71 TREMONT ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts 4 AL
Board of Building Regulations and Standafds " TY OF
Massachusetts State Building Code, 780 CMR SALEM
� ' 2 A Weii0d Mar 2011
Building Permit Application To Construct,Repair, Renova r e oltsh a
One-or Two-Family Dwelling
This Section For Official Use Only \f r_-72r3 t�,1_ CA I v gt�3 C3 Id)I
Building Permit Number: Date lied: I
�
Building Official(Print Name) Signature Date
I SECTION 1: SITE INFORMATION
i� 1 1 Pro ¢rty Address:' 1.2 Assessors Map&Parcel Numbers
TI . rnDrj ST. 5Rt.-en
L 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 ft) Frontage(ft)
1.5 Building Setbacks(it)
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'
2.1 Owner of Record:
R" .5 i m'P5ID f'] SALEn1 MA
Name(Pr' t) City,State,ZIP
TI IMEMDIJT ST, god-S x-39n J ut-st • csm4 �qma 1. n�•
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other 'Specify: i
Brief Description of Proposed Work':
� \
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1 D0 •0D 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ j ✓ 7 ❑Paid in Full ❑Outstanding Balance Due:
s�luf> of S psaQ
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston, MA 02I14-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Avillicant Information
Please Print Legibly l
Name (Buiness/Orrgaization/Individual): C.LOD PCrA CONT `P- C
Address:- a'?) �� eltt � .
City/State/Zip: Cbft_)n-D,,MPv
OOIS4� Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
I I am a employer with employees(full and/orpart-time).• 7. ❑New construction
2.0 1 am a sole proprietor or partnership and have no employees working for me in S. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑ Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 1 I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13. Roof repairs
These sub-contractors have employees and have workers'camp.insurance.t
6.❑we are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other
152,§1(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 a new affidavit indicating such.
tContractors that check this box most 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 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. � r (- Rol
Company Name: [ `
Insurance Co C�] p��
Policy#or Self-ins.Lic.#: lY�-�y�l.(1 oLUr,J-p� O'7J-I f —I� Expiration Datecnv`}�—ay�S ImI
Job Site Address �[t GJNT sr- City/State/Zip: 5R ,[1 I [l l t1T
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 certi under the pains and penalties of perjury that the information provided above is true and correct.
Si ature. 7 I-� Date: I
LIJ
Phone# (D � a�t V 4
Official use only. Do not write in this area,to be completed by city or town oJjiciaL
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#:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ' O/ „ -t 2 0-+ z�oi u
�0 `OD Q)IT P" License Number J Expiiration Dateo'V
Name of CSL older
List CSL Type(see below)
308 i &t� Si^.
No.and Street Type Description
au P
l�O O n�L.J i0, O�1 —F-. Unrestricted(Buildings u to 35,000 cu.ft.
'`em J R Restricted 1&2 Family Dwelling
City/town,State,ZIP M Masonry
RC Ranting Covering
WS Window and Siding
Q'C1 �y�h /��� l SF Solid Fuel Burning Appliances
VJI JWV� �h r"E! f)C-CCLYAYALA, I' I Insulation
Tele hone —ram Email address D Demolition
'5''.�2 Registered Home Improvement Contrac�tor,..�(HI-C�) -�^ I'lc- � 1 S7
" � Ry `S� •IVTI -��`I`VWGU`1 HIC"lReegistratioCn Number pir
m WCi� tName t")O( ,bmnG' c- a, . Lon�
(Q3W' Wb f'X�(� � p5�a�s..�� Email dresa� s
City/Town,State,ZIP 0 N� D 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 .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR ILDING PERMIT
/J�� /�
I,as Owner of the subject property,hereby author' 0-60 A
to act on my be , 'n all matters r I ive to wor uthorized bkllhis building permit a plication.
Print Owner's NaVe(Ele is Signature) /e
SECTION 7b: OW '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.
u
PrintOwner's or Authorized Agent's Name(Electronic Signature) 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 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"
+ t
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3
JB RG
General Contractor, Inc.
