4 TREMONT ST - BUILDING INSPECTION I'fie Commonwealth of Massachuscits
I o Board of Building Regulations and Standards CITY OF y 5,
' Massach usetts State Building Code. 780 CNIR e,,.. lr,•ri.,ed.t�,rr Jell
Building Permit Application To Construct. Repair. Renovate Or Denwlish a
One-orTuu•funril) Duelling,
This Section For Official Use Only
p7o-ning0istrict
Permit Number: _ Date Ap lied:
b�011icial(Print Niune) Signature pule
SECTION I:SITE INFORM TION
{ L {. L 1.2 Assessors.%Np& Parcel Numbers
ao accepteddstretTyes no \hip Number Parcel Numhcr
g Information: 1.6 Property Dimensions:
rict Proposed(Jae Lot Area(sq 11) Prootage(11)
1.5 Building Setbacks(11)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. Jm. §74) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Ihtblic❑ Private❑ Zone: _ Outside Flood Zonal Municipal❑ On site disposal s)stem ❑
Check il' es❑
SECTION 1: PROPERTY OWNERSHIP'
2.1 Ow er'ofReca : �� r M^
'Jaw
Mune(Print) oily,Slatc.ZIP
No.and Street Telephone Email A ress
SECTION J: DESCRIPTION OF PROPOSED WORKs(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repoirs(s) ❑ Alteration(s) Q Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Spccily:
Brief Description or proposed Work':
��- - y'oc� ✓v(-SC Fi�IS (i--c'21L
(% SECTION Jt ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor:md..\I:uerials) Y
I. Building S I. Building Permit Fee: f Indicate how fee is determined:
2. Electrical S ❑Standard CityiTosvn Application Fee
j',`t ,�` ❑Total Project Cost'(Ila 6)n x multiplier ___ x
1. 1'lunihing S 2*1J ?. Other Fees: S �'- -- -
J, Mechanical ill\.1(') S List:._
5 Mechanical (Fire
ucsiionn S Totnl .\IlFces: S
Check \b. _('heck :\nunnn: (', h \molars:
A r. Total Project Cu+(: S ❑ Paid in Full ❑Outstanding Ilahmce Ouc:
v
SE( IIONS: CONNI-RUct-IONSERVICFS
tG 67
Npiralion Pole
St. I(older 4 - L SI. 1.%IV('ev
S- --- 3e
Dcsariplion
No and Street I I t lirvs1ricied(Iluildinp on it,
R lic.,tricted 1A,I F i...ill 011111i"I
City m,SI'lle. Mason
RC itoolin L'..,qrinj
Windowa-1-i
SF Solid Fuel Ihlming "pli-11"-
Insulation
FelcPholic Finai-I addrv.i D Demolition
3.2 Registered Home Improvement Contractor(HIC) �7-1c)3 11
F\piralioil Date
IIIC Regibiration Nuin
I I IIC Ile * trant Ni is S;"'j'as'
Email address
�14 and truet
Zi, frown.State,ZIP relechone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.it. 152. 1 2SCM)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atYidavit will result in the denial of the Issuance of the building permit.
Signed A Mdavit Attached? Yes ..........cr" No...........0
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 rily'l J� /4-pilaur
to act 2amy behalf,in all matters relative to work authorized by this building permit application.
