1 UGO RD - BUILDING INSPECTION (3) i
The Commonwealth of Massachusetts CITY OF
JBoard of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwell'
This Section For Offici se Iy
Building Permit Number: - Date A plied:
Building Official(Print Name) Si e _ ate
SECTION 1:SITE RMATION
1.1 Property 44dress: 1.2 Assessors Map&Parcel Numbers
1 1��n— 11
_ no Map Number
LI a Is A an accepted street?yes Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
y
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system 13Public❑ Private❑ Check if yes❑ P P
SECTION 2: PROPERTY OWNERSHIP'
Owner'of R ord: y\ ckm M,n WOO
1' 1 t 111
Qq 9
Nmne(Print) City,State,ZIP
No.an S et Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed World: r
r
SECTION 4:ESTIMATED CONSTRUCTION:COSTS
Item Estimated Costs: Official Use Only
Labor and Materials -
I. Building $ 1. Building Permit Fee:$ - Indicate how fee is determined:
❑Standard City/Town Application.Fee
2.Electrical $ 13 Total Project Cost;(Item 6)x multiplier _ x
3.Plumbing $ 2. Other Fees: $'
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:.$ - -
Su ression
Check No. . Check Amount: -- Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
���, �r3✓!; 6�3 0
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �(] t a� I
�)p r f e M YI -era License Number Expiration Date
Name of CSL Holder ` List CSL Type(see below) V
Po LJ0tSo,y tRC
Description
No.and Street
Unrestricted(Buildings u to 35,000 cu.ft.
AyP\I \ 1 11g1(LI Restricted 1&2 FamilyDwelling
City/rowo, e,ZIP Masonry
RoofinCoverinWindowand Sidin
(� SF Solid Fuel Burning Appliances
gi q`-9 t I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) �'�h��
H
QQ 'I DV yS0dA r0y1�y1� HIC Registration Number Expiration Date
(Colmp Name or ��C�la(n,�y''"J,t
and Street Irn� ®I n1 bL) C c R9yR n 1 I Email address
�i /Town,S te,ZIP " Tele hone
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 Issu a of the building permit.
Signed Affidavit Attached? Yes .......... No...........El
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1
I,as Owner of the subject property,hereby authorize l "1(�'nl�� ClnSyrQC NN on
to
act onI my behalf, in all matters relative to work authorized by tl;s building permit application.
'_i�40.X171 S L'�G�I : ✓1 ���-!� ✓�-� �j-- Cn �- 1
Print Owner's Name(ElectronicSignature) Date
SECTION 7b:OWNER'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.
Print Owner's or Authorized Age is Name(Elecuonm'Siture
gna— ) 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 w%vw.rnass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
CITY OF S�U.EN1, iN'LUSACF- USEITS
BuimmG DEPART\I&NT
N e 120 WASHNGTON STREET, 3° Rom
TEi.. (978)745-9595
Feat(978) 740-9846
KI.,iBERLF-Y DRISCOLL THOsuS ST.PIERRE
MAYOR
DIRECTOR OF PtiBLIC PROPERTY/Ht:lID4�IG COxL%IISSIONER
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# 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
111, S 150A.
The debris will be transported by:
�{r��c}t�n ��mp lratle�
(name of hauler)
The debris will be disposed of in :
raa, Y1
(name of facility)
(address of facility)
�- ignatti7re
p��
date
Jchrirdr.Jix:
,< CITX OF S.U.F_,N4 UNSSACHLSEM
BUILDING DEPARTMENT
• <? 120 WASHLNGTON STREET, 3m FLOOR
TEL (978) 735-9595
FAx(978) 730-9846
iCi.,iBFRt EY DRISCOLL TiimwST.PmRRs
,NjAYOR
DIRECCOR OF PUBLIC PROPERTY/BUILDING CO%L\BSSfONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
pplicant Information Please Print Legibly
Name(Busiirn OrWiizzattimuindividual): G ooAer, _ moa)&^ cin
Address: 2- () I Q
l°C �LI MA ()Jq h9 Phone#: G�� 29 ll (DOO
City/State/Zip:
Are u an employer?Chec the appropriate box: Type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-tittle).' have hired the sub-contractors
2.❑ lam a sole proprietor or partner- listed on the attached sheet 7. El Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
(No workers comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their I0.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,g 1(4),and we have no 12.❑Roof",
airs
insurance required.]t employees.LNo workers' .4.her, e
comp.insurance required.j
-Any applicant that clucks box#1 most also fill out the section below stowing their workers'compensation policy information.
t I Inmeowraxs who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such
:Contmctors that check this box muaY attached an additional sheet showing the name of the subcomractors and their workem'ramp,policy infornution.
I am an employer that is providing workers'compensation insurance for my emplayees. Below is the policy and job site
information.
