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96 TREMONT ST - BUILDING INSPECTION
The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CM SALEMR Iteri,e,l,t hip 'nll Building Permit Application To Construct, Repair. Renovate Or Demolish a One- or Two-Fand1v Duelling This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORNIATION 1.1 Property Address: Si 1.2 Assessors Nlap& Parcel Numbers )( 99 i P f-rt 0&- 1.to 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 It) Frontage(11) 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?Check if ycs❑ Municipal ❑ On site disposal system ❑ SECTION2: PROPERTY OWNERSHIP' kNew Owner'of Record: QE-T-R,R Q �t N � �AL�t✓. rA A X (Print) City.State,ZIP (_ `C e c c,'D � S1 C � R — 11 z d Street telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description-of Proposed Work': prr,ov6- E* rr�r wL.t:E" ram✓ yi L;2chr12`c ro,�,fic ah r.,.je„ r,,Z6sc rlPr 3� yEn&s a rvr ✓car: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building S 1. Building Permit Fee: S Indicate how fee is determined: ❑Standard City/Town Application Fee '. Electrical S ❑Total Project Costa(Item 6)x multiplier x i, Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. :Mechanical (Fire S — Suppression) Total :III Fees: S_ Check No. Check:�muunt: = fi•K;uh Anwu X G. Total Project Cost: S qjr 6©O 0 Paid in Full 13 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES • v 5.1 Construction Supervisor License(C'SL) 7 1/a �"� 9 �i1ao)3 —t" '4 e! _$E 42 cam. License Number---- F-mination Dute Nano of C'SL Holder 020 clrNc7 ListC51.T)peIseebelow) St No. :urd Street - — Type Description aLI I InNstricted(Buildings u' to 35,000 ca. II.) eKh 7 /�'I iQ, Oor((6� R Restricted 1&2 FamilyDteellin+ Ciq/fatty.Slate.ZIP I Masonry RC Rooting Covering X WS Window and Siding e SF Solid Fuel Burning Appliances Cha4Ce.?,pC�Pi6,�J1k1> sr-,v I Insulation "rcic I one Y ail ddress D Demolition 5.2 Registered [Ionic Improvement Contractor(HIC) G(n"OIOE (?-0!t rt GRP• IIIC Registration Number ExpirationDate I IIC'Company Name t 111 Registrant Name No. and Street o20 Qu!My u/N�w Q r A.0 Email address City/Town, State,ZIP 6 f`l At? 1 - J $ Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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...........O SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW 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 ' true and accurate to the best of my knowledge and understanding. , X ;Z//) /// Prh )oner's or Autht ized, gent's Nome I lilectrunic Signature) Date 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 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 nu) Information on the Construction Supervisor License can be found at o k.nyus.;u� dlis '_. when substantial work is planned,provide the information below: Total floor area(sq. R.) _(including garage, finished basentent'attics,decks or porch) Gross lieing area(sq. It.) Habitable room count \'umber of lireplaces ._-- __-- Number of bedrooms ----- --------- Number of bathrooms Number of half'baths r)Pe of heating system --__---- _- Number of decks,porches 1)PCofcoolingSyslem Enclosed 3. "fnwl Project Square Footage•ma) be substituted for-rotal Project Cost. CITY OF S'U.E.Nl, WSACHUSETTS BCIIANG DEPARTMENT t 110 Wm1iLVGTON STxm, Ji FLOOR TEL (978) 745-9595 FAx(978) 740.9846 KISBEY.LEY DRISCOLL MAYOR THOVASST.PII■sn DIRECTOR OF PLBLIC PROPERTY/BUUMLNG CONSUSSIOrER 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 c 40, S 54; Building Permit At 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 l 11, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in G P�Ih�/tid W /si FiEIPv (name of facility) (address of facility) signature of p� mil applicant date CITY OF SALEN i eVll PUBLIC PROPRERTY DEPARTMENT NMI.II:1 Y:ralN,ql rA^ilatLr $ i,uv\f, M.ttt.t4.u1 a.1 N ,)7A Cr.l. /7F:IS•tili •1'tx '"OF-74C•936 Workers' Cumpenaadon Insurance Ufiduvit: Huilders/Contract� 1 un/!I rlfcant Infilnnrtlo ectrlcllens/Ylumben a 'hl V;Irnallla.rlw',rilhaanullinrvindn�duull: GKr�LC��Dc.7�/rr.�P r!j�P City,.5larc,%ip• (P e/ ,vc 11`4 on Phones/: 161�JL/�1 — Sf4$ .lru t nu an exlployer?Chuck the upprnprlule boa: 1.�1 am a cmpluycr with 4. 1•yM a/project(rvqulred): --a_ ❑ I wn a gcncrai contractor and 1 �•Qcalpluy'ees(lull alld/ur puft•tlllle). hove hired he.vuh•conoacturs h• ❑New construction 1 ant a solo prnpricuw or partner• listed on the anached..hcut : ?