11riTit Owner's Nanic(ENctrunicStanuturtF Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my D low, I hereby attest under the pains and penalties of perjury that all of the information
contained it s lication is true and accurate to the best of my knowledge and understanding
riot owicr'i orAuthoriivd,%gel1l'A Nano:(EICCLAMIC Signature) Dwc
No ULS: I
I An O%�iicr 7\sho'obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program). will LU) have access to the arbitration
program or guaranly l'usid under.M.G.L. c. 142A. Other important information on the HIC Program can be lbund at
wa, Information on the Construction Supervisor License can be found at%%%%,, 111,1,; �;ol .111,
[2.:\%he:nsubsiantial ourk is planned, provide the information below:
r tal flour
r, 1,4 t
rota) floorarva I,+ fl.) I including garage. finished basement attics,decks or porch)
Habitable room couni
Gr0!i5Ii%ing area(s4. It I
11 \omhcr offircillaces \o,,,her o(bcdrooms
Numberol'hathrooms \tooher of hall ball'i
I\pc of heating i%'Ieol \owhcr ot'decks, porches
I* I'V ofcoolillq '%ilein I'ncloicd . ..Open
I Foi.il Prow Square Foolacc- toj1% [,v itibminacd 11or l'olal Project CONI"
CCI•Y OF S:1LE��[, AkSSACHC;SETTS
BUILDING DEPARTMENT
120 \V.ISHLNGTON STREET )aa FLOUR
TEL (978) 735-9595
F.kX(978) 710-98. 4
Kl.\IBERLEY DRISCOLL
Alkyo Z TNo\LU ST.P{EA"
DIRECTOR OF PL'OLIC PRO PERTY/aumo NG CO\OIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractorv/Electrlcian.*JPlumbers
limillcant Information AA 11 __ PI ye Pr hit Le2ihty
V;ttlu tl{mitesOrWamratinn Individual): �as /fn �l
Address: 17H
City/State/Zip: An �t J d hone
Are you in employer!Check the appropriate boar 'type of prnicet(required):
I.❑ lam a employer with _ 4. ❑ 1 am a general contractor and I
employees(fill and/or part-time).• have hired the sub-cantrctar 6. O Now construction
2.i] 1 am a sole proprietor or partner• listed on the attached shc4m t 7•Z�4emadeling
,hip and have no cmplayees These subcontractors have V. Demolition
Working for me in any capacity. %vorkers'comp,insurance. ), Building addition
(, o workers'.comp. insurance S. Cl We are a corporation and its
required.) ofOcers have exercised their 10.❑Electrical repairs or additions
3.111 am a homeowner doing all work right of axamption per MOL 1 I.❑Plumbing repairs or additions
myself.(No workers'comp, c. 132, ¢1(4),and we have no 12.0 Roof repair
insurance required.( r umpluyees, [No workers'
Lump. insurance requireJ.) 13.0 Other
-.try appllawn awl ehcuks but rI mwt also fill I'll the wuliuo below showing their waken'compenudun punay inaumudon.
'I hvmuw,ave wha.uhail this arrldava indieaing they am doing ill,writ and thet him uullide eealn ten MIMI Iuhmlt s raw alaldavit indicting malu
:t•,mtmvwn that check this box must anached.m s.Wtdumd-hsl shuwing Iho awno a/the rule wousctun and their workers•wrap,policy InPooradon.
/urn an eurpluyrr that/s pruvfdholl rvarkrrs'cumparrar/un brsuraneejor my etnplayres
injurnrurinn Befuw b the policy undJub slr�
Imurutce Company Name• ��'G It�C
Policy Y or Seif-ins• Lic• H: PTOLS —q n 0 P r `—q—I Expiration Date• /U 03
lob Sile Address: Cilyistute zip:=XM0'/ 'L
Attach a copy of the workers'compensalloo pulley declaration page(showing the policy number and esplradoe data).
Fit tutu to secure coverage as required under.Section 2JA )t'\IGL c. 152 can lead to the imposition of criminal penalties of a
fire up to SI,500.00 und/ur one-year imprisonment.it well is civil penakies in the romil offs STOP WORK ORDER and aline
of up to S_'J0.00 a Jay against flit violator. Ile advised that i copy of this,fatumcnt may be furwirdcd tothe Ol'licd of la rc,I i gat iuns,dthe f)IA liar i nsurancecovcragc vcri kcal ion.
/du hereby cerrij a du r mid prnu/t/r.r nIprrjury that the injunnudun Provided abuse it tsar auJ carrrrr.
h •,P
F
ue manly. Oa nor write in drip area, to hr cunfplrred by City ur sown.�/Jlriul
vo: _ _ __ PermiriLlcenre d
ulhnnc)tul lieahh '. Ituihlim, I)eparlmenl { ('ity/fuan C'ILrk ). lircetric.11 6I'lict6tr i. Dlnntbin�
ernnn:
Big s A' Home Improvement
Lynn,Ma 01.902
81 Gertrude Street
(857)891-2589
Licensed and Insured
Thalia& cTrav-�
4 Tremont St.
Salem.Ma
Job description:
Bathroom:
-Demo left bathroom wall/and dispose.
-Move left side bathroom wall over to desired location
-Purchase and install light vent cut hole in exterior wall to vent outside.
-Purchase and install GFI outlet.
-Sheetrock/plaster/paint
-Plumb in new shower stall and valve.(Supplied by home owner).
-Disconnect toilet/vanity
-Move flange to toilet/install new toilet (purchased by home owner).
Install new vanity/faucet (supplied by homeowner).
-Prep floor and install file (supplied by home owner) .
LAUNDRY ROOM:
-BUILD IN WASHER/DRYER WITH AN L SHAPED WALL COMPLETE WITH
DOOR.
