4 SUMMIT AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
' Board of Building Regulations and Standards CITY
l� Massachusetts State Building Code,780 CMR, 7"edition OF SALEM
Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family D elling
This Section For fficial Use Only
Building Permit Numb e • ( 'G (7 Date Applied: A114.110
Signature: 2j�24��1 J
Buildingo er n Commissis a or of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: V 3 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes a 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'
21 Owner'of Rgcord:
9A'LG'WLA tk'l
Name(Print) Address for Service:
9ais• 60�( -`-t�t35
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s).q Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': "PAN? W &12,L �. .:� TJ . v1 7e
1� C.t...�J0 k4t, INSV1411Ma 414_0 eAS_-C c` I R\ArJN
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ �'L)L. y11 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g El Standard City/Town Application Fee
_ ❑Total Project Cost'(Item 6)x multiplied x
�
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ p List:
5.Mechanical (Fire $ p
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 52 tL,4? ❑Paid in Full ❑Outstanding Balance Due:
��09
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Re, Fit 3 3
C.4 Jl*a'4I Z-L 1, License Number Expiration Date
Name of CSL-Holder C
S`kO CA4(1A"%1a.J Jl P �M84pt4s List CSL Type(see below) y
Address / Type Description. t
��-- U Unrestricted u to 35,000 Cu.Ft.
gnature R Restricted 1&2 FamilyDwelling
. YI � Z6 �ZIZ. M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) (3 } t
IJew 6s1ti�A n1'� bJr�.� A-.10 �2.cSYJ�,:
HIC ny Name or HIC Registrant Name Registration Number
Scmoo 51. Q:.Mg -Locz
Address \'
)-Is(- $L6,3L1Z. Expiration Date
rate 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 .........P� ' No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, ' tRrl.Raz A I 1 A LU t.J as Owner of the subject property hereby
authorize A j E u to act on my behalf,in all matters
relative to work authorized by this building permit application.
Yignature of Owner Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
I, 2sa^CT �y`V`c�17�2.>, 4, ,as Owner or 421 orized A nt hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
'?>2 y .s- �J1y12 J 3�
Print Name
3/2Z/SO
Sign re of wn or th d Agee Date
Si ed under the pai uejury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 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"maybe substituted for"Total Project Cost"
NEW ENGLAND BUILD & RESTORE INC.
590 Washington St.Pembroke,MA. 02359
Professional building damage evaluation&repair experts
(781)826-7212 Fax(781)826-0240
Client: Barbara Galvin Cellular: (978)604-4935
Property: 4 Summit Ave,#3 Business: (978)657-8331
Salem,MA 01970
Operator Info:
Operator: BRANT
Estimator: Brant Guthenberg Business: (781) 826-7212 x 28
Business: 590 Washington Street
Pembroke,MA 02359
Type of Estimate: Water Damage
Date Entered: 3/11/2010 Date Assigned:
Price List: MAB05B_MAR10
Restoration/Service/Remodel
Estimate: 59401
This estimate is based solely on the findings at the time of our inspection.NEBR Inc. reserves the right to amend this estimate
should hidden or unforeseen damages and/or building code violations or unsuitable job site access be discovered during or
prior to construction.
NEBR Inc. has estimated this project based on completing the entire scope of work as written,performing all phases in a
continuous workman like manner. All work to be performed within normal working hours.
NEBR Inc.to have complete control of job site at all times which includes the following but not limited to:
Job supervision and scheduling, Subcontractor selection and scheduling,job site access,and construction methods and
materials.
Job site access may be limited by NEBR Inc.for safety reasons at any time during construction.No work to be allowed by
owner or any other parties without written approval from NEBR Inc.
After the pre-construction meeting is completed,any and all requests for changes to the scope of work or changes to the
project under construction,shall be addressed in writing to the contractor NEBR Inc. on the form provided to the owner by
the contractor,called"change order request". Once the form has been submitted to NEBR Inc.,we will calculate the cost of
the requested changes,if any,and submit them in writing to the owner for approval.Upon approval of both parties will sign
the change order and the changes shall be completed.Payment for approved change orders are due at the signing of said
change orders.Change orders can affect the construction schedule and projected completion date.
