5 ROCKDALE AVE - BUILDING INSPECTION i
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
\�y Massachusetts State Building Code, 780 CMR, 7'" edition
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Fancily Dwelling
Q� This Section For Official Use Only
Building Permit No er. Date Applied: LL, -z r�
Signature: =IL� I / r z- �t �C-b
�(� Buil g Commissioner/Inspector of Buildings Date
" J SECTION 1.SITE INFORMATION
1.I,P ; rtr��dre s: �� 1.2 Assessors Map& Parcel Numbers
I.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 fit) Frontage(It)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[]
Deird/� n>vP,rT SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of R ord: ///�n // /
Name(Print) Address for Service:
g ?f-- 7s'y -62 S" 73
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑lExisting Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work2: -ST/li%✓ O/-"� GG.O v�f
iyt T a c "'Va a /lac /L7
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ S ,Pv 1. 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: $ ff file
4. Mechanical (HVAC) $ List t��
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
efi Bc er License Number Expiration Date
Name of CSL,-Hel �
der List CSL Type(see below) C
Ad ss Type Description
< r ' �/ U Unrestricted u to 35,000 Cu. Ft.)
!—� R Restricted I&2 FamilyDwelling
Signature M Masonry Only
97�� 7�y—p.3--rf RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 egisterss Home Improvement ontractor(HIC)
HIC Company Name or HIC Reptran[Nj Registration Number
Add
(T �� 9����y_O.�rf Expiration Date
Signature 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 ..........A4, No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
Signature of Owner Date
SECTIO�NJ7b: OWWNEW O�R�SIAUTHO,RIIZED AGENT DECLARATION
I, G �°�YLU� S' —41ZI 41S. ,as Owner or Authorized Aden[hereby declare
that the statements and nforotation on the foregoing application are true and accurate,to the best of my knowledge and
be f.
1 me4, <a ie./,
Print�me � A �` ���
� _ it- y-y c
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.115, 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"
CITY OF SALEM
z
PUBLIC PROPRERTY
DEPARTMENT
III 974-74n-9;95 # I:x\": 9,8 .74- 9845
Construction Debt-is Disposal Affidavit
(ICCII.Iiied flur all demolition and renovation work)
In accordance wvith the sixth edition of the State Building Code, 780 CNIR section 111.5
Debris, and the provisions ofMGL c 40, S 54;
Bililding Permit # - m - is issued with the condition that the debris resulting from
this work shall be disposed of a properly licensed waste disposal facility as defined by MGL c
111. S I 50A.
The debris will be transported by:
The debris/will be disposed of in
(name of facility)
(address ol'tacility)
signature of permit applicarn
date
�� CITY OF SALEM
jrwPUBLIC PROPRERTY
DEPARTMENT
I\I I;:'RCI:),I)RISCOLL
4fA)k)R 12C WASHING J ON S I BELT 4 SALEU,MASSACI It tit:'I'I S 01970
Ti,i, 978-745-9595 0 FAX. 978-74C-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
-kpplicant information / Please Print Leeiblv
Name (Business/Orro (Aanizatiordlndividuul): /4 9ez",, �//h7 r✓ /C ( �Y
Address: �� t�o/�i�9i ->Z s
City,Statci/.ip: Phone I"- �7�—�7y d--rs
titre you an employer!Check the appropriate box: 'Type of project(required):
L❑ I am a employer with A. ❑ I am a general contractor and 1 6. ❑ New construction
mp or
loyees(full anWor part-tte).• have hired the sub-contractors
2.�un a sole proprietor or partner- listed on the attached sheet. �• Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in an capacity. workers' comp. insurance. 9. Building addition
b Y P� • y ❑ g
INo workers'comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.] oftiecrs have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I E] Plumbing repairs or additions
myself. [No workers' comp. c. 152, y 1(4),and we have no 12;ZRouf repairs
insurance required.] r employees. LNo workers' 13.0 Other
comp. insurance required.]
'Any:glphcuut that decks box is must also lilt out the union below showing(heir workats'compensation policy information.
'i lumeowta;ra who submit this affidavit indicating they ate doing ull work and then him outside contractors must nutmtit a new affidavit indiuling such.
�Commcton that check this box must attachod on additional sheet showing the name of the sub-aontractors and their workers'comp.policy information.
/our an employer that is providing workers'compensation insurance fur toy employees. Below is the policy and jub.sire
infururation. _
IrsuranccCurttpany Vmne: '��✓/ �__.�/��� —o
I'olicv B or Self-ins. Lic/� /�e�C/o;2--Y07 . ._ ._,_____ Expirution Dattee::
Job Site Address: -rt,l1 /�r/1-- City/State/Zip: 44
mtach it copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure insecure coverage as required under Section 25A of.MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 m S250.00 a day against [Ile violator. Be advised that a copy of this statement may be forwarded to the Office of
Invrsligatiunfs ol'Lhc DIA for insurance covcra.-c%en ication.
