64 VALLEY ST - BUILDING INSPECTION fIIC t'rrnlnur,nlr•ahh (II IN1JSSJrhuSritS -- ---- - ----
' \� t l3oarJ nl 13uIIJulg RCCtIIaIItuIS ,Iod S1.111J.IIdS I t I!!
' wV) t KtN %lassaihusilis .SI.I(e I;;IIIdim! ( JJC. 7S(1( \(R, /'1' eJIIiUII \II \Il ll' 1i I I
L ' _ I V
HuilJinr' I'rrntit :1pp1!�Jurin fll (•nn.uuil. Rrpeu. Rrnm.l(r (h I)rnwli.h a ' '7,
t' Onrlliq�, ! s;
t i l hI, ,•.arm Fnr ( Riclai ! hr Onl}--
Bioldol_ Pcnnu ♦ ml ar _ h !e .\pph�J.
,,_nalalr _ 9 / �/�
BuIIJIn�C . mn ';a En r ,.n •. i: ll:. - _.__._ U.nr �� �
SF( I fON 1: ,1111. INj 010 :\'I ION -
,yL G)� ` ' 1� I I ' 1,.e sun flop K i Ir ci Vurs I I :
i 1 1.1 I, 9h .Illar r e' ned
1.3 Zoning Information: II A Property - ---------`-I
Dinernsiuns:
Zom ng )ulncl Pn q>tl,id Use I Lol Arco!, ill
4 h`ur.l.:gr :lil
1.5 Building Setbacks (ft)
Fnml Y'arJ .SiJr Yards —I
Ri.li Y .ill) --
KryunrJ Prodded Rr uocJ
_ 4 Prrn lJed Rryw L i'or iJrd I
1.6 Water Supply: :.\fQL c_ 10. §51l IJ Flood Zone Information: Lg Sewage Disposal System: - -�
public ❑ Pn c:dc i7 Zone: _ Outside Flood Zone:'
Check it yes❑ lhnuapal ❑ On ,ile Julw,al ,�,Irm�
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record: ----'
1 Nome I,n(t Address for Service —
---- I— 'is 4
_
5!e - -- - j
nxiarr Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that applyl
r---- --->--_—'T'--
' New C�m,t«Iciion ❑ cciuin Buildin ❑ OwnerOceupled ❑ Repa!rs(s) a Al(eraul,m:.) L �---- 0
� Drnn;hnon L 'I AcrrSSr,ry Bldg. ❑ —__
Number of Units ..._ Other ❑ .SpccilY
— —
uriet I -pl un o Prupos.d Work'
Ga.ernO,\Jt NSPA4A LT- 5%a.ttiG� i >✓S \�®o sr
- ._ --
..5�'E.V� �L�l.i��l_�� [_ASRRIAt_Z'�
_ SECTION is ESTIMATED CONSTRUCTION COSTS
i;rm ---------TEStnna(eJ
11 ahur and .".laterl.:!Si
Official Use Only
j limlJlne }I—q I I. Building Permit Fee: 5__ Indicate ho,s Ice ,, Jet,nurr•,1
' F!cr local -------I `$-- ❑ Standard Citylfown Application Fee
-- ❑ Total Project Cosi' I frem GI Y mullipher __ r
I Plumh!nu
_�_ ! '. Other Fees: S _
1 .\irchumcal Ili\':\CI ) ---- Luc —_ -----
5 :%1ech.imtA !Fire _
Supprr„eon I S I\a.11 :\II Free: S -_.-.-
('heck .i,h \nenon
/ focal Project Cult
v--__. _ ����• ❑ P.oJ In Full ❑ Out,tdnJ!11L R.Ilanrr 1)ur
'C� lc 60 e G16(jftt7� i
SEC FION CONSTRUCTION SERVI('FS
___ - --- -- -- s5 9
GA I.icensed ('unstruction Supersisor Il G�
'SI.1 `-'��IT - )
\wuh:r Lynl :I mI)a (P/ '2j1
\alni ,il l-]I IInIJir a p,N-bOVGVZfslx nii hi hi,sl
------
1 ,tililiJ ui,l,i
------/ a H ,_Hill i.l,J I.\J Fan I
l
�/�� /I�� q I�\1l H I ill.d \\
_1 // VV ` ��^�� ! GC_�� D R l I nu.d 1 IIJ I l 'I 14 Inn \hi l l Ilnl.i .nI
III YJ •Jt 1, rH_ lJ w .il thin„l:'...... -
'r j._' Registered Ilome Intprosement Contractor IllIt )
If e81,11111,p) Vnlnhir
lilt C,iuq,.ills Samdfn III(' Rceis ralit \�I�
\JJri, Z✓ i![ N✓ /T 12� �1M w �7 D"�'b c�(w Ij I':\pirao"ll D.uc
l signal.
uue [.. _.