Roofing Specialists
Email: jbrggcinc@gmail.com
Website: www.medfordroofservices.com
Address: 328 High St. Medford, MA 02155
Phone: 857-251-5404 or 617-415-3264
License & Insured
CS-106753 HIC-175198
Client Name:Amy Simpsom
Address: 71 tremont at
Phone#802 522 7899
Email: nurse.ams®gmall.eom
Set up before
We will review the plan to protect plants, walls,windows,door, around each section of the
house as the work progresses that area.
Multiple-day Installation: If our installation takes more than one day, our crew will clean up
their work site, collect debris and leave you able to walk around the house at the end of each
day.
Estimate to Strip 100% 1 Layer of Asphalt Shingle and Install New Shingle on Entire Roof,
Main Roof Front and Back of the House.
*Install new ice water shield all way around of the roof edge skylight,vent pipe,valley, chimney
*Install new Rhino Roof Synthetic Roofing Underlayment,Shingle-Mate® Roof Deck Protection (also
called roofing felt for underlayment)Superior-PROTECTION Quality Roof
*Install new 8 inch white drip edge on entire roof edge Drip-edge materials protect the edges of roof
sheathing from water penetration due to driving rains;
*Install new flashing on chimney new lead;
*Install ice water shield all way up on the chimney under flashing;
*Install new pipe boot flashing;
*Install new cobra exhaust ventilation on the ridge;
*Install new start strip;
*Install new Architectural shingle roofing GAF TIMBERLINE LIFE TIME owner chose the color;
*Install new roof ridge cap.
Rubber strip one existing layer of rubber and insulation
1 Rubber strip one existing layer of rubber and insulation
t1 Install new half inch insulation install new rubber install
\ Finish with cover tape seam tape uncle flashing drip edge
Dumpster will be provide by contractor
Permit will be provide by contractor
100%labor and material specified above included
Note only 60 line ft.of roof plank is included for the rotten wood if there is some, more than 60 will be
charge$25 by plank installed Install if needed the plank size is 8x16 long
8 years labor warranty
'After Installation:We will do a walk through with you,to assure your complete satisfaction.
We want you to be JW%satisfied with your projectl
Payment:
30%of payment upfront when sign the contract and pull the permit and the remaining balance when
job is 100%completely done.
Total:$5,000
At signing of the contract:$1,500
At the completion of the project:$3,500
N\ S, have read this Agreement and agree to the terms and
conditions.
Owner Signature: 71 " r I�
Hom Own r date
Contractor Signature:4* ���•t'6
Joao Baia date
JBRG General Contractor Inc.
•; f Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supcn-mir
License: CS-106753
JOAO BALA
328 HIGH STREET a 1
Medford MA 02135 ? ,�i ZOO
Expiration
Commissioner 07/2 212 01 6
t
i Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
e - Registration: 175198
x}
Type: Corporation
t"I- Expiration: 4/29/2017 Tr# 263431
JB RG GENERAL CONTRACTOR, INCH t,
JOAO BAIA P
328 HIGH ST 47 r i
MEDFORD, MA 02155
Update Address and return card.Mark reason for change.
seA1 e, z0n+osm _ Address �`1 Renewal i_l Employment ❑ Lost Card
w Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
_- HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 175198 Type: Office of Consumer Affairs and Business Regulation
_' Expiration:. 4/29/2017 Corporation 10 Park Plaza-Suite 5170
Boston,MA 02116
JB RG GENERAL CONTRACTOR, INC.
j
JOAO BAIA
328 HIGH ST
MEDFORD,MA 02155 Undersecretary Not valid without signature
JBRGG-1 OP ID: RB
,4CORv' CERTIFICATE OF LIABILITY INSURANCE DATE 08113/2016
`-� 1312015
THIS 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(les) must be endorsed. If SUBROGATION IS WAIVED,subject to
•`- --"-•- -�-'�'�policies may require an endorsement A statement on this certificate does not confer rights to the
Sylvia F. Costa
INSURANCE AGENCY CONTACT Robert Brudnick
1 --e--�.l:=- �.y.'.- NAME:
lAuto•Home•Business �MC Ario Ex:817-847-0005 FAX No: 617-847-0006
15 Montalto Street Oil 28) Brockton,MA 02301 ADDRESS:
Phone(508)583-0022 F..(508)583-7744 INSURERS AFFORDING COVERAGE NAIC k
E-mail:SFCoslaheif➢Yarizon.net INSURER A:Penn-America Insurance Co.