/do hereby certify ruder the utin.s and Pena/tics of perjury that the inforinudon provided above is true and correct.
Phl 1'C 4 / 0�0
O_flicial use only. Do not write in this area, to be cutup/sled by city or town ojficiuL
City or Torn:
Issuing;\ulhuriiy (circle rate):
I. Board of Health 2. Building Department 3.Cilylfowu Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Otlter ._._
Contact Person: __._ _. _..— Phone th
L
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empluree 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 tither legal entity, or any two or more �,I
of the toregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of:m individual, association or other legal entity,employing employees. However the
partnership,
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
s persons to do maintenance construction or repair work on such dwelling house
dwelling house of another who employ. pe ors p
or on the.,,rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
SSGL 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, NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perforniance 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 continuation 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permittlicettse number which will be used as a reference number. In addition,an applicant
that must submit multiple permin'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 tilled 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
"I"hc Oil ice of Investigations would like (o thank you in advance for your cooperation and should you have :my questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlee of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05
www.mass.gov/dia
AcoRn! CERTIFICATE OF LIABILiI Y INbUKAna.c ;u 07 14/0S
THIS CERTiflCATE IS ISSUED AS A NATTER OF INFORMATION
TDacet ONLY AND CONFERS NO RIGHTS UPON THE CERT)ACATE
an Hurley insurance Agency HOLDER,THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
Ziestnut Green, Suite 24 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
;even Federal Street
Ianvers wA 01923-3620 NAICS
?hone-978--777-9394 Fax:978-777-3306 INSURERS AFFORDING COVERAGE
;�A. Preferred Mutual 15024
MUFNER& Granite State
Aileeyy Brothers construction HLSIAM C:
Bartholomew Ailey DBA ¢
D Danvers HA 01Street
3
e
;OVERAGES
THE POLICIES OF u=RMTCE LISTED BELOW HAVE SUN TSSUEv TO THE NOWIED NAMEO ABOVE FOR RE POLO PER)06 NUCATED.WOIYYDWAMM
ANY REOUREMBIr TERN OR COMMUM OF ANY CONWACT OR OTHM OOCuMEHr WIOIRESPECTTO WHIOI7WS CEMIRCATE MAY BE ISSUED OR
MAY PEBm ni,THE 80UPANCE WFFORDEO BY THE POLICIES DESCRIBED HEREW Is SUBJECT TO ALL THE TETRAS.ENCLUSHM ANO CTIDMM OF SUCH
PQJcIES.AGGHECATE LOBOS SHOWN MAY HAVE BEEN W3WCED BY PAID CLAWS. InFwunmw
.TR 7YPEOFa
POuO'NUL®9t OA7E OOLIDCVYY) WDEwump f)
EACH ocaemEReE s 300000
GEWMALU 8LnV
A X fQk6ERCIALGENEmLisHm epp01SO564252 10/16/07 10/16/08 FRtle5E5(EeAcmaxa) s100000
cinamMAOE n OCCUR LIMEXP(Acy®Po^^®) $5000
PBrCML SAMRAW $300000
GENE ALAGGREORTE S 600000
QM AGONEGATE LBO APRJES PER: PROIAICIS-COAfP/OP AMs 60000D
POIIGY LOG
A)TOMOBRE uRaLnv CDIIDWD SOME LWD $
(ER=Cdard)
ANYA TO
P ONEDAIDOS WDILY MOW
y
SCHEDULED AUTOS
HSEDALROS 80 s
NOµOMED AUTOS
PROPEIOY DAMAGE $
(Pa mck�o
GAiUtGEUAWMT AUTO ONLY-EA ACCMff P
ANY AUTO OTHER THAN EA AM i
AUD)ONLY. AM S
LIAMIM EACH OCdWPH10E i
OCCUR DCWMS MADE AOGREGATE $
S
DEDUCTIBLE $
VJCRKEn CC ANON MID - X TOW UUMS I I ER
EAeLDrERV UgeRJrY L
WM428831 06/20/08 06/20/09 E.L.EACH ACODEK $200000
AW B nRLUDED? n� SEE ATTACRE.D NOTE FLOISEASE-EAMPLOYEE $100000
mrmeomer L.EDMEASE=POUCYLNR $500000
sPEaAI PRGv�ss
07HER
DE6C58RIION OF OPBUO—LOCAMMS Jjj0&S IERCTD RDIM AWED BYMOR6EOMI SPEWB.PIOwS�S
Sole Proprietor excluded from workers compensation.
