35 VALIANT WAY - BUILDING INSPECTION • 1
j The Commonwealth 01.Massachusetts
Board of Building Regulations and Standards CITY
t y ) Massachusetts State Building Code, 780 CMR. 7'"edition OF SALEM
r/ Rrvised Jmruawy
Iuilding Permit Application To Construct, Repair. Reno •rte Or Demolish a l. :01AV
One-or TIVO-F 7r Dwelling
This Sectioqi FoAQfYjcial Qpfonly
Building Permit Num a A ied:
Signature: J IZALZ-V�r q
Ruilding Commissioner/In tmof Buildings Dale '
SECTION 1:Nft INFORMATION
I.1 Property Address: V 1.2 Assessors Mop& Parcel Numbers
1.1 a Is this an accepted street°yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lol Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
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 Dhposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 gqwwaertotRep�rd. /
Nome(Print) Address for Service:
972 I YI� S3 Co Z
Signature Telephone
SECTION J:DESCRIPTION OF PROPOSED WORK'(check sR that apply)
New Construction❑ Existing Building O Owner-Occupied Repain(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': e 16QttJ ethC•\
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: I Ofllelol Use Only
Labor and Materials
I. Building is 1. Building Permit Fee:f Indicate how fee is determined:
❑Standard City/Town Application Fee
_. Electrical f ❑Total Project Cost'(Item 6)x multiplier x
). Plumbing S 2. Other Fees: S h�
4. Mechanical (BVAC) f List:
S. Mechanical (Fire S
Suppression) Total All Fees:S
/ Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 7 /3 ❑Paid in Full O Outstanding Balance Due:
SECTION 3: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor WSW C5 SL (Gb(5V Za(Z t
I.i
gig � ✓L ccn Number 1: Ora
lnl>me
Name of('. -I loldcr 5- 1 _ r(l I.isi('SL type Isee below) tt) J
1 d�t-•- 'd-�^� f I Descri ion
:\JJrcs UI llitmstricicJ to 35.000 Cu.Ft.
It FRcstricted Id2 Family Dwelling
Si o M mg2n Only
Z RC Residential Roulin C'overin
1'cicpMme WS Residential Window and Sidirl
SF Residential Solid Fuel Burning Appliance Installation
D Tgesidential Demolition
3.2,(teglstered Hgme 1r�/�prorement C/oplyn/ygfor(HIC) /Z r 7�`
- �l Regisuation Number
I IIC Company NFne or IIIC ItTsst�t It e
5i7 Ct 7 l v.. S VV (�
AJJre eriC� 9 78 1rZ Z Eapirat on Date
Sigrwturc 'dephune �/
sg&hdiii 6: W,bRKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL y 2SC(6))
WorkW5 Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
his affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 Owner of the subject property hereby
authorize t� f L �� o �,-c SarJCc�to, t on my behalf,in all matters
relative to work authorized by this building permit application.
Si umofOwner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate,to the best of my knowledge and
behalf.
Q. O• B'VC. ,-- r Co
Print O
Si u ner or thorizcd Agent e
C-riguied under the PaiWand 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 have access to the arbitration
program or guaranty fund under M.G.L.c. IJ2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations I I O.R6 and I IO.R5.respectively.
2 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 half/baths
Type of heating system Number of decks/porches
Type of Enclosed ()Pen
). "Total Project Square Footage"may be substituted Ibr'Total Prcject Cost"
Y. �� CITY OF SALEM
gji PUBLIC PROPRERTY
DEPARTMENT
JUPd N:f)':)RIS(ULL
>Is sw m 12^.WASHING I ON S fa ELT * SAL EM,MAss.u:l tf s&I'f\uI97^�
fta.: 978-715-9595 • h.sx: 978.740--')S46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
11)ucant Information 6e,//�) Please Print LeCibly
Narne(OucilxSs/Or,ganiratimNlndly ulut4: Go V/= kV c"' C '
Address: `aq l '0(Ov�_ �L U
Cityisratc;%ip: OL !S Phonei:: ( 78 9zZ_ 01;1-E�
:\re you an employer:' Check the appropriate box: 'Type of project(required):
I. 1 :un a employer with_- _ 4. ❑ I sun a general contractor and 1 G. ❑ New construction
,employees(full unt.Vor port-tune).• have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 :un 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
No workers'con insurance 5. ❑ We are a corporation and its
1 P• exercised required.) O 10.❑ Electrical repairs or additions
r�flCCrx have their
right of exent tion a ll I LE] Plumbing repairs or additions
3.❑ I am a homeowner doing all work S P P'
myself. LNo workers' comp. c. 152, §1(4),and we have no 12.❑ Ruufrepairsl 1
insurance required.) t employees. LNo workers' I IVOther Cd/` ('-��`----
comp. insurance required.]