• Q Retnodoling Ship and have no wnpluyeds n1cas subcontractors have working tier One in any capacity, workers'comp. Insurance. g• Q Demolition I Nit woritars'camp. insurance J. ❑ We are a colporotion and its q• ❑ Oulwing addition 7.Qrcquircd.) otrcers have esercirud heir 10.13 Electrical repair$at additions ' ;A"'a hnlrtcuwner doing all work right ofe.ecmption pur hlCt, I I.Q Plumbing rupuin ur additions myself.(N•o wnrkera'comp. C. 132, ¢1(4).and we hove no insurance rcquired.) r employees. (No worker' 12•0 Ruufrepuifs camp insuranctt ru uircd. 1 J•Q Uglier a. 4 y phcu/IhW chncb has elm ) 'I lumw,wryra.. �:,Iw Iel uW the wcl,un 41uw dww,ne IMir ayxYW 'he"Joint Ohio affidavit in lt&uin I e a iet too,NYluw in,liar Inhnawriwa er+aa Juin all wurY me Ihvw him uuraida euxrnaran mwl na rhea •ulenw a Nw aln taw iMiarlin r.Mhal eAvrh hot muW Jilwhad.In A.10i'll n i,ldlliunal,haet ot nN of ft rue.eWeratte/a and lhfx t"is a e' imhert l r Y.,it. /aunt all emplayer that Ir pruvieln)f IvurAers'rurnpenmdon harurnntee w/x ern u. �'Ircy mgxrrranua Lrifunnwh!!s / !' P/J eea Bdonv IS/Air pu/lay axrl/ae site Insurance Company Vnme: /1"%4Ar•-j1 C c/,f?IPj /atS, —T--- — EApiralwn Data: ILLIZ, .2 Attach n cn C1ly'slate/zlp: ©/� yy of lla workon'cumpunsatlna pulley ducleratlun page(showing the policy number and ecplratlun date). "allure to,ccury cuteruge as required under Suctiun 25A ul'\IGL c. 152 eau lead to the im title up nl 1'1 500JA and/ur mle•yeir impris,mmcnt, us a'cll ua civil pcnahlp in the 1'unn dl'a STOP WUR position o/criminal Penalties of a oI up rn i?JQ.rM a Jay.Igtlinst the violator. lie advlacd but a copy urlhls,fulcment may be lurwarded io h 'I e URD)uoR 1, s Rne Inn.angau�nls ur;he DI.\ .or m,ur:u'ce envcr�3e tcl Ilk Alin. /du h••rrhy r crli/y run/ur rin point,are penn/iier ufpe !ry that the ix urmudon- ! prvrieeeu0uve/ Irveifnecorract c I •: uul. / rl,, ; . ' leg Ir)%/4iu/arse uady, pu,rnl nviu in rhi.r urru, ru Ae rump/tree Ay oily ur town,a//laiuL — Parmit/Llcvnta Y i„uing.\ulhurily (circle nnc); i I, Ilu.lrJ nr Ilr.lhh !. Iluddinq Ilcpartvnent I. (;iti.'Ibnn Clerk J. L••icceric.11 lolpccrur c• Plumping hl,peetor I G. (hher I'hune Y• � I f i information and Instructions \LUi.IG IluiettY(Jeneral Laws ehaytet I i2 nywrcs all eery p#eon in the ss 10 ary iX of another#enter,illy cuntmct f hire' 1`unu.utt to tins vutule, in r,eplurre is derived as"...every Iri ;%Press Or unplied, oral Or written." orarion ur other legal enhry,or any two or more oyer,Or the �n e,npluprr i+dcrineJ as"an individual, partnership,association.cory a the ta'yer 14 ctlnedJ m a Juror enterprise, and including the legal rcpreseuutives acceisloytes.IHowevcr the lig engage e�mver Or trustee ot'.at iudividuul. p rr enterprise ,association or other legal entity,employing ' p ant of the c ,ions th Jo maintenance,cunswetion or repair aunt on such dwelling hat" owner of a dwelling{house having not more than three aparmenu and who resides therein,or the acts dwelling huuia Of another who employ. Pa or on the grounJs or building appurtenant thereto shall.not because of such employment be dcemeJ to be an employer. �tGL chapter 152, 42SC(6) also states that"every state or local lleensi"%agency shag withhold the Issuance a or gage#with the Insurance covers%#required.' renewal of s Ilccase at permit to operate•buslasss or t"construct buildings la the eommaawaultY or any applicant who has not produced accaptslae evidence of a con \dd111oeally. �IGL CIW PIaf l S+_, S23C171 st°tea"Neither the commonwealth not any of iU political subdivisions shag enter into in;contractrfor a f performanChaw been p o Of pJbo the contra cling atil uthorityiable viJenca of cunrpli nice with the insurance requirements of this P Applies"$$ ing the boxes that apply to your situation and,if ensation affldavit completely.li hane numbers)along with their cortillcate(s)of Please fill.su the workers' comp with no employees other than the necessary, supply sd lability Co s) n Companies (s).add1 Limited i )' P nsurance. Limited Liability Companies(LLCworkersiteompetrs+stioe ilnursnce,(If an)LLC or LLP does have ineinbers or partners, are not required to carry be submitted to the Departrnettf of Industrial entployeas,a policy is required Be advised that this