73 TREMONT ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards c'AL Massachusetts Slate Building Code. 780 C'MR, 7a'edition (1F SEM
/+ Rrvisrd Jornvv n
Iuilding Permit Application To Construct, Repair. Renovate Or Demolish a /. 1aAr
One-or r1vu-FumilVRWe1finK
This Section For ITicird Use Om
Building Permit Number: ate Applied:
Signature. AAA1C���/f✓/'D
Building Cummissi d Ins Buildings Date
ECTION 1:SITE INFORMATION
1.1 Property Address. 1.2 Assessors Mop di Parcel.Numbers
� Z -XReNror/f SjZ.
I.la Is this an accepted street?yes - no Map Number Forst Number
IJ Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Use Lot Am(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
F14Water
d Provided Required Provided Required Provided
Supply:(M.G.1.c.40,§54) 1.7 Flood Zone Information: I.8 Sewage Disposal System:
Private❑ Zone: Outside Flood Zone? Municipal O On site disposal system ❑
Check if es❑SECTION 2: PROPERTY OWNERSHIP'
r'ofRecord:
) Address for Service:
tTetephone
SECTION 3: DESCRIPT ON OF PROPOSED WORK"(ebeck aB that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alleration(s) ❑ AdditioJC3
Demolition ❑ Accessory Bldg.❑ 1 Number of Units—_L I Other ❑ Specify:
Brief Description of Proposed Work': 6
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllelal Use Only
Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how lee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cosl'(Item 6).x multiplier x
). Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) $ List:
S. Mechanical (Fire S
Su ression Total All Fees:S
OCR Check No. Check Am unt: Cash Amount:
6. Total Project Cost: S (� �7�d ❑Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
I a. 1 W R_a I.i.•enae Number :: pinu Irate /
Name of(.'St.- I fadder /) List C'SL-t)pe laee below)
Rn
Deacri ion
A� mss IlnrestricteJ to 11,000 Cu.Ft.
Restricted Id2 Famil Uwellin
Signature - M lAtl
727-7(0 Z—11= Residential Roolin Coverin
Nlephoi a Residential Window and Sidin
Residential Solid Fuel Bumin A liartee Irotallatiun
Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) )
III 'Cum y Nan or III 'Registrant Name Registration Number
A d �r Espirati n Due
Odd Sigrwure 'telephone 9 Ile
/
SECTION : WORKERS•COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I52.} ZSC(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 ..........O No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWN AGENT OR CONTRACTOR—APPLIES FOR BUILDING PERMIT
1 Y as Owner of the subject property hereby
authorize nr to act on my behalf,in all matters
relati t work authorized by this bui in it application.
tW
Si ore f caner DOW —
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
_ae /i -A D ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
Print Name
yr Fll-.�RlLr�>t= -R (sod, f.dG o 0 2
.`Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
NOTES:
I. 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 sag 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 7110 CMR Regulations 1 IO.R6 and I IO.RS.respectively.
a. 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 half1baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage"may be substituted for"Total Project Cost"
Eric°s Roofing Invoice No. 1
155 Goodale St
Peabody, Ma 01960
978-317-1967 fax 978-535-7837
INVOICE -
Customer
Name Raymond A Derby Date 10/1/2010
Address 73 Tremont st Order No.
City Salem State Ma Mass 01970 Rep
Phone 7817271931 FOB
Qty Description Unit Price TOTAL
1 we will strip al shingles roofs donw to boards $7,000.00 $7,000.00
we will install 3 It of ice and watershield around
peremeters we will instal 15 felt paper rest of roof
we will install 8 inch dripedge installshingles will be
30 Yr architectural to be picked by homeowner
we will relad chenmy
Remof Job Trash
labor warranty 3yr
half donw
the rest when job is done
SubTotal r��7F
Payment Details Shipping & Handling
y O Cash Taxes State
E OO Check
O Credit Card TOTAL $7,000.00
Name
CC# Office Use Only
Expires
I. Fine Print Here
Insert Farewell Statement Here
12-11-09; 14: 28 ; patrick-j-woods- Insurence 917813143286 ; 9785318617 # 1/ 1
GRANITE STATE INSURANCE COMPANY 0071845-06 WC 005-09-1734
13102 ------------ - — - -- - —
013-66-1oog-oo
r 1 . 11013 17171il 5410111plifillil
HENRIQQUE GODINHO
155 GOODALE ST
PEABODY, MA o196o-2338
EXECUTIVE OFFICE$: f
70 PINE,STREET, NEW YORK.-N.Y. 10210 r_
SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610
LDS . MA Ul#-
WOODS P J INSURANCE AGENCY INC
WORKERS COMPENSATION AND EMPLOYERS PO BOX 353
LIABILITY POLICY INFORMATION PAGE PEABODY, MA 01960-6853
INSURED IS PREVK)U8 POLICY NUMBER
PARTNERSHIP RENEWAL 004 2068
OTHER WORKPLACES NOT SHOWN ABOVE: . SEE EXTENSION OF ITEM 1. OF THE INFORMATION PAGE - WC990610
REM 2 POLICY PERIOD la01 A.M.standard time at the Insured', _
mailing address FROM 10/18/09 TO 10/18/10
ITEM A. Workers Compensation Insurance: Part One of the policy applies to the.WorkersCompensatlon Law of the states listed
here: .