I
NEW ENGLAND BUILD & RESTORE INC.
590 Washington St.Pembroke,MA. 02359
Professional building damage evaluation&repair experts
(781)826-7212 Fax(781)826-0240
59401
Demolition
DESCRIPTION QNTY
1. Dumpster load-Approx. 12 yards, 1-3 ton of debris 1.00 EA
Main Level
Master BDRM Ceiling Height: 7' 11"
Subroom 1: offset Ceiling Height: Sloped
DESCRIPTION QNTY
2. Light fixture-Detach&reset 1.00 EA
3. Ceiling fan-Detach&reset 1.00 EA
4. Smoke detector-Detach&reset 1.00 EA
5. Outlet or switch-Detach&reset 9.00 EA
6. (Material Only)Thin coat plaster over 5/8" gypsum core blueboard 32.00 SF
7. Plasterer-per hour 2.00 HR
Note: One sheet material and labor to repair plaster
Closet Ceiling Height: 7' 11"
DESCRIPTION QNTY
No damaged noted
BDRM2 Ceiling Height: 7' 11"
Subroom 1: Room2 Ceiling Height: Sloped
Subroom 2: Room3 Ceiling Height: Sloped
DESCRIPTION QNTY
8. Smoke detector-Detach&reset 1.00 EA
9. Outlet or switch-Detach&reset 2.00 EA
10. Baseboard-Detach and reset-oversized or multimember 57.17 LF
11. R&R Batt insulation- 10" -R30 144.72 SF
12. R&R Batt insulation-4"-R13 209.53 SF
13. R&R Thin coat plaster over 5/8"gypsum core blueboard 354.24 SF
14. Seal then paint more than the ceiling twice(3 coats) 354.24 SF
Note: Seal raw plaster
15. R&R Light fixture 1.00 EA
Note: $29.48 material allowance
5940_1 3/22/2010 Page: 2
NEW ENGLAND BUILD & RESTORE INC.
590 Washington St.Pembroke,MA. 02359
Professional building damage evaluation&repair experts
(781)826-7212 Fax(781) 826-0240
Closet2 Ceiling Height: Sloped
DESCRIPTION QNTY
No damaged noted
Dining Ceiling Height: 8' 6"
DESCRIPTION QNTY
16. Chandelier- Detach&reset 1.00 EA
17. Detach&Reset Casing-oversized-3 1/4" 50.00 LF
18. Window stool&apron-Detach&reset 12.00 LF
19. (Install)Rosette-corner block-3/4"x 3 1/2" -Hardwood 6.00 EA
Note: Detach and reset rosette and window trim. All care will be used to perform this task without damage. Due to the nature of
this material, damage may occur. If this happens the adjuster will be notified
20. R&R Batt insulation- 10" -R30 176.93 SF
21. R&R Batt insulation-4"-R13 216.15 SF
22. R&R Thin coat plaster over 5/8" gypsum core blueboard 393.07 SF
Grand Total 8,212.47
Brant Guthenberg
Grand Total Areas:
1,686.61 SF Walls 607.86 SF Ceiling 2,294.47 SF Walls and Ceiling
583.05 SF Floor 64.78 SY Flooring 223.32 LF Floor Perimeter
0.00 SF Long Wall 0.00 SF Short Wall 262.72 LF Ceil. Perimeter
583.05 Floor Area 654.88 Total Area 1,686.61 Interior Wall Area
1,502.82 Exterior Wall Area 203.15 Exterior Perimeter of
Walls
0.00 Surface Area 0.00 Number of Squares 0.00 Total Perimeter Length
0.00 Total Ridge Length 0.00 Total Hip Length
5940_1 3/22/2010 Page: 3
NEW ENGLAND BUILD & RESTORE INC.