CERTIFICATE HOLDER CANCELLATION
FORIBFO SWULD AM OF THE ABOVE DESCRIDEOPOUCIDSBE CWTCEIl<n BEFOPE IXE OFWA)ON
DATE TIMMM.TIE ISSUNS 91MAER WILHO]EAWR 10 CULL 10 DAYS LYPoTTEN
For information purposes only. NOTiCETD4ff CEOFIGA7EHOU)rRNABIDTODELEFT.BVTFAILURET000 SD SLMLL
Please contact agency for WOSENDOml UMCRLMMMYOFMTMMLWMWWWMXa3.RSAGENTSWT
individual certificate. REPRESEHmTNEIL
AUT OMMED REPRESOMTAIE
Dattiel J Hurl
ACORD 25(200UM 0 ACORD CORPORATION 1980
� Colonp HIC # 126-356
®Cb �uilberg, 3nc.
13 SEWALL STREET
PEABODY, MA 01960
OFFICE: 978-922-6120
SPECIFICATION SHEET
Home Phone:1. 21-77�Zl6 J.—2J
Owners Name.C/O�Y. .'T . . . . . . . . . . . . . . . . . . . . . . . . . . . .Work Phone:
rn . . . . . . . . . . . . . . . . . . . . .
Hoe Address . ,� . . . . . . . . a2i.". . . . . . . CiN . . . State 9�N'. . . . Zip . . . . . . . . .
Job Address . . . . . . . . . . . .�9 . . . . . . . . . . . . . . City, . . . . . . . . . . State . . . . . zip
SIDING
. Siding Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Width . . . . . . . . . . . . Color . . . -:
.Area one. Main House . . . . . . . . . . . . . /3ree;eway . . . . . . . . . . . . . Garage . . . . . . . . . . . . ..Addittnns . . . . . . . . . . . . . .
Dormers . . . . . . . . . . . . . . . . . . . . . . . . . Other . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Insulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
4. Trim cover U Yes J No Color . . . . . . . . . . . . . . . . . Trim lobe done: Sgfftts . . . . . . . . . . . . Fascia . . . . . . . . . . . . . .
Rakes . . . . . . . . . . . . . . . . . . . . . etling,s . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
5. Casings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .- . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
6. Gutters and.s .s ❑ Yes ❑No Use heavy gauge seamless . . . . . . . . . . . . . . . . . . . . . . . . . . . . Color . . . . . . . . . . . . . . . .
7.Shull ❑ Yes ❑No . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
tndow,sand Doors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ~`
ROOFING -y- f,� �,,_, — t� �---.
Material Type . . ...L. ./� . . . .�(J. . CTi�. i2 . . . . . . . . . Color�'� �"�X. .
Areas to be dome . . �. . . .
_ . . . . . .
Remove existing ,shingles Q-Te—v 'J No 15 lb. elt . .
f . . . _ . . . . . . . Metal
Chimneya vents etc. .!,>z.c-sy.,(J„p .�/ . . . Other J � C✓7G� rGG.LIa
NOTES �. . .
.. . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . i .A' "f�.jj.,,. .,. . . . . . . : . . . . . . . . . . . . . .
.Deposit
Material and labor to cost $.V. �J.t, GG� ) payable as follows: $_ ' . , , ,fst Installment
$. . . . . . . . . . . . 2nd Installment
Con -.Zr— ^t?alance on completion
other
will do all said work in a goad workmanship his manner. You may cancel this agreement if it has Seen consummated by a party thereto at a place
other than an address of the seller, which mar he his main office or branch thereof,provided you notify the seller in writing at his main of ice or branch
by ordinary mail posted,by telegram sent or by delivery,not later than midnight of the third business day following the signing of this agreement. �"IN WITNES THEREOF; the p roes have hereunto signed their names this. . . . . . . /r� day o .!/.�'Z-ram, zp �6
////AA . . . . . . . . . . . . . .
Cb [anp dui berg, Inc. aw er
Signed. . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . .
Per. . . . .
L Owner
Representative
Authorized Rep. . . . . . . . . . . . . . . . . . . . . .
Strikes,labor disputes,inclement weathcq or material supplier delays resulting in work stoppage are beyond the control gl
of the company.
The company guarantees all workmanship for a period of l year from the date of installation. Guarantee of workmanship assumes performanceceof ct
acts o(Cad or nature, neglect of proper maintenance
installation under normal wear and tear conditions and does not guarantee against,storm damage, ci
malicious damage or vandalism. Material guarantees are the.vole responsibility of the manufacturer. or