-Ally upphcanl that checks box#t must Aso fill out the Section Wuw showing(heir workui cumpemution policy information
'l tomeuwnen whu submit this affidavit indicating Ihc-y ore doing all work aui then him outside cunuxtors must auhmit a new affidavit indiunng such.
-C,mtnntom that check this box must attached an additional.,beet Showing tho name of the sub-contruiors and their workers'comp.rn licy information.
/tut un rwpluyer tlrut ix pruv/ding ivurkrrs'(•mapencmiun incurnnee jar ray employees. Below is the puliey and job.cite
information. 'S 1 R(� A-
Insurance Company Name: 'J-_ ..-. ._..------.---.__---
Policy is or Sclf-ins. Lie.n: (A)G �O 19'0�- ` O - Expiration Date: 1 / Zu�
c I C` /r
Job Site Andress: 31 V�(11�.� City/State/Zip: �YXGC,s.
Attach n copy of the workers'cmnpeasution policy decla atiott pulse (showing the policy number and expiration date).
failure to secure coverage as required under Section 25A uf.%lGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1.500,00 and/or one-year imprisonment, us well as civil penalties in the furat of a STOP WORK ORDER and a fine
Of up to S250.00 it Jay against the violator. lie advised that a copy of this statement may be lerwarded to the Office of
Incattgaunns ul'thu DIA for insurance covcrayc vcrilie.uion.
/do hereby certify uncle a pains and pr nl es jperjury that the infurnnution proyided above is tru and correct.
tii,�:Inulre. _ [)are, - q 3
O/fk•/al use only. Do nol prite in this area, to be completed by city or town official.
City or Town:
tssuin-., ,%ulhoriiy (circle one):
1. Board of lleallh 2. Building Delrarttneut ].Cilyi fosur Clerk 4. Electrical inspector 5. Plumbing Inspector
b. 01 her -_—
(.nittaet Person: ---. Phone Y:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation fix their employees.
Pursuant to this,tatule, an emplc lee 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 tither legal entity, or any two or more
of the tbreguing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,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."
:`IGL chapter 152. §25C(6) also states that"every state or local licensing agency shall 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, &IGL chapter 152, §25C(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 fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) nante(s),address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or 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 confinnation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he 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 of 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.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current
policy.intormation(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 not related to any business or commercial venture
(i.e.a dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he oilicc of,lnve.srigations 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.
The 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
Fax #617-727-7749
itevi,ed 5-2e-05 - www.mass.gov/dia
y CITY OF SALEM
_� PUBLIC PROPRERTY
DEI'AR"I'VIENT
..,,I
Construction Debris Disposal Affidavit
(required lirr all demolition and icnovation work)
fit accordance �%itlt the sixth edition of the State Building Code, 780 Ch1R section 1 1 L5
Debris, and the provisions of 1AGL c 40, S 54;
Building Permit It is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris wi/ll/be transported by:
0,�SSeG[�
(name of hauler)
The debris willbe disposed of in : /
Ca 54 L�l ri. _/ C�LXJI�G. /,U_ _w` e '04", f r v>
(name ut lacimy) E
i n, tress u(taclluv)
�Icnamre otI mit .71)phcant
/ /�vo la
date
SELF INSURED LUMBER BUSINESSES ASSOCIATION
NCCI CARRIER CODE NO. WC 00 00 01A
•WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY
INFORMATION PAGE
1. The Insured: Gove Lumber Company Policy No. WC 000806-10
Renewalof: WC 000806-9
Individual Partnership
Mailing address: P. O. Box 12 X Corporation or
Beverly, MA 01915 04-1382050
Federal Employers I.D.#
Inter/Intrastate Risk I.D. # 012217
Other I.D. #
Other workplaces not shown above: See Schedule
2. The policy period is from 01/0112 010 12:01 a.m. to 01/01/2 011 12:01 a.m. standard time at the Insured's
mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in item 3.A. The limits of
our liability under Part Two are: Bodily Injury by Accident $ 500, 000 each accident
Bodily Injury by Disease $ 500, 000 policy limit
Bodily Injury by Disease $ 50 0, Q n Q each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
COVERAGE REPLACED BY ENDORSEMENT WC 20 03 06 A
D. This policy includes these endorsements and schedules: See Schedule
4. 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 by audit.
Premium Basis Rate Per
Code Total Estimated $100 of Estimated
Classification No. Annual Remuneration Remuneration Annual Premium
See Item 4 . Extension WC 00 00 01A
Total Estimated Annual Premium $ 20, 187
Deposit Premium $ 5, 051
Minimum Premium $ 500 (MA) 5645 Expense Constant $ 338
MA - DIA Assessment 0 . 020 413 . 00
Premium Adjustment Period: Annual Countersigned by:
Servicing Office: SELF INSURED LUMBER BUSINESSES ASSOCIATION Date: 10129/2009
Producer: MEADOWBROOK/TPA ASSOCIATES
Copyright 1987 National Council on Compensation Insurance.