affidavit mayrequested, nog the Wpdavit should of \ccidents for confirmation of insurance coverage Also be sure to sign a is dote the u LL the affidavit ha rcalmed to die city or town that the upplieation for the permit or license is being I nJustrial,%ccidonts. Should you have any yuesttoa regarding the low ur if you era required to obtain u workers' compewation Policy.pica"call the Department at the number listed below. Self-insured companies should enter their self•insurance license number on th#a ro riaro line. c'Ity or Town Officials The Department has provided u spun at the boom the app Pteasc he sure that the agTldavit is complete and printed legibly. applicant f dte ft aiFdavit for you to lilt out in the event the Office of Investi%atians boa to contact you regarding applications in an given year, need only submit one affidavit indicating curent I f dw be sure te.till in the permit/liccnse number which wi I be used us a refere�e number. In addition,an aPP that must submit multiple pernit,,license provided to the policy information lit nccossary)and under"Job Site Address" h marphedtby+lu City or townmay be pin (city or town). ,\copy Of the ut7ldavit that has heart officially sump' applicant as proof that a valid affidavit is on ills for nature permits or licenses. A now arfidavit roost be tilled out each year. Where a hums owner or citizen is obtaining a license or Penn"not related to any business or commercial venture l i.e. . het a hoicense a permit to burn leave ere.)sail person is YOT required to complete this affidavit. uesuoas, og 1 he )I li.c ill Investigations wuuld like to Ulank)'au ill idValll'e tar your cooperation alld iI1UUId you ha\e.ulY y plea,#do nut hesitate to give us a call. fhe U.parunent's,addrns, telephone and fax number: The Cornmonwealth of Massachusetts Department of Industrial Accidents 011fea of Investigations 600 Washington Street Boston, MA 02111 617-7274900 ext 406 or 1.877-MASSAFE Fax N 617-727.7749 d i-Ill www.mam.gov/dia " r Ntlssachusetts- Department of PubliC S;rret Board of Buildin_ Re�_'ulations and Standard Construction Supervisor Specialty License License: CS SL 99129 Restricted to: RF,WS REZART BEQO 20 QUINCY STREET i QUINCY, MA 02169 0 Expiration: 7/1/2013 . (1nm�is.ioner i�" p Tr#: 16256 r.. � . ... . . ✓/tCiO4�NH U/E¢� O�✓��aaeaC�trrde(Q Office of Consumer Affairs&Susia'ess Regulati6B HOME IMPROVEMENT CONTRACTOR i Registratlorr;�.-x j30821 Expiration 413/20T?. Tlilit 294502 TYPe l-,, ndroiduat-,� i CHOICE ROOFING.CtT - 1 REZ,ART BEQO,-�.�. 'a`•, 20 QUINCY ST i OUINCY,.MA02169 _ - undersecretary Exclusion; Garage, Flat Roof above the Back Entrance, Building Permit Fee, Durilpster, Skylight Replacement, Weather Delays,Broken or Rotting Board Replacement not included. However if any board/plywood shall be replace extra cost will be added on last invoice, board_$3.75 per foot/plywood_$ 65.00 per sheet (labor&material included). Note# t.Any additional work beyond the above scope of work like carpentry, metal work etc, will be dome at rate$75.75 per man/per hour plus material,portal to portal and $.585 per mile travel expense. Note#2.Access next to the house for trucks,dumpster is required. We hereby Propose to furnish materials and labor to complete in accordance with the above specifications, for the sum of: six thousand six hundred dollars and zero'cent. ($6,600.00) Payment to be made as follows: $3,000.00 deposit and the balance due upon completion of all work. All materials are guaranteed to be specified.All work to be completed in a Authorized 4.. Professional manner according to standard practices.My alteration or deviation Signature: From above specification involving extra costs will be executed only upon written R eqo Orders,and will become an extra charge over and above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. Owner to carry five,tornado and other necessary insurance.Our workers are Note:This proposal may be drawn by us fully covered by Worker's Compensation Insurance. if no[accepted wi 30 days. ACCEPTANCE OF PROPOSAL-The above prices, specifications and conditions are satisfactory and are Name hereby accepted. You are authorized to do the work as specified.Payment will be made outl' above. Signature: Date of Acceptance: Q 7 1(� I Tine Page 2 of 2 96 Tremont St.Salem,Ma.01970 July( /J y 4 2010)