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30 SHORE AVE - BUILDING INSPECTION The Commonwealth of Massachusetts EIVEIT Board of Building Regulations and Standards INSPiC I TIC NAI:(.SEXVCES Massachusetts State Building Code, 780 CMR 'SALEM :x (n('' Revisgd Mar 2011 Building Permit Application To Construct,Repair,Renovate Or DeAY,1 AN 4 A IQ 2.5 One-or Two-Family Dwelling This Seddon For Official Use ben, DatdApplie . Budding Official(Print Name) - Signature -� ate SECTION 1:31TE INFORMATION' 1.1 Pro 3D_ rty Addr ss: . 1.2 Assessors Map&Parcel Numbers�v�tore �� le,n,In�v�47� I.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 a) Frontage(I) 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? Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' �2 Owner of RR fK J 0.��no r� ,eM m p Q q Q Name(Print) City,State,ZIP aoG�. c ku -`Jul- �I — No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF'PROPOSED WORK'(check all that apply) New Construction❑ Existing Building jL Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:tY')O n Brief Description of Proposed Work': o r ;k 2 f . I eA SECTION 4 ESTI'MATED CONSTRUCTION COSTS Item Estimated Costs: Uffldiul Use Uhl Labor and Materials y I.Building $ i 1. Building Permit Fee:$ ''ldicate how fee is determidcd: 2.Electrical $ ❑Standard.'City/Town Application Fee 0 Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other pees: $ 4.Mechanical (HVAC) $ List: S.Mechanical (Fire Su ression) $ TotalAh Fees:$ 6.Total Project Cost: $ 3 Check No. Chock Amount: Cash,Amount: r ��0 • ❑Paid inTull O Outstanding Balance Due: (�1 Kt Lleo (-") ( � t SESCTION Si.CONSTRUCTION SERVICES ' l 5.1 Construction Supervisor License(CSL) �6rakAllursor g License Number Expiration Date Name of CSL Holder 3 1 r) /1 r)r ora c List CSL Type(see below) No.and Street 1_ J Type Description G1OUG2,ST°r Y7 Q1 U Unrestricted(Buildings up to 35 000 Cu!ft. R Restricted 1&2 Family Dwelling City/r w State,ZIP M Meson RC Roofing Covering oN WS Window and Siding SF Solid Fuel Burning Appliances d D� 77 I Insulation Tale hone Email address D Demolition 5.2 Re(istered Home Im rovem�++ent Contractor(HIC) 8 7 3.S ke& n OO rt JErJ oC Di'�Lt.J�y1 I . HIC Registration Number Expiration Date --- --`I Col pay3c Name or HIC Re ' (rent Name n l e rd 'pE- �ngRPrCC;S1Un (bC�rn4.U N . nd Street Email address A rouaes-�Cr mA' 61430 9-77-AI-33C/6 Cityrrown,State,ZIP Telephone SECTION'li:W©RKERS'COMPENSATION INSURANCE AFFIDAVIT{M.G.L.c. 1!52.§ 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 ..........FL No...........❑ SECTION 7n: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 1 rec I Coo+tn �erJ i CeS D� Mr< t1on act �on my behalf,in all matters relative to work authorized ®by t is buildin pe it application. I , '(�rK�cc1U ar4 4 s - 13 — �Y Print Owner's Name(Electronic argnature) Date SF,CTIUN 7b: OWNER( .R 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 y k owie a and understanding. r r ZJ/1of Print Owner's or Au 'zed Agent's Name(Electr rc ignature) 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 Ut 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. oP v/oca Information on the Construction Supervisor License can be found at wy mass eov/dos 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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" � 1 The Commonwealth of Massachusetts Department of IndustrialAccidents Ogee of Investigations d I Congress Street, Suite 100 Boston, MA 02114-2017 www mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organization/Individual): PRECISION ROOFING SERVICES OF N.E. INC Address:321 CONCORD STREET City/State/Zip:GLOUCESTER, MA 01930 Phone#:978-281-3340 Are you an employer? Check the appropriate box: Type of project(required): 1.X-I am a employer with 10 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 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. employees and have workers' comp. insurance.t 9. ❑ Building addition required.) workers' comp. insurance p' 10. Electrical repairs or additions required.] 5. ❑ We are a corporation and its ❑ P 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑0 Roof repairs insurance required.] t c. 152, §1(4),and we have no 13.