4 SUMMIT AVE - BUILDING INSPECTION (4) The Commonwealth of Mtt cQ*kaL6Us SERVICES
Department of Public Safety
W
Massachusetts State Building Code(7�()�Ch�R�� �� ^ '�. 14 Building Permit Application for any Building other than` A U r o amr y Welling
(This Section For Official Use Onl )
Building Permit Number: Date,Applied: Building Official;
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of MA Stab Code used_ If New Construction check here❑or check allthat apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration 07 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change Of Occupancy ❑ 1 Other O Specify:"
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: QG
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) ❑
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq,ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 If Hi h Hazard H-1❑, H-2❑ H-3 ❑ H4❑ H-5 O
1: Institutional 1-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use: -
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ 116 O ILIA ❑ 11111 ❑ IV O VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CbIR 111.0 for details on each item)
Debris Removal:Trench Permit:
Water Supply: Flood Zone Information: Sewage Disposal: Trench
Disposal Site❑
Public❑ Check if Outsideus d Flood Zone❑ Indicate municipal❑ A trench will not be P s
required❑or trench or specify:
Private❑ or indemify,Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: %I,1\Il,tpri G nmmigion l:�.rtpr.l}girC
Not Applicable❑ Is Structure within airport approach Brea? Is their review completed?
or Clmsent to Build enclosed❑ Yes❑ or Nu❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction:_ Occupant Load per Floor:
Does the building contain in Sprinkler System?: _ Special Slipulatiuns: __—.—
r
SECTION 9: PROPERTY OWNER AUTHORIZATION
7(Print)
ess of Property Owner
I-lSuh+n:T RVC _ _ satr�-� hA 0_�
No.and Street City/Town Zip
Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
.� 4-fYtru-T ft\je
Name Street Address City/Town State - Zip
to act on the property owners behalf, in all matters relative to work authorized by this budding permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.it.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
sFal.) orAr�Notzr 9�1��
Name(Registrant) r Telephone No. a-mail address Registration Number
O?1 11 i .4�nc9 ST r Eh nk- V k O 114
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
C, �Nvi�-cep
Company Name
ESL/ CS OQ'J !03
Name of Person Responsible for Construction License No. and Type if Applicable
f2ro C` n—tJV� 1;i-N-- "Pr ox ��
LOB.
A�dddrree�ss,�� City/Town State Zip
S'x—>- 3 ii*"'Telephone No. business Telephone No. cell e-mail address
SECTION 11:VVORRFh9'<:OfsIPFN5AI ION INSURAN(T.AFFIUAVFI' M.C.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12.,CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ -'H 10
1. Building $ Building Permit Fee-Total Construction Cost x_(insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
d. Nechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check tble to
6.Total Cost $ {'� (contact nunicia
vra
ality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 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 ofe knowledge and understanding.
Please print and sigr>,mm�e Title Telephone No. Date
_ C 'J b EP�6�iu 4ve0-� S`C �Prl f� VIQ_ o(e 40
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name Date
The Commonwealth of Massachusetts
Department of lndustrialAccidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
uVom-orkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Auolicant Information { Please Print Leeibly
Name (Business/Organization/IndMdual): }fx�
Address: ao--,?W wwwy_��
City/State/Zip: i: , "4. Phone
7Are you an employer?Check the appropriate box: Type of project(required):
I.�I am a employer with _employees(full and/or part-time).* 7. ❑New construction
2.❑I am asole proprietor or partnership and have no employees working for me in g, ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
9. ❑Demolition
❑4.�I am a homeowner and will be hiring contractors to conduct all work on my property. =will 10 Building addition
ensure that all contractors either have workers'compensation insurance or are sole I LL]Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet ]3.❑Roof repairs
These sub-contracmrs have employees and have workers'comp.insurance.= .-, ,�r��.
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Otber we pr..f 9teo QQOC
152,§I(4),and we have no 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.
=Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they most 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: t`12
Policy#or Self-ins.Lic.#: Expiration Date: �S �o
Job Site Address: AV-Ez, City/State/Zip: S� hl t, 05`
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.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/pa1i and penalties ofperjury that the information provided above is true and correct.