590 Washington St. Pembroke,MA.02359
Professional building damage evaluation&repair experts
(781)826-7212 Fax (781)826-0240
i ' JZ( ��.i K.E. _ _ ti•lr
i 4a
II �IIMI
1 Front elevation 3/3/2010 Taken By: Brant Guthenberg
Front elevation
L5940 3/22/2010 Page: 4
I
Main Level
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Main Level
5940_1 3/22/2010 Page: 5
CITY OF SMYN, ANSSACHUSETTS
BuUMLNG DEPAMELNT
120 WASHNGTON STREET,Yo FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
1CI\iBERLZY DRISCOLL
MAYOR THOmAs ST.PIERAB
DIRECTOR OF PIBLIC PROPERTY/BuELDING CONLMSIONER
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 it 1.5
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
I 11, S 150A.
The debris will be transported by:
T-'Lc',S4-J L+1-5..1C
(name of hauler)
The debris will be disposed of in :
(name of facility)
I J C �C..ZD.V MA
(address of facility)
sisna}y a ofpernt pplicant
3 /zLf/ ,�)
date
dcbrivwff.dnc
CITY OF &U.F.Ms N'I1SSACHUSETTS
BUILDING DEPARTJtENT
• a• 120 WASHINGTON STREET,3"FLOOR
° TEL (978)745-9595
FAX(978)740-9M
KI.%fBERLEY DRISCOLL
MAYOR THOAfAs ST.P>ERRB
DIRECTOR OF PUBLIC PROPERTY/BUMI)tNG COMNUSSIONER
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumben
Applicant Information Please Print Legibly
Name(BusinesiOrganintion/individual): Z.ZS7TUA ,
Address: SA y W qS Yl t 4 Ta S7
City/State/Zip: 0.N Phone#: \"CtZb 3Lt -z
Are you an empiayer?Check the appropriate box: Type of project(required):
I Aa1 am a employer with ZD 4. ❑ 1 am a general contractor and I 6. ❑New construction
(full and/or part-time).* have hired the sub-contractors ❑
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7• Remodeling
ship and have no employees These subcontractors 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 10❑Electrical repairs or additions
officers have exercised their repo
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LCI 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.] l3.❑Other
;Any applicant that checks box si mutt also fill out the section below showing their workem'comp""don policy information.
t Ih+meownen why submit this sMdwvit indicating they are doing all work and then hire outside contractors matt submit a new allidavil indicating such
=Commioo tMt check this bon mwy a.1140001011 ad9itional shsa showina the none of tM nub.eontngon and their workon'comp,policy Warne Won.
1 am an employer that is providing workers'compensatlon insuraneefar my employees. Below Is the polley and fob site
information.
Insurance Company dame: 4,i art o k,41
Policy It or Self-ins.Lie.#:.LI'Gr" C b a fr O F S Expiration Date: I t I e I L D
Job Site Address: trt S y M M of A-) 3 City/Stme/Zip:__,'>A tsNt MA
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 and/or one-year imprisonment'as well as civil penalties in the form of a STOP WORK ORDER and a Rae
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.
1 do Hereby certify ander th alas and nalrles of peryary that the information provided above Is true and correct
i+n 1 Ire Date: Z L L O
Phone#:
0jr1cial use only. Donor write in this area,lobe completed by city or town officiaL
City or Town: PermitfLicense#
Issuing Authority(circle one):
1.Board of health 2.Building Department J.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person:__ Phone#:
r
c CERTIFICATE OF LIABILITY INSURANCE OP ID RR DATE`MMDDAYYY)
--
PRODUCER NE148II-2 03/22/10
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Mcl3weaney & Ricci Ina Ag Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
2021 Ocean Street HOLDER THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Marshfield MA 02050
-Phone:781-837-7788 Pax:781-837-3399 INSURERS AFFORDING COVERAGE
INSURED NAIL III
INSURER A: Guard Insurance Group
New England Build & Restore, INSURER B: Steadfast zaeatatte Co a�
Inc. INSURERC: Peerless Insurance C an 24298
590 Washington Street INsuRERD Pembroke MMAA
NSURER E:
' . 59
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMEDABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDINGANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY RE ISSUED OR
MAY PERTAIN,THE INSURANCEAFFORDED BYTHE POUCIESDESCRIBED HEREIN IS SUBIECTTOAIL THETERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BYPAID CLAIMS.