Insurance Company Name:
Policy 4 or Seif--ins.Lic.#: O �),�FC. �J C) Expiration Date:
��^ 1�.(�_ (�-7
Job Site Address:�gn R� City/state/Zip.,5M 1_A 019 l0
Attach a copy of the worke compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonmem as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby certify trader the
pains and penalties of perjury that the information provided above is true and correct
4i n mtre,, p�-✓//p/ /�/� Date'
Phoned: ��O ��C7 10Wl
Official use only. Do not write in this area,to be completed by city or town ofjrciat
City or Town: ___ Permit/l.icense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other___ k
Contact Person: __ Phone#:
00 (Policy Provisions: WC 00 00 00 B)
27
LJ INFORMATION PAGE
WEC WORKERS COMPENSATION AND EMPLOYERS LIABILITY POLICY
INSURER: HARTFORD FIRE INSURANCE COMPANY
ONE HARTFORD PLAZA, HARTFORD, CONNECTICUT 06155 'T'
NCCICompany Number: 13269 1�E
Com p Y HARTFORD
Company Code: 1
m
m
N
O
Suffix
LARS RENEWAL
POLICY NUMBER: 08 WEC LJ2700 02
o Previous Policy Number: 108 WEC LJ2700
- HOUSING CODE: SB
CN 1. Named Insured and Mailing Address: DARREL GONYEA
a (No., Street, Town;-State, Zip Code) (SEE ENDT)
m
0
N
o P 0 BOX 504
� FEIN Number: 042790276 ROWLEY, MA 01969
State Identification Number(s):
UIN:
The Named Insured is: INDIVIDUAL
Business of Named Insured: PLUMBING - RESIDENTIAL
Other workplaces not shown above: 105 FENNO DRIVE, ROWLEY MA
ROWLEY MA 01969
2. Policy Period: From 03/13/13 To 03/13/14
12:01 a.m., Standard time at the insured's mailing address.
Producer's Name: PRESCOTT & SON INSURANCE AGCY INC
963 EASTERN AVENUE
MALDEN, MA 02148
Producer's Code: 088914
Issuing Office: THE HARTFORD
301 WOODS PARR DRIVE
CLINTON NY 13323
(B00) 962-6170
Total Estimated Annual Premium: $1, 684
Deposit Premium:
Policy Minimum Premium: $483 MA
Audit Period: ANNUAL Installment Term:
The policy is not binding unless countersigned by our authorized.representative-
Countersigned by #` 6at�e—
Form
/�
Aurd6T-.thdRepreszntative WC 00 00 01 A (1) Printed in U.S.A. Page 1 (Continued on next page)
Process Date: 02/02/13 Policy Expiration Date: 03/13/14
ORIGINAL
L
I i
T'=COIvLA4T0NTWh-ALTH OF MASS,ACfiUSETTS
DEPAMNIENT OF.BOR
ANA
c DIVISION OF OCCUPATIONAL S-AFETY
19ST�NlFoxnSTzE;T:BOSTON,-1-ASSACHUSEr�s. 0211�'.
j
I aD-SAFEREv'{}VATIO CONTRACTORLICEl>isE
-GONYYA CONSTRUCTION j
105F—F; DRIVE
RONNLEY NLA 01969
i
LICENSE: 'LRO00031 EXPIRES: Tuesday.September 01,2015
N ACCORDANCE T\n?Ft\f.G:T:C. ?13: S ?97P(b; ansa._± 4 C�,L?t:�Og, MS LICENSE 1S?SSLTE'D B
T FE bI�SS_iCHC?SETTS D t. OF OCCI PATiO� �S rrTY TO Ti3E CON T RECTOR SBO 4'E FOR i r E
PLjRPOSE OF E\GAGLNTG N LEAD-SAFE R_ENTOVATION,AND MODENGIV, lu:Ri { Er _
I
THIS LICENSE IS VA—T FOR?-PERIOD OF Ff v-(_)S-E -S.
:MSLiCSTBE� AiVF4LtiTEDBi'TiTFCONiR^CTOR!N?CCORDA\CERII ]h.G.i.C.
197B(b)(2)A ND 45-C�IR22-04 WHENT ENGAGED 1N LE AD-SA E RENOirA!-ON AItiD
i YfODER_ATE-RISKDEL �i\GWORK
. _ HEATHEp E.R054e_z . iTG CO-MMiSSTONE2
I
)�f 'f=_5_cr•'_c= -'r= o 'L Office 1`T7onsnmera_.irs 1'Bufness egulanon
i
Board of Bu•'. .l[ '"-a�i�:ure,"-""''--' (;HOME.IMPROVEMENT CONTRACTOR Type.
+,:rvt�.,--�,.p•-rw so: - ... ._Registration: ,557515 -
f CS-023124 - _,•Expiration: ]02072010 DBA
D_ARRELLJGO-NNYEA Go tEACONS
PO BOX 504
Rowley yL4 01969 - DARRELL GONYEA
105 FENNO DRIVE �-
- ROWLEY,MA 01969 .;�...` Undenecretarp
`l.��•--JJiAit ' 0 610 81201 4
.rl
i
Gonyea Construction Building & Remodeling
P.O. Box 504
Rowley, Ma 01969
Phone & Fax 978-948-6001
www.gonyeaconstruction.com gonyeaconstruction@verizon.net
Proposal
June 24, 2013
Mr. &Mrs. Richard Eagan
1 Ugo Road
Salem, Ma 01970 " ,
978-744-8242 #
General Repairs To Property !
Patch in any rotted exterior trim work on doors, windows, and siding.
Apply '/2"drywall to damaged walls in den and hallway, compound out to smooth finish, ready for paint by
other.
$2,600.00
A
t
a A
s �
I Accept the Terms of This Proposal:
Signature Date: ��S