INSSURERE
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 LIMBS SHOWN MAY HAVE SEEN REDUCED BY PAID CLAIMS.
IHER
DOT! pOUCY NUMBEq POLICY EFFECTIVE POLICY EXPIRATIONI LIMIT
GATE IMMOD
ENERALUABILITY EACH OCCUflflENCE 5 1.ODD,D00
X COMMEflLOLL GENERAL LIPBILR'T I IS RENTED
ISE - encA 5 50,000
A X cLMMs MADE OX OCCUR IrMPD�DOIIBG-2 L14/2009 6/14/2010 MEO EAP Aty.2 ersnn S Excluded
X Ded $10,00D I i PERSONALS AD' INJURY 5 1,000 000
GENERAL AGGREGATE 5 . 2,000,000
GENIAGGREGATEUMIT APPLIES PEfl: PRODUCTS-COMPIOP AGG 5 2 000 000
X POLICY X PRO- LOG
A!ITOMOBILEUASILnY COMBINED SINGLE LIMB 5 1,000,000
_ ANY AL
T
O C pccNenU
$ X ALL OWNED AUTOS 702651 1/9/2009 1/9/2010 BODILY INJURY �S
$X,
SCHEDULED AUTOSHIRED AUTOS flDDILY INNflY 5
NON-OWNED AUTOSCOLL Ded $1,000 PROPERTY DAMAGE 5
Coap Dad $1,000 (Pr
OAAAGEUASIUTY AUTO ONLY-EA ACCIDENT 5
ANY AUTO I I IOTHERTHAN EA ACC 5
AUTO ONLY: AGG 5
A EXCESS!UMBRELLA I EACH OCCURRENCE IS 5 000,000
X OCCUR CLAIMS WOE ICOMA000117-3 6/14/2009 6/14/2010 AGGREGATE S 5,000.000
5
X DEDUCTIBLE 5
X RETENTION 5
L. WOAHFA9COMPENSATION I I X w�YU TU-
QSI I ETM
AND EMPLOYEfl5 WABILIrY -
ANV PflOPARTOHIPMTNEWEXECUTNE YIN EL EACH ACCIDENT 5 500 000
OFFlCEMdEMBER"LUDE04
(MAndelory lnNM CVDO754902 I115/2009 1/5/2010. EL DISEASE-EAEMPLOYE 5 500,000
Ugyy d.,c umler EL DISEASE-POLICY LIMIT 5 500 000
5PECIALPROVIBIDN6 be1PW
i amERlnland T4arine
D Miscellaneous Tools I 567004801 �2/28/2009 2/29/2010 $5,DOG T;m;t
G Equipment IAl nnn Deductible,
DESCRIPTION OFOPERAT ONS I LOCATIONSI VEHICLES/EXCLUMONSADDEO BY ENOOfl6ELffHif SPEGAL PROWSU)NS
CERTIFICATE HOLDER - - -CANCELLATION- - - `
5140UM ANY OFTHEASOVEDESLRIBED POLICIES BEGANCELLED BEFORETHE MPIRATION
DATETHEREOF,THE ISSUING INSURER WITS ENDEAVOR TO MAIL 30 DAYS WRITTEN
NOTICETO THE C,mpCATe HOLDER NAMEDTOTHE LEFT,BUT FAILURE TO OD SO SHALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY MIND UPON THE INSURER,ITS AGENYS ON
REPRESENTATIVES.
AIRNORQ3UDREPRE5ENTATWE
Lisa Polito/LP L- t.TZ
ACORD 25(2009101) 01988.2009 ACORD CORPORATION. All rights reserved.
INS025(2QW01) The ACORD name and logo are registered marks of ACORD
:At'..Ob.2UU9 UO:Sa -D TE(MWDWYTYYI
ACnRD CERTIFICATE OF LIABILITY INSURANCE ovowsoas
TM
PRODUCER PWn 617)(bY5no Fv�l6T71W.5H2 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
KNIGHT INTERNATONAL INSURANCE GROUP ONLY AND CONFERS NO RIGHTS UPON THE CERNFTOATE
500 VICTORY ROAD HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
MARINA BAY
LTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
QUINCY MA 02177
INSURERS AFFORDING COVERAGE NAIC fF
-' INSURED INSURERA' ANontic Charier ln5ufe0ce Company
ALPINE PROPERTY SERVICES CO.,INC. INSURER e:
DBA OLYMPIC INSURER C,
11 WILSON STREET WSIIRERD:
SALEM MA 01970 INSURERE: _
COVERAGES
THE POLICIES OF INSURANCE LiSTEO G OW HAVE SEEN ISSUED TO THE INSURED HAMED ASOVE FOR THB POUCYPERIOp IHOIDATEO, D Hfi memo
ANY 0.EOUSLBdEM.TEPM OR pONDmON DF ANY CGMMDT D0.OTMER OOGUF43YT WNH RESPECT TO WHILH THIS CEATvcut!NAY EE ISSUEO OR
PODCIES�.AGGREGATWSUWCE ELWOS SAFFORDEDHOWN ImAy NAVE E POLICIES
Iell REDUCES RI ENE EERW�S SUBJECT TO ALLTME TERMS,EXCLuSIONS AND CONOMONS OF SUCH
IxSR TVAEOF MGURANCE MUCYNM6ER muF RP6Arrve ore Tou LW95
LTR IxA 6
GENEMLUA81LffY EACH OCCURRENCE
CAMMEACML G6NBW.LIAEILRY P oP"LA7n® I S
CLAWSMAUE❑OCCUR 51Q:0.ESP,lAnyRRperteh) 6
PERSONAL&MVINAIRY S
GENERALAOGREGATE 5
GE)rLAGGREGATE UMRAPPLIES PER PRODUCE+ P/OPAGG., 5
PRO.