❑ Other 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 anew affidavit indicating such. tContractors that check this box must attached"additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contmetors 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:A.l.l. MUTUAL INSURANCE COMPANY Policy#or Self-ins. Lic. #:VWC10060174602014A Expiration Date:04/17/2015 Job Site Address: %.rC y . City/State/Zip: I Q Q 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$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. Be advised that 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 an en ties of perjury that the information provided above is true and correct. Silmafore: ` ' Date: j L Phone#: 978-281-3340 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#: 06/03/20,14 15:23 19783565227 GREGORY INSURANCE PAGE 03/04 ACORD. CERTIFICATE OF LIABILITY INSURANCE oATB03/2014 O a Zo14 PRODUCER (978) 356-2116 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Gregory Insurance Agency ltd ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE B Y 9 Y HOLDER, THIS CERTIFICATE DOES NOT AMEND EXTEND OR 61 Market atreet ALTER THE COVERAGE AFFORDED THE POLI&S EL P.O. Box 625 Ipswich MIL 01938-0625 INSURERS AFFORDINGCOVERAO NAIC INSURED IN pea •Ataia Specialty _ Precision Rooting Services IN as :AIM Mutual Ins. Cc 321 Concord Street Ns e 11R D: W. Gloucester MA 01930- INSURER 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 CONTRACTOR 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, VOLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN RFOUCND SY PAID CLAIMS. �I(yy INSRAOD'L Typ®OFINSIIRANOB POLICY NUMBER 081'�wF CT H B T MMI N LIMITS In .1A GENERAL LIABILITY OURR 0 1,000.000 R C MEROIALGENERAL LIABILITY gEN7ED ° 100,000 OLAIMBMAOfi I 1 OCCUR CIP109792 11/00/2013 11/08/2014 MEDEXP A cne era n e 10,000 PERSONALA ADV IN4URY s 1,000,000 GENERAL AGGREGATE 0 2,000,000 GEN'L ACOREOATE LIMIT APPUE6 PER; •CO A 2,OD0,000 CV 28 F7 C / AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMB 0 ANY AUTO fEaaxldentl ALL OMMAD AUTOS / / / / BODILY INJURY 0 (Per 0Bu0n) 90HEOULfi0 AUT09 HIREDAUTOS / / / / SODILY INJURY NON-OWNED AUTOS (Per daddenB I PROPERTY DAMAGE 0 Mar w0werI) GARAGE UABILRY AUTO ONLY-NAAOCIDENT 0 ANYAUTO / / / / OTHERTHAN RAA AUTO ONLY: O 0 EXCUSAIMBRELLA LIABILITY OCCUR CLAIMS MADE AGGREGATE 0 0 DEDUCTIBLE RRTENTICNE 9 WORKERS RCOMPPEN COMPENSATION AND RMC 0015645012013 04/17/2014 04/17/2015 R 9 q CIDON 4500,000 ANY PROPRIETOPoPARTNERJUXECUTNE OPPIOERINIFMBERBXOLUDEO? / / / / E.L.DISEASE-EAEMPL YE 0 506,000 "M, OTHER de00dce under . .DIBEA 6.P LICYLIMIT 0 $00,000 / OESGRIPTION OF OP80UTIONBA.DCATIONSNENICLBNEXCLUBIONS ADDED BY ENDORSEUBNTISPECIAL PROVISIONS CERT C RHO RHOLOPR OANCELLATIQN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE TIE' BXPIRATIGN DATE THRREOF. THE ISSUING INSURER WILL ENDEAVOR TO MAIL: 20 DAYS WRITTRN NOTICE M THE"FITIFICAW HOLDER NAMED TO THE LEFT.BUT. City Ot Salem FAILURE TO DO 90 SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON TH8' 120 Washington Street ifffiggeg,IT$A9FNTAG EP NT AUTHORRRD REPRESENTATIVE 8 lem ACORD CORPORATION 1 BB8 tORD 28(2001108) ELEOTRONIC LASER FORMS,INC.•(OW)32T•D608 Page 1 cIY ;INS028M0405 Massachusetts -Department of Public Safety Board of Building Regulations and Standards ('(instruction Supervisor 14r 2 Famih License. CSFA-092959 _, 1 I, DONALD PARSONS 317 CONCORD S7' GLOUCESTER10 1 10,? Fxpiration Commissioner 04/04/2016 i Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 178735 Type: Corporation Expiration: 5/14/2016 Tr# 251924 PRECISION ROOFING SERVICES OF NE I ANTHONY CORRAOJR 321 CONCORD ST _— GLOUCESTER, MA 01930 -- - - -- ---- -- --- -- Update Address and return card. Mark reason for change. Address Renewal [_j Employment r_1 Lost Card SCA 1 0 200-05111 P�. Office of Consumer Affairs&Business Regulation License or registration valid for individul use only _ iwk1OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: registration: 178735 Type: Office of Consumer Affairs and Business Regulation Expiration: 5/14/2016 Corporation 10 Park Plaza-Suite 5170 ryj Boston,MA 02116 PRECISION ROOFING SERVICES OF NE INC. ANTHONY CORRAO JR 321 CONCORD ST moo• -�� ` n GLOUCESTER,MA 01930 Undersecretary Not valid without signature