INSURED JB RG General Contractor,Inc. INSURER B:
328 High Street#1 -
Medford,MA 02155 INSURERC:
INSURER D-
INSURER E:
NSURERF-
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 MATH 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.
POUCYEFF ILSR TYPE OF INSURANCE POLICY NUMBER MMIOD M NDryYYY LIMITS
A X I COMMERCIAL GENERAL UABIUTY EACH OCCURRENCE S 1,000,00
CWMS-MADE M OCCUR PAV00579680 07/2412016 07/24/2016 PREMISES Eao nee 3 100,00
NED EXP(My ans Persan) 3 5,00
PERSONAL B ADV INJURY 3 1,000,00
GENL AGGREGATE UNIT APPLIES PER GENERAL AGGREGATE 3 2,000,00
X POLICY❑SM LOC PRODUCTS-COMPIOP AGG 3 2,000,00
OTHER: S
AUTOMOBILE UABIUTY COMBINED
SINGLE LIMIT 3
(Ea aceidenn
ANY AUTO BODILY INJURY(Pw person) S
AUTOS
SCHEDULED BODILY INJURY(PW accident) S
HIRED AUTOS n
AUTOS EO PWaaddent $
S
UMBRELLA UAS OCCUR EACH OCCURRENCE 3
EXCESS LAB CLAIMS-MADE AGGREGATE 3
DED I I RETENTION 3 S
WORKERS COMPENSATION PER
AND EMPLOYERS'LABILITY YIN STATUTE ER
ANY PROPRIETORIPARTNERAE ECUTIVE ❑MIA E.L EACH ACCIDENT 3
A(Man R ry in N R EXCLUDED?(MannaRfiAE BER EL.DISEASE-EA EMPLOYE 3
It yes.deswMa Inner
DESCRIPTION OF OPERATIONS eekne E.L.DISEASE-POLICY UNIT 3
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACORD taL Adaitbnal Remarb Sclmdub,may tw eNactlod U moro apaaa is requiron)
Insured is covered for only the following opearations: Roofing 6 Carpentry-
Residential-not over three stories in height exterior work, Commercial
Carpentry not over three stories in height exterior work, any other
operations are excluded.Coverage is of the effective date and may change
during the policy year.Property claims are settled @$1,000 deductible
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
JIB FIG General Contractor,Inc THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
328 High Street#1 ACCORDANCE WITH THE POLICY PROVISIONS.
Medford,MA 02155
AUTHORRED REPRESENTATIVE
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD
^ f
TI E Z NOTICE NO C NO CE
TO A o TO
EMPLOYEES EMPLOYEES
o
9 0
M �
S
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
1 Congress Street, Suite 100, Boston, Massachusetts 02114 — 2017
617-727-4900 — http://w�«v.state.ma.us/dia
As required by Massachusetts General Law. Chapter 152. Sections 21. 22 & 10. this will give you notice that
I (we) have provided for payment to our injured employees under the above mentioned chapter by
insuring with:
ACE GROUP `
NAME OF INSURANCE COMPANY
P .O. BOX 1450
MIDDLEBORD MA 02344-1450'
ADDRESS OF INSURANCE COMPANY
(6S62UB-2E10754-4-16) 03-25-16 TO 03-25-17
POLICY NUMBER EFFECTIVE DATES
AMAZONIA INS AGCY INC 66 BOW ST
SOMERVILLE MA 02143
NAME OF INSURANCE AGENT ADDRESS PHONE #
JB RG GENERAL CONTRACTOR INC 328 HIGH ST # 1
MEDFORD
MA 02155
EMPLOYER ADDRESS
_ EMPLOYER'S WORKERS COMPENSATION OFFICER (IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical serxices in accordance with the
provisions of the Workers' Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
�= provided by the treating physician will be paid by the insurer. if the treatment is necessary and reasonably
connected to the work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
013657 W20P1G15 TO BE POSTED BY EMPLOYER