I
CTION 6: WORKE S' 'OMPENSATION INSURANCE AFFIDAVIT IN1.G.L. c. 152. 5 2506)
Wutl.ers Cornprnsauun Insurance attidavn must be c,nnpleted :u)d submitted \ ith this apph,all,n). 1�:ulurr I,I poi,IJ
this affidavit will result in the denial of the Issuance of the building permit.
Signed Atficlavit Attached-) Yes ......_ - ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the x)bp_ct pmperly hereby
I. _-_---_ - ---- to act .,n rnv h.ch.Jt. In .III Manzi.,
auduirize
by this building permit apphcaoon.
Iro!au•:r to •.vurk authorized l
Date
Solna Wrl ul Ownef
SECTION 7b: OW'.NF.RI OR :(UTHORIZED :GENT DECLARATION
�N��4 ! (�
, as Owner ur :Nuthofimd agent hrrrh}' Jrclarc
I. 'v
.u)
that the statements and information on the tilregulne application are true and accurate, to the best ,)r Inv kni,svxdee
behalf. S L uS Gon�S�a'LvG��oA/ Itj
,/, ice G� ;
Pont Vain (L 1 (v 0 ---
Date
SI¢n ore of Owner or Authorized : gent
I.' ned under the 2aill,and penalties ul erju 1 NOTES:
\n Owner s,ho tobtams a building permit u, du his/her town shirk. iir an owner \vho hires an unicgnliied c„nlracl„r
(not registered In the Home lmpro.ement Contractor IHIC) Priwraml. will not hase access It, thelp
u -b""tnin
program or guaranl,v Lund under NI.CLI_. c. 14_1A. Other important inh,rmauton on the ill(' Pnig
( n u n n Sup rvl r I i nsing iCSI ) can he h and in 'RO (AIR Regulations 110Rb end 1 It) RS. lc,pcolr clv
When substantial work is planned. pl,nide the intormati n het w
onclud)ng garag h ,
e. ni,hed haelnetiU:)tIl". JrCk„lr
T,nal floors area i 5y. Ft.l li,iltihi
H.ihu.lhlr room count
Gn,es tieing area iSy. FrANuinher
j Number rt hrrpl:ices__------ Number of hall'h.11h.
Vun)bel it h.uhrroin)s ----- Number M Je.k.i p,n,hc,
I
I we ,d ',�iling ,.\,Iei._—.
,ist
� I. ��I-,nal Pnyret Square I",oltage ma} hr ,uh,ntuted ha .:Il,i.11 I'ngect _.
09/03/2008 11:52 6176660037 AMAZONIA INSURANCE PAGE 01/01
ACORD. CERTIFICATE OF LIABILITY INSURANCE D/1e""9/°
PRODUCER TMS CONTIRCATE R5 ISSUED AS A MATTHt OP INFORMATION
ATIAP,ONi a Iaeura>;Ice Agency Inc. WRY AND COFFBtS NO RIdRS UPON THE GERrIRCATE
66 Bow Street AALTER HE COVERAGE TAFFORO®E DOES BY TIRE GaICII�S 9MOYY,
Somervi Lle, KA 02143
INSURm AFFORvW COVERAGE NAIC 0
INWRBO MURERA GraSµite State IneTSreace Cc Re _
FRS ROEIFING & GUTTER SERVICE INSURERS;
FAZIO IRA SILVA PJ$URERQ
53 mm)•ORD ST S 2 �NSUREEI D:
xAwmF mh 02148 PSURERE
COVERAGES
THE POLK IES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING
ANY REW IREMENT. TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERT UN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.E)CLUSIONS AND CONDITIONS OF SUCH
POLICIES. iGGREGATE LIMITS SHOWN MAY NAVE BEEN REDUCED BY PAID CLAIMS.
