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12 SAVOY RD - BUILDING INSPECTION r r The Commonwealth of Massachusetts I� Board of Building Regulations and Standards CITY OF ALEM Massachusetts State Building Code, 780 CMR SdMar Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For 9fficial Use my Building Permit Number: I kate Appf d: Building Official(Print Name) Sign / D e SECTION 1: SITE INFORMATION 1.1 Property Address: �� 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accep ed street?yeses/ 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(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❑ SECTION 2: PROPERTY OWNERSHIP' 2.ltOwner� Record:G � C 4 Ya V thy-. 4 Name(Print) City,State,ZIP ' 12 �auOY ��• W 7Y No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building Owner-Occupied a Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': ke C (tee 4 1•V-x Sic - S i 7 e SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 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: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees: $ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 1 7Z : 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 1a)! �� 3 KOrfy C, Go✓i!L License Number e4irmilon Date Name of C51,Holder List CSL Type(see below) S �(/O�% N St o. and reet Type Description U Unrestricted(Buildings up to 35,000 cu. ft. L R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone �, ail address D Demolition 5.2 Registered Home Improvement Contractor(HIC) !Z`I/7d /Z— �/.t��' rr ( O- HIC Registration Number xp ration Date HI Company,Name or HIC egtstrant Name // G,�n✓� :fir inCa�v�'�uwMP .0 :Signed and ��J l� Ema'1 address /Tow ,State,ZIP Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) rkers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide affidavit will result in the denial of the Issuance of the building permit. Affidavit Attached? Yes .......... ❑ No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, as Owner of the subject property,hereby authorize /rl6�trA 01f 4L. to act on my behalf, in all /matters relative to work authorized by this buil �ng permit app icatio(� t b nst�d UV (-,-L",J 6414^Z-- Print Owner's Name(Electronic Signature) I I Date 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 and accurate to the best of my knowledge and understanding. Print Own is or Authoriz d Agent's Name(Electro is Signature) ate 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.eov/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"may be substituted for"Total Project Cost" CITY OF SALEN4 NIASSACHLSETTS • BUILDING DEPAIMIENT ' 120 W ASHINGTON STREET, 3so FLOOR "IEX.- (978) 745-9595 F.1x(978) 740-9846 KIN IBERLEY DRISCOLL I1lOMAS ST.PIERR MAYOR RI?DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\L�RSSIONER Workers' Compensation Insurance Affidavit: BuildersfContractors/Electricians/Plumbers Applicant Information /] Please Print Legibly Name (Busimx&Organization/indivpid�ual): I l�r L �St ( l am �J ��✓[h� Address: &3q �ouLL Mal-n City/state/Zip: lvi(� I e Gam , X/k. 017a Phone #: 0707 764 0C10 _7 Ar�et you an employer?Check the appropriate box: Type of project(required): 1.[ry.I am a employer with �(� 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ I am a sole proprietor or partner. listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors 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 required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑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' comp. insurance required.] 13.0 Other *Any applicant that checks box 01 must also fill out the wilux,below showing their workers'wmpenation policy infutmation. t I hxm:uwners who submit this affidavit indicating they arc doing all work and then hire outside commctota most submit a new affidavit indicating such =f'otnmctors that check this box must attachod an a fi itional sheel showing The name of the sub-contractors and their workers'comp.policy infomution. 1 am an employer that Is providing workers'compensation insurance for my employees. Below Is the policy and Job site information. Insurance Company Name: ' vt� Gh.\ °-1.�yt.c,C { II4cXcl �i,�5 l.�J Policy 4 or Seif-ins. Lic. #: u C (c, U S<7 L. Expiration Date, IS Job Site Address: lZ (Sei(J2.cg � City/State/Zip: c, �LUt,.. IA,&, Attacb 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 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations or the DIA for insurance coverage verification. /do hereby certify drder the p;7 it penalties of perfury that the information provided above is true and correct Signature' Date: /-/ /Z Phone x ! 73 ! Z 2, 0 e/ Z Oficial use only. Do not write in this area,to be completed by city or town ofrchfL City or Town: Permit/License Issuing Authority(circle one): I. Board of Health 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other __- Contact Person: ----- --__.. roans#: ACORQ CERTIFICATE OF LIABILITY INSURANCE DATE 29/2 os/ s/z012lz PRODUCER 860.482.5591 FAX 860.496.9713 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Burns, Brooks & McNe i I ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR www burnsbrooksmcne i I .com ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. 