-Sheetrock/plaster.
GRAND ROOM:
-Install lally column covers (purchased by homeowner)
-Patch in tile in needed areas. I W
-Sheetock/plaster/prime stairwell wall/and backside of same wall.
- Wrap beam with sheetrock/plaster.
-Plaster in ceilings where needed and match texture
-Install base board and widow trim for 2 windows
-Purchase and install douglas fir handrail system.
TOTAL 10,350.00
WITH A DEPOSIT OF 3,450.00
2"d payment when all wall are framed and boarded.3,450.00
Final payment of 3,450.00 when job is complete.
"PERMITS INCLUDED"
"DISPOSAL INCLUDED"
**ANY WORK NOT LISTED IS NOT INCLUDED AND CAN BE
DISCUSSED .**
Thank you,
Sean Anderson
X
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lr
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05/25/2012, 09:16 7815985957 DIVIRGILIO GROUP PAGE 02/02
CERTIFICATE OF LIABILITY INSURANCE °""�" '
���� CER 5 S12S 25 12
TMS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the Policy(ies) must be Endorsed. 0 SUBROGATION IS WAIVED,subject to
the terms and Conditions of the policy,certain policies may require an endorsement A statement on this certificate does not confer rights to the
Certificate holder In lieu of such endorSernentil
C
PRODUCER NAME,, _-
Divirgilio Insurance Agency PHONE y, ,781) 592-5220 FAX
(781) 59B-s95T
270 Broadway A USE, al@divir ilioinsurance.com
P.O. BOX 8065 WSUrnm a AFFORDING COVERAGE NAICg
Lynn, MA 01904 INSURERA:Patrons Mutual Insurance
INSURED INSURER a:Travelers
SEAN ANDERSON INsuRERc: _
BIG A'S HOME IMPROVEMENT LLC INSURERD: _
al GERTRVDE ST 1 INSURER E: -
LYNN, MA 01902 1 INS[I P:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LT TYPEOFINEURANCE I=im
ER POLICY NUMB ER PMIDnrr MMND/Ym' LIMITS
A GENIRAL4IAEILITY CTR0010445 5/23/11 5/23/12 EACH OCCURRENCE $ 500.,000
OAMAGETO RFRTED S 5O,OOO
_ COMMERCIAL GENERAL LIABILITY 'cCALSF,9_(Fa.00WRPRt
_ CLAIMSM. DE nOCCUR MED EXP IArryE�xam) L 5���0
PER60 NALA ADVINJURY 4 SOD QOO
GENERAL AGGREGATE 4• 1,000,000
GENT.AGGREGATE LIMIT APPLIES PER PRODUCTS-00011DIIAGG 5 X,000,OQQ__
POLICY PRO-ACT LOC $
AVTOMOaIL£UABIUTY EaMgccloemyl u LIMIT T
$001L Pinion)
Y INJURY Pion) $
ANYAU O
ALL OWNFO SCHEDULED BODILY IN.IURY(Pei ACGdanU $
AUTOSAUTOS
PRTJPERd- DAMAGE
HIRED AUTOS AUTOSWNFD (PaLpal•aM)
$
U Me REWA LIAR OCCUR
—^ EACHOCCURRENCE $
E%CESS LIAB CLAIMS,MADF. _AGGREGATE
DED RETENTION 4 $
B WORKERS COMPENSATION 7PJUB-487OP77-4-11 10/13/11 10/13/12 X WC STATU- DTH-
AND EMPLOYERS'LIABILITY YIN _LIMI.T.$_
ANY MOPRFMRIPARTNRR/EXBCUTNE NIA E.L,EACH ACCI GENT S• 100,OOD
OFFIM MIEM9ER EXCLUDED? E.L.DISEASE-F.A EMPLOYE $ 500,000
Pdaedemry In NH)
TyBA dMEllbe undo! E.L.DEEAEE E.
POLICY LIMIT $ 10D DDQ
DESCRIPTION OF OPERATIONS below
UESCRIPTIONOFOPFRATIONS/LOCATION9/VEMICLES (AMecN ACORD 101.Addlllonel Rv"A Schedule."M.-space le regU red)
Carpentry
re: Thalia Acruias
4 Tremont Street
Salem, MA
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES 9E CANCELLED BEFORE I,
THE EXPIRATION DATE THEREOF, NOTICE WILL OF DELIVERED IN
City of Salem ACCORDANCE WITH THE POLICY PROVISIONS.