INER POLICYPOLIC7 EFFECtIre POLICY LIMITS
m MORAL.LIAORM EAOIOCCURAENC6 _ 'J
COMM9lCNLCENERPLLN6 O S
CLANS MADE El OCCUR Lm®ETIv aIu s _
IyRWNALA AOV NAAr S
GEERALAGG EGRE $
Of WLAGGFMCATE LAIR APPLIES Pei: MMUCfS-CCMPOPAOB 5
POLICY Fj too
Al TOMOBRe LIABILITY COMIRMOSNMEUMB =
Ira atlaV)
WIYAUTO
_ AU.OANWAVMS WOLYNJURY :
S IDIIIED AUTOS (ti Nlem)
MAEO AUTOS ®aLrNJURY s
(RI SmIeN)
NOILDWPEDAUTOS
MCPGRTYOVAAGE 5
(Por H.T)La )
a RAWUABILm ALTOOWY-EAAOCDINT t ANY AUTO aPERTHAN EAACC 5
oumorlr: AGO S
V CE65ARBt LUWILIW 6WHOCCIPUENCE 5
JOCCUR CEABISMADE /CmMWATE i
5
DWLICTIRLE _ -
RETENTION 5 S
WC STATLF Om
WORM a CuavENSATION WD LWR$
MPLOI ERTUABMr
A 9TC7429237 6/22/09 6/22/09 ELBICNACi s 500
ANYPRI oRR?TOiNARTNEWF3tECVRVE
OFFICE•lAIEMBER EXCLUOED'rOFS ,000
AA-EA ELVI,dff S 500,000
N ��, ELOMASE.POULYLMIr 5 500,000
OTHER
OBSWS>TION 3F OPERATIONS$LOCAPONS I VEHICM IEXCMWG ADDED BYENDC S8 W I SPECIAL PROVISIONS
C6RIRCA TE NOLOBI CANCELLATLON
SNDYw AIPYOR fNE ABOVE OTALCRIBlD PaueSseE CARCFL{.EO BBORB THE F�@M71DN
ANTONIO SANTOS DATE THEREOP,TTIE ISGRNG INSUNER WILL ENDEAVOR TO MAIL 30 GAYS WRITTEN
PAS 978-475-9565 NOREE TO THE CE RINCATE HOLDIM NASM TO THE LER.BUT FA URe TO OD SO E(A
64 VALLEY ST MPOW NO OBLIGATION OR LVMUTT OF (O UPON THE INSURER,ITS ACETITS OR
SALEK, MA 01970 RePRESEMTATrAN
W N10RIB:DREPATiSBNTA
Amazonia Insuraunoe
ACOID 25(2001M6) `•
TION 1938
Bo n uJ mt gIfegul`lg iohs as tanda7dds
Air
Construction Supervisor License .
License: CS 85904
Birthdate: 6/13/1954
Expiration:6/13/2009 Trill 16835
-Restriction:-00
ANTONIO C SANTOS -
25 LINDA RD-
AN66VER,MA 01810 - Commissioner
Boar)of Building Regulations and Stan a,Js - - -
. HOME IMPROVEMENT CONTRACTOR License or registration valid for individul use only
before the expiration date. If found return to:
Registration ,,140671 Board of Building Regulations and Standards
Ezplptlon. t1/10/2009- Tr# 266319 .One Ashburton Place Rm 1301
Type: Individual - _ Boston,Ala.021US -
ANTONIO C.SANTOS - - -
- ANTONIO SANTOS - - -Al COLONIAL DRIVE 97
ANDOVER,MA 01810 e =�
Administrator- - Not vagd without mgdature
CITY OF SALEM
PUBLIC PROPRERTY
DEPART' vIENT
Construction Debris Disposal Affidavit
(tcquired l'or all demolition and renuv ation work)
In accordance ith the sixth edition of the State Building Code, 780 Cb1R section 1 1 1.5
Debris, and the provisions of v1GL c 40, S 54;
Building Permit f is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
l t 1. S 150A.
The debris will be transported by:
/-;I-LL/ G -t) Wl -�; I_C-
Inamc of hauler)
I he debris will be disposed of in : /
(name ut facility)
loddress ul facililyl I'
vgnalure of permit .g1plieam
lo Lo 2-o
,rile
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I%W; N:1 V )KI'( -11
\I u r,a 12^C W MI a.\6I().%S I x LL r' • S:\t I'M.M.\.n.\(.I n if I ISO I 97-_
Thl, 978-:45.9595 • 1'.\x. 978-741--')846
Workers' Compensation Insurance :%ffidavit: Builders/Contractors/Electricians/Plumbers
li i tlicant Information Please Print LeCihly
NainC lausntcsy 1�r�anir:1lialV lndty uluull.
Address:
City,Slale;Zip: Phone
Are \ou an employer:' Check the appropriate box: 'Type of project (required):
i
I.❑ 1 :un a employer with 4 m 6.n a general cautractor and 1 New construction
❑
c ntployces(full undi ur part-IiIII0.• have hired the sub-contracture 7 Remodeling
2.El ;un a sole proprietor or partner- listed on the a .nached sheet. _
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. workers' comp. Insurance. 9. ❑ Building addition
INn workers' comp. insurance 5. ❑ We are it corporation and its 10.0 Electrical repairs or additions
l required.] officers have exercised their
tight of exemption per h1GL I I.❑ Plumbing repairs or additions
3.❑ 1 not a homcowncr doing all work c y152, i 1(4),end w have no
myself. ]No\workers' curnp. 112.❑ Roof repairs
insurance required.] i employees. ]No workers' 13.❑ Other
::omp. insurance required.]