Signature: _/ Date: (0/B23/)-5__
Phone#: `/ Q � 14-fS 8
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee 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 other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL 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,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance 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 maybe submitted to the Department of Industrial
Accidents for confirmation 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 be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sureto fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemnit/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 filled 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. a dqg license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
203 WASHINGTON ST.#256
P R E S E R V E SALEM,MA 01970 '
SERVICES carpentryIpaintingIroofingIgutters PHONe978.745.8745
FAX:978.745.3476
r e- SALES@PRESERVESERVICES.COM .,
4 Summit Ave Condominium
4 Summit Ave Date Bid:1/24/2014
Estimator:Sean O'Connor
Salem MA, 01970 Email:sean@preserveservices.com
(978) 500-9290 017-1*5 Mobile:(978)395-7737
jtaberpublicity@gmai.l.com
ROOFING ESTIMATE
COMMENTS The below basic estimate is to replace the front and right upper sloped roofs.
PRIOR PREPARATION
PERMITTING: All permits will be obtained in accordance with the law as required.
DISPOSAL: A dumpster will be placed in an area designated by the homeowner.
ROOFING PREPARATION
COVERING: Tarp the exterior of the house so as not to damage the siding.
SHINGLE REMOVAL: Remove all layer(s) of old shingles.
NAILING: Re-nail roof decking as necessary.
UNDERLAYMENT
FELT: Install 15 lb felt on all areas not covered by ice and water shield.
ICE AND WATER SHIELD: Install 3 feet of ice and water shield on eves and valleys. Install as
necessary on other areas.
FLASHING
DRIP EDGE: Install drip edge on all perimeters.
WALL JUNCTION: Install or rework flashing where the roof meets the wall.
CHIMNEY(S): Install new flashing around all chimney(s).
ROOFING MATERIALS
ASPHALT SHINGLES: Install architectural Limited Lifetime shingles.
PRICING
Basic $ 7110
Sales Tax $ 0
Total Price $ 7110 including Labor & Material
Payment Terms: 20% deposit (day of start); 30% progress; 50% end of job McNisa/Amex
/ (.vtll-, lL-
Sean O'Connor Customer Signature
ADDITIONAL TO ABOVE ESTIMATE:
BID 1: Rear Roof: Same system as above.
Price $ 2375 Including Labor and Material
BID 2: Lower flat roofs above the porch and bay window. Replace the flat roofs with a rubber roof.
Price $ 1975 Including Labor and Material
New T
Installation Note:
If you have an older home that has dimensional lumber for roof decking you will need to cover your
attic because shingle debris may fall into the attic and create a mess.
*Above additional prices includes all discounts and coupons discussed prior to estimate. The
above quote is valid for 60 days.
*Warranty: Craftsmanship: Kyron Inc. DBA Preserve Services warrantees all work performed
for a period of 2 years. If any problems occur we will cover the cost of labor and materials. For the
warranty to be valid the invoice that was presented at the time of completion must have been paid in full.
Materials: The duration of the manufacture's warranty is specified in the materials section above. Acts
of god are excluded in warranty such as but not limited to tornados and hurricanes.
Licenses:
Home Improvement Contractor (HIC): 123553
Protection: It is required by law that roofing contractors have a home improvement contractor
license. If a contractor is properly registered, you are entitled to limited protection by the
Residential Contractor Guaranty Fund up to $10,000. (The above is a only a summary of
Massachusetts General Law 142A) To check our license or our competitors go to:
http•//db.state.ma.us/homeimprovement/licenseelist.asp and license 123553.
Constructor Supervisor (CS): 93403
The construction Supervisors license is under an individual's name, not a company name. To
check Sean O'Connor, owner of the Kyron Inc. DBA Preserve, license go to:
http://db.state.ma.us/dps/licenseelist.as� select Construction Supervisor and license 93403.
Insurance:
Worker's Compensation:
Our policy is under Kyron Inc. DBA Preserve Services
Protection: Covers the injury of a worker employed by the contractor doing work at your home.
To check our policy or our completions go to ham://mass. ovg /dia/ on this page go to "check
worker's compensation proof of coverage" our license is under Kyron Inc.
Liability Insurance
Our policy is under Kyron Inc. DBA Preserve Services and has limit of$1,000,000.