MA
R: Employers Liability Insurance: Part Two of the policy applies to the work in each state listed In item-3.A. M—
The limits of our liability under Part Two are: .Bodily Injury by Accident $ 100,000_ each accident
Bodily Injury by Disease $ - n,00.000 policy limit
Bodily Injury by Disease $ 1.02 000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed have:
SEE ENDORSEMENT - WC2003o6A
-D. This policy includes,these - -
SEE EXTENSION OF ITEM 3.D. OF THE INFORMATION PAGE - WCSSB612
ITEM The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans.,
All information required below is Subject to verification and change It -eudlt
Estimated Total Rate Per Estin eted
CIBSClassificationsCode Number Remuneration S100 OF R® Premium
-
- � Annual ❑.3 Year munemtion ®Annual 0 3 Year
SEE EXTENSION OF ITEM 4, OF THE INFORMATION PAGE - WC7754 -
TAXES/ASSESSMENTS/SURGHARGES $318
EXPENSE CONSTANT(EXCEPT WHERE APPLICABLE BY STATE) 8 MA
MINIMUM PREMIUM 00 MA TOTAL ESTIMATED PREMIUM $4,759
nt If_indicated below, Ierim edl--t--nts of premium shell be made: ��..J 7 3
Semi-Annually Ouerteriy MDelhly DEPOSIT PREMIUM
1
10/28/09 ASSIGNED RISK 66Mr
Issue Date Issding Office Authorized Representative WC 00 00 01
99267 (Rev'd 041081
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.NI I!;a!I:)k IsC,n.l.
.\1\)oit 12:WASHIN6 ION S'I It ELT • SAMM.MASSACI It'iJ:'J-1s0197.^
Ttr.1.:978.745-9595 Is P.sx: 978.740•9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
l ylicant lnformution Please Print Leeihly
t
Nilille l0usilnxsi Or;;aniratioNlndlvlduufU:
Address: T� c{ e- M�� q/
City,'St:State,Zip:& -A-f5Q yr l �, Phone y.•:
Are you an employer? Check the appropriate box: Type of project(required):
1.El 1 ;un employer with
4. ❑ 1 a g 6. ❑eneral contractor and 1 new construction
_ am
emploo yees(full and/or part-tune).• have hired the xuh-convectors - 7. �Remodeling
2.❑ 1 ;mt a sole proprietor or partner-
listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
IKo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
raquired.) officers have exercised their
right of per MGL 11.❑ Plumbing repairs or additions
3.❑ I am exemption a homeowner doing all work S P P'
myself. [No workers' comp. C. 152, j 1(4),and we have no 12.pRuol'repairs
insurance required.) r employees. IKo workers' 13.0 Other
comp. insurance rcquircd.)
-.4uy:glplicma/hot chucks box AI mull:llsu Jill uul the mctiml Wow showing/heir wurkuri cumpen>ution pul icy inlilrnwlium
' i lumcuwmr%who utb.nil this affidavit indicating Ihuy are doing all work arul lien hire uuiside cwurnelon moll.ulmsil a new al'r:,tavit indi"ing such.
w(' nlrlctu"that check this box Must altwhed an additional shoe/showing the nano of the sub-conirxtors and their wurkon'comp.policy information.
l am are eorpfuyer that is providing workers'c•anpensnriorl insurance for rely eelnployees. Below is the policy andlob site
iafonnation.
htsurance Company Name:
Policy a or Self ins. Lie. it: __...-_ Expiration Date:
Job Site -%ddress; City1SlateiZip:
Attach it copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ul':vIOL c. 152 can lead to the imposition of criminal penalties of a
tint up m S 1.500.00 and/or one-year imprisonment, as well as civil penaltics in the form of a STOP WORK ORDER and a fine
of up to S250.00 it day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
I Ill'bllgallDlli of llle MA for insurance coverage verification.
/do hereby cartijy under the pains and penalties of perjury that the iaforination provided above is(frue and correct.
Sir:);uurc:
Date, j0
I'ht na ri:
Ofjiciat list only. Do not write in this area, to be completed by city or folvn official,
City or'1'osvn; . . Pcnnit/License k.__
Issuing,\uiborily(circle one):
1. Ill,ard of Ilcalth 2. Building Department 3.Cityi roan Clerk 4. Llectrical lnspcctor 5• Plumbing Inspector
6. Other --_ - - -
Contact I'crsoin _. . .--- Phonic l:
Information and Instructions
\lassachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, ail ernplUt'ee 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, parmership,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 shalt 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. NIGL chapter 152, s25C(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 All 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 nuiuber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members ur.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 may be 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.
I'I,:asc be sure to till in the permittlicense number which will be used as a reference number. In addition,an applicant
that most submit multiple pennit/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 n'ot related to any business or commercial venture
(i.e. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he 011ice tit Investigations would like to thank you in advance fur your cooperation and should you have any questions,
Please do not hesitate to give us a call.
"fhe Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
R,t;scd 5-26-05 Fax #617-727-7749
www.mass.gov/dia