POLICY IM LOG
AUTUMOEILELUL®DIY COMBINEASINGUiUMIT S
lee er66ea0
ANY AUTO
ALL OWNED AUTOS SMILTDLUW
IPvp5vonl s'
SCHEObLEOAUTOS '
ARGO AUTOS EODILTWNRY 5
NON-0WNEOAUTOS IPerArr:;deq
PROPERTTOAIMGE S
P6(6GtlM
GARAGELIAWLrTY OONLY.EA ccmb E 5
ANYAUTO UPHERTww GA AOC S
AUTO ONLY' ADS 15
EACEaG IUMBRFIL4 WBIlRY PACN UCOUMENCE a
OCLUR �CULIMSNIADE AGGREGATE s
5
oeourneLE S...
RETGNRON5 5
woNLERs wxpsxeAnox ANO WCV0075a902 0110s,00 01105710 mr`mMMw"Fio RTMER
E11PLOYFA6'UABILIfY fiL,FACMACCIOENT •5 , 500.000
A W.R.YWpmacum aT vlfR ELOISEAEEf DE FLOYEE 3 SOD.000
ep.,mePne�mu EL msEAs6AouCYUMR 6 ,60Ur000
MP6ruLpawMlcxpml..
OTHER: •
DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED DY ENDORSEMENT/SPECIAL PROVISIONS
CERTIFICATE HOMER CANCELLATION
SHOULD ANY OF THE MOVE OESCRom POLICIES BE CANCELLED REFORETHE
EXPIRATION DATE THENEOF.THE MCUING INSURER WILLMOFAV,ORTO MAa.10 DAYS
WRRTM NOTICE TO THE CERDMATE HOLLER MNIED TO THE,LEFT,OU6FALLURE
TO 0080B WFDSE NO OBLIGATION OR UAEUTy OF AEA'NNOUPONTNE)N6DRER
nS AGEMSOR REPRESENTATNES.
AUTHMIM REP)ESENFATNE G�./✓/t�j,/(4�7.. ,f�P!!J}"�r
AttcnOPn: Harold`J_Y•rll9h[ v�
ACORD 25(2001103) Can)Rcate m 8149 m ACORO CORPORAnON 19EE
HIC#154326
EIN#56-2618812
Tim Collette
5 Read St
Salem,MA 01970
September 14,2009
Dear Jim,
The following estimate is for the roof installation for the property located at the above address. The following paragraphs describe the
work that will be performed.In addition to installing your roof, I would like to offer you the opportunity to obtain a warranty directly
from GAF or CertainTeed. We, as GAF Master Elite Certified Installer and Certified CertainTeed installers have the ability to provide
you with a 25-30 year labor warranty directly from the manufacturer.To view the benefits of Stripping vs.Going Over the existing roof,
please visit our website @ www.olympicroofing.com
Installation Procedure
1 Strip existing roof on the entire house down to the roof deck
1. Install an 8 inch drip edge on all leading edges(rakes&fascia)
1 Install ice&water on all leading edges&valleys
1 Transitional walls are optional and incur an additional cost for the siding repair
1 Install new vent pipe flanges
t Replace any rotten or damaged decking(we allow 32SF @ no charge,$80.00/sheet thereafter)
1 Replace any rotten or damaged ledger board(we allow 30f.at no charge,$3.00/8.thereafter)
1 Install 15 pound felt paper on all areas that is not covered by ice&water shield
1 Install new GAF 3-TAB shingles—Upgraded to T-30 Architectural at no charge
1 Install new ridge vent system
Additional Spedflcadons
1 Homeowner to choose color of shingles COLOR: _Charcoal T-30
I Our dumpsters are sent to a recycling facility;therefore no additional trash may be placed in them. The transfer station will
charge us a fee for additional trash which will be passed on to the homeowner.
I Chimney re-pointing and re-leading is not part of the roofing contract and will be quoted separately if needed.
1 Transition walls are an option,and if the existing flashing is in good shape,usually do not require replacement
1 During a roof job,the nails could break the sheathing during the nailing of the shingles
1 We are not responsible for any of the cracks that may arise in any walls or ceilings
1 Please cover all your floors in your attic to protect from dust and debris
4- We will remove all of the job related debris
1 Permit costs vary from town to town and are not included in this bid
Initial the options you are choosine below:
Cost for Labor&Material for Roof: $4,395.00_�
Cost for GAF System Plus Warranty: $ 250.00
Payment Terms: U3 deposit upon signing contract $ .V3 work in progress $ and 1/3 upon completion$
Remit to: Alpine Property SeMcesr Company,Inc,P.O.Box 365,TopsfteJ4 AM 01983
Total Amount Agreed To Be Paid: $ 3
The following schedule will be adhered to unless circumstances beyond Alpine's control arise:
Work Scheduled to Begin:_TBD Expected Date of Completion: TBD
Warranty: Alpine Property Services Inc. guarantees all work performed for a period of one year. If any problems occur we will cover
the cost of all labor and material to correct the problem and meet the customer's
Do not sign this contract if t e are y blank space.
(additional provisions follow and ar orpor ted herein by this eference
Geor Vasi rades,CEO II
Alpine Property Services Company Inc., omeowner
d/b/a Olympic by(Name)