Protection: Covers your property in the event of accidental damage up to a dollar limit specified
on the policy. To check our policy we will have to contact our insurance company.
i
QTY OF SALEA MASSAaiLISEnS
({� } B[IILDINGDEFARTMENT
120 WASHINGTON STREET,YDRDOR
TEL.(978)745-9595
RIMER LEYDRISQOLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF FVBLicFROFERTY/BU[LDING ODASHSSIOMR
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 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit#i is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
s K
(name of hauler)
The debris will be disposed of in:
(2�7
(name of facility)
/eo -,
(address of facility)
Sign ture of applicant
Date
Massachusetts -Department of Public Safety
•'� Board of Building Regulations and Standards
- - Construction Supen isor _
Qcense CS-093403
SEAN OCONNOR-- _
26 CHESTNUT Si 41
SALEM MA 01710 - -
�yl ;
f"�� - .-Expl ratior
-Commissioner - 12/311201:
- �J/aa 1po�ixnzmrurreall�a��lamac�rue
Office of ComumerAITain&Business Regoladon
VExpjratlon:,�36t&7�.,
OME IMPROVEMENT CONTRACTOR
egistration 123553 Type:. .. DBA
Preserve Painting -
Sean O'Connor -
203 WASHINGTON ST #256
SALEM,MA 01970 -- �_ Undersecretary
ACORD CERTIFICATE OF LIABILITY INSURANCE 05/`M"5/27/20152015
PRODUCER (978) 745-6464. THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 958
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC 0
INSURED INSIRERAWESTERN WORLD INSURANCE C
&yron Inc. clba Preserve Services INSURERR Hartford
203 Washington Street #256 1 INSURER c Travelers
IIN=D,-Great AlDerican
em Sal MA 01970- NSURER 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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.
INSR ADDL FOLICYEFFECTIVE POLICY EXPIRATION
LTR NSR TYPE OF fNSURANCE POLICY NUMBER GATE NMm DATE(MM7DDIYYI LIMITS
A GENERAL LIABILITY NPP8236095 05/22/2015 05/22/2016 JAG��TE
CCURRENCE T 1000000
$ COMMERCIAL GENERAL LIABILITY ETORENTED 100000
SES Ea occwrence $
CLAIMS MADE ❑OCCUR / / / / P(AAY oIe 1 3 5000
NAL&ADVINJURY 3 1000000
ALAGGREGATE $ 2000000
GENLAGGREGATELIMIT APMJESPER: CTS-CDMP/OPAGG 3 2000000
X POLICYT& LOC I /C AUTOMOBILELIABILRY 46BCS5787 06/05/2015 06/05/2016 NFDSINGLE UMTTANYAUTO IdeaU 3 1000000
ALLwr®AUTOS / / / / ENJURYSCHEDULED AUTOSrsan)x HIRED AUTOS INJURY
X NONOWNEDAuros (Perawileny 3
/ / / / PROP DAMAGE
a
GARAGELIABIUTY
AUTO ONLY-EA ACCIDENT $
ANY AUTO / / / / OTHER THAN EA ACC $
AUTO ONLY. AGG $
D E(cEssANniNeaLA LIABIUTv 2BS0040350 06/01/2015 06/01/2016 EACH OCCURRENCE s 2000000
OCCUR ®CWMS MADE AGGREGATE 3 2000000
5
DEDUCOBLE / / / / 3-
-RETENTION S
3
B WORKERSCOMPENSATIONAND 6S60tMO523NOO914 05/20/2015 05/20/2016 X ToRYu"Iw`r's �"'
EMPLOYERS LIABILITY
ANY PROPRIE70RIPARTNERA7(ECUOVE EL EACH ACCIDENT $ 500000
OFFICERIMEMBER EXCLUDED? / / EL DISEASE-EA EMPLOYEE S 500000
N Yes,dernNle undV
SPEQALPROVVaGNSb E.L.DISEASE_POUCY UWT 3 500000
DE9CNPTION OF OPHN/\TIONSILIXATIONSIVpiIGLESE](CLUSIONSADD®BY ENDORSEMENT/SPECIgL.PROVI510N5
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BffORE THE
EXPIRATION DATE THEREOF, THE ISSUING NSVRET WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT
Barbara and Frank BOdengraven FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
19 Brookside Road INSURER,ITS AGENTS OR REPRESENTATIVES.
Boxford, MA 01921 AIJTHOR•ZE0 TATNE 'd•OC. 0"'?,
ACORD 25(2001108) 1 0 ACORD CORPORATION 1988
INS026(mge).w Page I d2