•an.-.�,phcaut that checks box III must:Ilsu lilt out the wcI.jn heluw;howina,heir workas compensation pulicy init,rmatiun.
'ilome11%mn who submit this affidavit indicasing they are doing all work alul then him uutsidc caurxron must.uhmil anew affdavit indiuong such.
-(',nir.Kwr,that check this box muei anxhed.m additional sheet showing Ibis name of this sub-contractors and their workers'comp.pnhcy intbor ruun.
l fun an employer that iv pruvidirtg workers'cotipensatioi insurance for uty employees. Brlaiv is the pulicy and%ob..ire
I llfuralunl/n.
Imurancc Company Vame: �yy)j'.iap M1ll f�- I'NS�IZ44-v\�C�S
Policy g or Sclf--ins. Lic. n: /t/`r ca 2-g2-3 Expiruuon Da�tr,:,.�r \ —
(a4 City;Slaiei"Ltpz2Vw&W � .
Job Si[c \dJress: -!
Attach it copy of the'workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required uodcr Section 25A ul�IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 anJ/ur une-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to )250.00 a Jay against life violator. He advised that a copy of this statement may be forwarded to the 011ice ut
IIN cati:;auum ui dic DIA :or ioswarcc vnengu \cmicatiOn.
l do hereby certify auhd•r the par'is sad penmhic jpgr'Fry that tl infuriation provided above is true and correct
Dat4_� �
Official use only. Do nat write in this area, to be completed by city,or town official.
City or fmvn: _-- .:. Pcimit/License tl_ _
Issuin, .%ulhurily (circle one):
I. Board of lie:dih 2. Building Department 3.Cilf.'1 o\w Clerk J. L•'lectrical luipector 5. Plumbing lnspcc for
6. Other --
Cn nlucf 1'cnuu; _ _ Phone tt:
Information and Instructions
Mal sachusells General Laws chapter 152 acquires all employers to provide workers' compensation for their employees.
Pursu.mt to this statute, an employee is defined its"...every person in the service of another under any contract of hire,
or cv ress implied. viral or written."
P P
An employer s defined as"an individual, partnership,association,corporation or other legal entity, or any two or more
or the Ktreeoing engaged in a Joint enterprise. and including the legal representatives of a deceased empluycr, or the
receiver or trustee of .ui 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."
MGL 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 vrho has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, :bIGL chapter 152, §2517(7) states-'Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance uf-puhlic 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-contractor(s) name(s), address(es)and phone nuniber(s)along with their certificate(s)of
insuance. 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 confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
tic rcmrned 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 Official
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of file affidavit fur 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 pennitilicense number which will be used as a reference number. In addition, an applicant
that must submit multiple permitiliceilse 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 burn leaves etc.)said person is NOT required to complete this affidavit.
t he ()(lice of Investigations would like to thank you in advance tar your cooperation and should you ]lave ;my questions,
please Jo not hesitate to give us a call.
The Deparuncnt's address, telephone and fax number'
The Commonwealth of Massachusetts
Department of Industrial Accidents , ,
Offlce of Invtstigadons
600 Washington Street
Boston, MA 02111
Tel. a 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
ail6cJ 5-_'b-f15
www.mass.gov/dia
LOGUS CON
STRUCTION INC.
Proposal # 1308
25 LINDA RD—ANDOVER—MA Date:September 3,2008
PHONE:978-475-9565 FAX:978-475-9565
CEL 978-886-9636
EMAIL:TMSANTOS G� MAIL.COM
Proposal/Specification for
CHI LE
Address:#64 Valley St.
Salem—MA
Phone: 978-335-8273
TO BE DONE AS REQUESTED:
1. Remove and disposal+/-1.600sf of asphalt shingle from the roof
2. Install+/-1.600sf of underlayment of Ice water shield
3. Install all new dripp edges
4. Install led protection around chimeney
f S. Install+/-1.600 sf of new asphalt shingle
6. General clean from the roof debris
LABOR AND MATERIAL COST: $5.500,00
Notes:
Material and labor will be supplied by contractor.
All materials Is guaranteed as specified.All work in a workmanlike manner according to standard
practices.Any alteration or deviation from above specification involving extra cost will be executed only
upon written orders,and will became an extra charge over and above the estimated.
We propose:Hereby to furnish labor in accordance with above specification for the sum of:$5.500,00
(five thousand and five hundred dollars).
Form of Payment:
$3.000,00 when material arrives
$2.500,00 when project's done
Date of acceptance: -OL Autorized signature
Acceptance of Proposal:The above price,specification and conditions are satisfactory and are hereby
accePew.You are authorized to work ass Payment will be made as outifined above.
Ifi aYm
LOGUsCONSMUMON,INC DATE