Original
�ice of Consumer airrandBusin�gu atio
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 129170
Type: Private Corporation
Expiration: 7/19/2011 Tr# 286747
Gove Lumber Company, Inc.
Bruce Gove
80 Colon Street
Beverly, MA 01915
Update Address and return card. Mark reason for change.
Address [I Renewal I] Employment Lost Card
DPS-CA1 A 50M-04/04-G1012166p
��re i0oanmworgie¢ i
�\ Office of Consumer Affairs&Business R License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. found return to:
Office of Consumer Affairs and Business Regulation
Registration: 129170 10 Park Plaza-Suite 5170
Expiration: 7/19/2011 Tr# 286747 Boston,MA 02116
Type: Private Corporation
Gove Lumber Company, Inc.
Bruce Gove
80 Colon Street -�--
Beverly, MA 01915 Undersecretary NIt,valyd wi out signature
-u= bl:ks: mYiusca DvI irtmr n1 +d Public `5 al 5
t3uaril of 6niltiin + Rcrnolauna. and "'4 rnd ar11s.
Construction Supervisor Specialty Licen,`L�T
a�Licen`sa. �S=St 100150 -„ j
ReStdl e8 to. WS
i
BARRY GOVE f
46 LINCOLN AVENUE
HAMILTON, MA0'1982
I
Expiration: 4111/2012
-+ - t'rmunCcsimer TNa 100150
978 921 4522 GOVE LUMBER COMPA 12:44:01 p.m. 07-24-2010 1 /1
Installation
,Marvin Window & Door Showcase by GLC Quote
100-B Newbury Street Route 1 South 978-762-0007
Danvers, NM 01923 978-762-0008 fax
£-tJtSMER---lIF REVISION DATE -71221i Quote expires in 30 days
ADDRESS 35 Vallai;way PROJECT NAME
C17Y,STATE ZIP SOaF0111,Mk S A WA Q I 6 ADDRESS
DAY TIME TEL 978-7455362 G508-498-8583 CITY,STATE,ZIP
SALESPERSON Matt Tiffany O O DAY TIME TEL
REV ON10
LABEL QUANTITY DESCRIPTION PRICE TOTAL
arvin Clad Ultimate Inserts. Stone White clad exterior,primed int.
3/4" rimed removable grills. Satin Taupe locks.
of 366 War on full screens
6 ANDH IO 32"X 45 3/4" 6 OVER 6 613.70 3,682.20
Marvin Clad Till Pac Stone white.. rimed inl 3/4"removable grills
Satin Taupe Locks NO SCREENS LoE 366 w/az on
2 CDHTP 1624 4over 4 360.90 721.80
1 CDHTP 3624 8 over 8 533.20 533.20
1 I[Building Permit Fee 134.00 134.00
1 Installation Fiat Labor Charge 1,550.00 1,550.00
1 Miscellaneous Materials 81.00 81.00
1 Rubbish Removal Fee 90.00 90.00
All installations will be left broom clean at the end of the day.All painting is by others.Gove Lumber warrantees the installation labor
only.All materials are covered under the Manufacturers warranty.Any rot found or extra work not specifically mentioned in this work
order will be billed at an hourly rate plus the cost of materials.Gove Lumber will not be held responsible for the fit of existing window
treatments to the installed replacement windows.Interior Vim included is BROSCO#8710.any change will be an additional cost.
Customer will supply electrical power and water when necessary.Customer will prepare the work area by removing all fumishings and
provide easy access to area.Massachusetts Home Improvement Contractor Registration#129170
TERMS DEPOSIT OF $2,860.24 REQUIRED PRIOR TO PLACING ORDER SUB TOTAL 6,792.20
$2.726.23 DUE WHEN MATERIALS TO BE INSTALLED ARE DELIVERED. DELV CHARGE 25.00
$1,560.00 FINAL BALANCE DUE ON THE LAST DAY OF INSTALLATION. 6.25%MA TAX 319.27
MAKE ALL CHECKS PAYABLE TO GOVE LUMBER COMPANY, INC. TOTAL $7,136.47
CUSTOMER HAS RIGHT TO CANCEL OR WITHIN 3 DAYS FROM DATE AT TOP
ORDER ACCEPTED
AS WRITTEN X
IF YOU HAVE ANY QUESTION EGARDING YOUR INSTALLATION
PLEASE CALL BA Y GOVE AT 978-922-0921