ftwwwM
LTR NSGU TYPE OF INSURANCE POUCY NUMBER LI 1 1
GATE MM/OD DATE MNBD UNITS
GENERAL LIABILITY EACHOCCURRENCE $1,000,000
8 X R COMMERCIN.GENERAL LIABILITY GPL596562702 03/tl8/10 03/08/11 PREMISES(Eaetarenee) $100,000
X I CLAIMS MADE ❑OCCUR MED EXP(Anyeneperson) $5,000
PERSONALS ADVINJURY $1,000,000.
X Pollution GENERAL AGGREGATE $2,000,000
GENLAGGREGATE UMITAPPUES PER PRODUCTS-COMP/OP AGG $2,000,000
POLICY 7 jEECT7 LOC
XAIrAE LIABILITY
COMBINED SINGLE LIMIT 51,000,000
ro SA8566858 12/19/09 12/19/10 (EaamaenqNED AUTOS
BODILY INJURY $
LED AUTOS (Pa Pertion)UTOS NEDAUTOS Bar trodILY ant) S
(Per aTadenUPROPERTY DAMAGE $
(Per amdent)BILITY AUTO ONLY-EA ACCIDENT S
O
OTHER THAN EAACC S
AUTO ONLY: AGG $
EXCESS/UMBRELLA LIABILITY EACHOCCURRENCE $1,000,000
B R OCCUR CLAIMS MADE SX05965633D2 03/08/10 03/08/12 AGGREGATE $1,000,0000
$
DEDUCTIBLE
$
X RETENTION $10000 $
WORKERSCOMPENSATION
AND EMPLOYERS`LIABILITY YIN X _to
RY UMRS X ER
'•.A ANY OFFICERIM SERE.LUOE�D4ECUTWF� NEWC006085 11/Dl/tl9 11/01/10 E.L EACH ACCIDENT $50 tl,otl0
(Mandatory in NHl u EL DISEASE-EA EMPLOYEE $500,000
N yes aeseib EL DISEASE-POLICY UMR S500,000
S PECIAL PROVISIONS below
OTHER
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL-PROVISIONS
: NEW Rentals is named as additional insured
CERTIFICATE HOLDER - CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
OATETHEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBUGAMON OR LIABILITY OF ANY HUND UPON THE INSURER,ITS AGENTS OR
REPRESENTATIVES.
AUV7 REPRESENTATIVE
ACORD 25(2009101) 01988.2009 ACORD CORPORATION. All rights reserved.
The ACORD name and logo are registered marks of ACORD
Massachusetts-.Department of Public Safch
Bti:ird oi'Building Regulations and Standards
Construction Supervisor License
License: CS 89597 Restricted to: 00
BRANT R GUTHENBERG
32 YEW STREET *` y
DOUGLAS, MA 01516 s
Expiration: 3/24/2012
('unnniscioner. Tr#: 20293
t i
f'` ✓/ee �JoonmzaruaeaCfli o�./�aaaac%uaella
' Board.of Building Regulations and Standards �4
ii HOME IMPROVEMENT CONTRACTOR '
f{ Registration., 137817
E - n 179/201 1 .
C[ Type Supplement Card
NEW ENGLAND BUILDTOR
UT
g 5FN&T GHENB RG s I.r t=t
F
590 WASHINGTOR'-STV�/% �-d,:+GLa•^� {
PEMBROKE MA 62359 Administrator 1
1