69 Water Street P.O. Box 717 Torrington, CT 06790 INSURERS AFFORDING COVERAGE NAIC# INSURED North Shore Window Solutions, LLC INSURER A: Nat i ona I Grange Mutual Ins Co 239 South Main Street INSURER B: Middleton, MA 01949 INSURER INSURER D: 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. ILT R O' TYPE OF INSURANCE POLICY NUMBER DATE MM/HOC/YIYY DATE MM/Do�YYOY LIMITS LTR NSR GENERALLIABILITY BPT6857E 05/15/2012 05/15/2013 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMISES Ea ccu ence $ 100,00D CLAIMS MADE OCCUR MED EXP(Anyone person) $ 10,000 A PERSONAL S ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000 POLICY PRO T LOG AUTOMOBILE LIABILITY - B1T6857E 05/15/2012 05/15/2013 COMBINED SINGLE LIMB ANY AUTO (Ea accident) $ 1,000,000 ALL OWNED AUTOS BODILY INJURY (Per person) $ A' . X SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHERTHAN EA ACC $ AUTO ONLY: AGO $ EXCESS/UMBRELLA LIABILITY CUT6857E 05/15/2012 05/15/2013 EACH OCCURRENCE $ 2,000,000 OCCUR CLAIMS MADE AGGREGATE $ 2,000,00D q',,.. $ DEDUCTIBLE $ X RETENTION $ 10,0D $ WORKERS COMPENSATION WCT6857E 05/15/2012 05/15/2013 TORV LIMfTS ER AND EMPLOYERS'LIABILITY YIN A ANY OFFICEOPRIETOR EXCLUDE09ECUTME❑ E.L.EACH ACCI DENT 8 1OO,DDD (Mantletory in NH) E.L.DISEASE-EA EMPLOYE $ 100,DDD If ye describe under E.L.DISEASE-POLICY LIMB $ $DD,DD SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS E: Evidence of Insurance CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO 50 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. To Whom It May Concern AUTHORIZED REPRESENTATIVE Patricia Tedesco, CIC ACORD 25(2009/01) ©1988-2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD �� -Cammaxweald Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 129170 Type: Private Corporation Expiration: 7/19/2013 Tr# 216244 Gove Lumber Company, Inc. h u' Bruce Gove i^ _ 80 Colon Street Beverly, MA 01915 K Vei 'T Update Address and return card.Mark reason for change. ❑ Address ❑ Renewal ❑ Employment ❑ Lost Card )PS-CAI 0 SOM-04/04-G101216 er� Consumer Affairs& °� tion License or registration valid for individul use only aas� Office of Consumer Affairs&Business Regulation g Y WRHOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: �V� Registration 029170 Type: Office of Consumer Affairs and Business Regulation Expiration 7/19/2013 Private Corporation 10 Park Plaza-Suite 5170 F Boston,MA 02116 Gove Lumber Company f-� � •per -';, Bruce Gove 80 Colon Street Beverly, MA 01915 Undersecretary At valid without signature Installation Marvin Design Gallery by NSWS Ouote 239 South Main Street, 978-762-0007 Middleton. MA 01949'' 866-809-D 36 , CUSTOMER Donald Michaud REVISION DATE 05/01/12 Quote expires in 30 days ADDRESS 12 Savoy Rd. PROJECT NAME OI7Y,STATE.ZIP Salem,Ma FDDRESS TIME DAY TEL 978-744-7988 CITY.STATE.ZIP SALESPERSON Bob Desrosiers DAY,TiriE TEL email:none - REV 03 10 LABEL QUANTITY DESCRIPTION PRICE TOTAL 1 1 Marvin Windo%%�-null Ullrex Fiberulass DH-see attached sheet 7.306.00 7,306.00 Ltstallation Plat Labor Charge:S36 0,00 stallation cousists otan Awnuo-,coafinttranon to a double huoa confirmation.Full Tety ont and instill. 2 1 Materials:I3Xlefu r=S975.00(Are brick Mold w bandmold)5 A flat 975.00 975.00 undbandmold 11.%$", MierelLru inls Materials:caulk.iceua[exshield.ixutdatiuu.F:Istcnert 1 Building Permit Fee 350.00 350.00 1 Inst:iWrtiun Flat Labor Charge 3,600.00 3.600.00 1 Miscellaneous Materials 125.00 125.00 1 Rubb€sh Remora]Fee 250.D0 250.00 All installations will be left broom clean at the end of the day..All painting Is by others.Marvin Showcase warrantees the installation labor only.All materials are covered under the Manufacturers warranty,Any rot found dr extra work not specifically mentioned in this work order will be billed wan hourly rate plus the cost of materials.Marvin Showcasewill not be held responsible for the fit of existing window treatmews to the i=alled replacement windows.Interior trim included is 8R(OSCO#8710,any change will be an additional cost.Customer will supply elec ncatpower and water when necessary.Customer will prepare the work area by removing all furnishings and provide easy access to,uraa.Masaachtcseaa Home Improvement Contractor Registration,# TERMS DEPOSIT OF',' $4,961.00 REQUIRED PRIOR TO PLACING ORDER SUE TOTAL 12.606.00 $4,611,00 DUE WHEN MATERIALS TO BE INSTALLED ARE DELIVERED. DELV CHARGE 25.00 $3,600.00 FINAL BALANCE DUE ON THE LAST DAY OF INSTALLATION. 6.25%MA TAX 541.00 MAKE ALL CHECKS PAYABLE to Marvin Design Gallery By NEWS TOTAL $13,172.00 CUSTOMER HAS RIGHT TO CANCEL ORDER WITHIN 3 DAYS FROM DATE AT TOP ORDER ACCEPTED �C� n fj ^ /� AS WRITTEN X 1�,}(/�(, y �/ NOIRETURNS AREALLOWED 01111WINDOWS,DOORSORS^�CJ L ORDER MILLWORK. IF YOU HAVE ANY QUESTIONS REGARDING YOUR INSTALLATION PLEASE CALL BARRY GOVE AT 978-922-0921 h{�% General Page 2 $nand of Boddu#4 Regulations and 5t#nda , t*... eansmcUon Impernsor Specialty Licensi` �y_, 4acepse: C,';.st 100150 Resirrc#ed in WS BARRY GOVE 46 LINCOLN AVENUE { HAMILTON, MA01982 , '�' Expiration: 4/1 112 01 2 _ -t (S>iami.!,ivner Am: 100150 ' t..avItu,t t. Gclait;l a t nI i,l PIIbIrl� `tiara y 99y. Roarti of Rudthn,-, Key ul Juan, and Standards.'+». Constmu bon Supervisor Specialty Llcentg 3.k -+zw-Srr L:1 J. ", *T LiZensP;'„CiS SL 100150 Restricted ta. W6 BARRY GOVE 46 LINCOLN AVENUE HAMILTON, MAa01982 Expiration: 4/11/2012 'c Cinemfaioncr Tr"S: 100150