Salem, MA 01970
AUTWORDED REPRESENTATIVE
Dan Richard
®1988,2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E-Mail:
Oflire of Comer�� a�&�B�nes��ujan
_-= HOMEIMPROVEMENT CONTRACTOR.
Registration sA62103.
Expiration 1/14 013 TYPe
Individual
S A ANDERSOfY'� -�
F.
�r1
SEA N ANDERSON ._ ,F.
81 GERTUDE ST. 4
LYNN, MA 01902
r.,
Ala.s.cachuscits - Department of Puhlic S:d'cth'.
1 BO:1 A of Buildin', Re ulations :(nd Standards
�— Construction Supervisor License
License: CS 99866 ,1 _
SEAN ANDERSON
81 GERTRUDE STREET y
LYNN, MA 01902
Expiration: 10/26/2013
(bnmisxioncr Tr#: 4283
06/07/2012 08: 30 7815985957 DIVIRGILIO GROUP PAGE 02/02
CERTIFICATE OF LIABILITY INSURANCE DATE(Mm/o6/7 wy"Y)
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CEFTIFlCATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALL THE COVERAGE AFFORDED BY THE POUCHES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING AFFORDED
R(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED, the PDllcy(les) must be endorsed. If SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In liau of such endorsemen s).
PRODUCER A T
Divirgilio Insurance Agency Fnpnle
270 Broadway .MwL 781 592-5220 FP'x N , (731) $98-5957
P.O. Box 8065 AbDREss: al@diva.r a-liolnaurance.com
Lynn, MA 01904 _.. INSUAR� AFFORDING COVERAGE NA_IC0
- INSURERA:Patrons Mutual Insurance
INSURE
'SEAx ANDERSON INSURER B:Travelers
.BIG AIS HOME IMPROVEMENT LLC INSURER c
81 GERTRUDE ST Ll"'LEIR
RER D:
LYNN, MA 01902 RERE: _.
ER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 15 SUBJECT TO ALL THE TERMS,
EXCLUSIONS ANDCONDTIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
TR TYPE NI OPINSURCE AWL URR '-
POUCYNUMBE PM=N IDWYYYY LINTS
A . GENERALUARILITY CTROO10445 5/23/12 5/23/13 FACHOCCURRENCE a _ 500,000
COMMERCIAL GENFRALLIARILITY DAMAGE TO •O —
11EMlSCS(Eo OccaRenFa E 50,000
culMs MnDE occuR MED Eon N Ndro Pernm) E 5 000
PERSONAL&ADV INJURY E _ 500.0_0_0_
-- I GENERAL AGGREGATE _E 1,000,ODO
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGG g
POLICY PRO. LOC 1 O0l),,000.11
w
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AUTOMOBILE LIA91UTY IN FINGLEL
Ee eddlda,I( g
ANYAUTD OODILY INJURY(Per p man) E
ALLOWNEO SCHEDULED .- ...._
AUTOS AUTOS BODILY INJURY(Per accident) E
HIREDAIJT08 ._.._nUTpSWNEO PROP• YpAMAGE a ---
PeracClpanU
„ E -
UMBR,L 13 B OCCUR EACH OCCURRENCE q
EXCESS LIAR .,CLAIMS,MADE Il
•- AGGREGATE __ E
bEb ENTION E "
E
B WORKERS EMPL YERS'LSATIDN 7PJU9-4B7OP77-4-11 10/13/11 10/13/12 WC STIMIT
AND BdPRIETOR'LIARILRY YIN X TDRY-41MIT
ANY PAT
ROPRIETOR?+ARTNERIE%ECUTNE NIA E. L.EAC_y-ACCIDENt E 100 000
OFFICERMIEMBER EXCLUDED?
(Ma MebD•In Nin —"
Il yyeadMariheundor E-L—RISEASE-EA EMPLDYEF, A 5DO,pqO
DESGI RIPTIONOFOPERATIONShalow E.L.DISEASE-POLICY LIMB E 100 000
VESCRIPTION OFOPERATIONS I LOCATIONS)VFNCMS (Mach ACORD 101,AMIdonal ROMAS Schaddla,If MDIR RPM Is mgUIM)
Carpentry
re: Jose Pena
189 Jefferson Avenue
Salem, MA
CERTIFICATE.HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE bESCRIBED POLICIES 96 CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem ACCORDANCE WITH THE POLICY PROVISIONS.
Salem, MA 01970
AUIHORLLED RFPRESENTATIYE
Dan Richard
®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E-Mall: