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76 VALLEY ST - BUILDING INSPECTION Oo CKOoi2'1 ! The Commonwealth of Massachusetts RECEIV �lCe�tY OF Board of Building Regulations and Stand �PEG7tpfdAL �" SALEM I Massachusetts State Building Code, 780 CIVIR yt, ,V/ur 20!! p PA. 44 Building Permit Application To Construct, Repair, Renovate*PW9&l1sBa One-or Two-Family Dwelling t This Section For Official P Onl ' (� Building Permit Numb err Date.Applied: Building 011icial(Print Name). Signature, Date SECTION I:SITE INFORtNIAT10N' (� I. Pro er)y,�tltle�Y ` 1.2 Assessors blop 3t Parcel Numbers 1.to Is this fan accepte street?yes no Map Number _ Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 'Zoning District Proposed Use Lot Area(sq R) Frontage(It) 1.5 Building Setbacks(it) �E� Front Yard Side Yards Rear Yard ReyuireJ Provided Required Provided Required Provided I.6 Water Supply:(M.G.L c.y0,§Sd) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ SECTION2: PROPERTYOWNERSHIPt' 2.1 nerl f I�corP�AA ao I� meePrint) I G( City,State,ZIP ✓aIl-7 s q �sy13�S l No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED\VORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Cl 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed%Vork-: s"TYa'1 e SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Lab and Materials 1. Building S' �.c�D,� 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cosh(Item 6)x multiplier x 3.Plumbing S P Qlher Fees: S d.Mechanical (IIVAC) S List: 5. Mechanical (Fire S Total All Fees:S Su ressiun) Check No._Check Amount: Cash Amount 6.Total Project Cost: S 'Z-10 . vJ ❑Paid in Full ❑Outstanding Balance Due: __ CI SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No. ;md Street Type. . Description . U Unarstricted(Buildings tip to 35,000 cu. ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Mason RC Roolin Coverin WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition j 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address _Ci /_Town State ZIP__ Telephone _ SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.[L c.IS2.§25.C(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 Isluance of the building permit. Signed Affidavit Attached? Yes..........❑ No...........O SECTION 7a,OWNER AUTHORIZATION.TO BE COMPLETED.WHEN, OWN ERIS AGENT OR CONTRA CTOILAPPOESFORBUILDING PERMIT: 1,as Owner of the subject property,hereby authorize t9 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 ORAUTHORIZED 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 Agent's Name(Electronic 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. I42A.Other important information on the HIC Program can be found at www.mass.cov'oca Information on the Construction Supervisor License can be found at www.mass. ov lJns 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) N ,(including garage, finished basementlattics,decks or porch) Gross living area(sq. 11.) Habitable room court Number of fireplaces Number of bedrooms Number of bathrooms Number of half/balks Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "rota] Project Square Footage'may be substituted for"Total Project Cost" SECTION 5: CONSTRUCTION SERVICES 5.1 Construction sp^Sypp�ervisorrLicense(CSL) CS M S 1 gs y '3/ IS G I c' t)CLVO / �K� License Number o Expiration l Date Name of CSL Holder / 6 t 'K ft.N�� S— iS I List CSL Type(see below) No.and Street Tr Type Description �%f-e"vy — ^jvtk_. ©Z 1 y --dk Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Mason RC Roofing Covering WS Window and Siding Z qq I -N lo n SF Solid Fuel Burning Appliances 1 '"1"I (O✓ WI I Insulation -Telephone Email address (iq w D Demolition 5.2 Registered Home Improvement Contractor(HIC) / q-S 9 5 HIC Company N or 1- HIC Registration Number Expiration Date , Re t ant Na y,and SMot) � 's 1— � ,� ` '1 �,�///ppp 9 137 ` ►� v Email address City/Town,State,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 Issuance of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........❑ 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 C t I? V / O &A 11 J to act on my behalf,in all matters relative to work authorized by this building permit application. (5er¢( CC R,�y�vt��� ��i--I ® �IIS Print Owner's Name(Electronic Signature) I 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 is true and accurate to the best of my knowledge and understanding. C►oi,dJW Print Owner's or Authorize Agent's NainbkElectronic Signature) 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. o�v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dI)s 2. When substantial work is planned,provide the information below: Total floor 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 cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" -Office of Consumer Atfairs&Business Regulation OME IMPROVEMENT CONTRACTOR egistration 168583 Type: Expiration 3/81207;7 ' Corporation k r—= WINTER HILL GENERAL CONTRACTOR, INC. CLAUDIO ARAUJO 170 MAIN ST NORTH READING, MA 01689 Undersecretary Massachusetts -,Department of Public Safety Board of Building Regulations and Standards Construction Supenisor License: CS 105185 c I rx CI.AUDIO M ARAtJ - 's. 163 HANCOCK ST .- EVERETT MA 0214 " 'o Expiration - Commissioner 07/13/2015 PROPOSAL ESTIMATE 170 Main 5[,North Reading,MA,01864 781-321-1991 WINTER HILL Claudio Araujo—License C5105185 GENERAL CONTRACTOR, ffdC. www.winterhiligc.com Gerald Raymond judysldp@comcast.net 76 Valley St Salem,MA 01970 978-745-1755 3/17/15 Job Location: Shingle Roof The following paragraphs describe the work that will be performed. • Remove existing shingle roof on the Front Entrance of house,Remove Existing Roof Cement&Lead Flashing from Brick. • Install Full ice&water shield step flashing&grid new lead into brick (Front Entrance)=Very Important Install New shingle roof on main house&Back yard shed(GO-OVER) Re-use existing drip edge • Hurricane Nailing:6 Nails per Shingle • Install starter strip on all leading edges. • Install 1 new vent pipe Large Rubber Pipe flanges(On Large Pipe) • Replace any rotten or damaged roof decking plywood(we aflow 32SF stop charge,$55.00Islhereafter) • Install new GAF Timberline High Definition Architecture Shingles • Remove existing lead flashing,install step flashing,ice,.&rater shield,and grind new lead flashing into chimney (Included In Contract) • Repolnfing Mason Rate Per HR $55 per(Example Chimney repair) • Note:Re-Seal,Re-Nall, existing guttersalong.house as needed • Shingle Color=" l..caN • All debris will be removed fromthe property 1 Initial the options you are choosing below: ' Cost for Labor&Material#or New Shingle Roof: $ 6,200 Payment Terms: 113 deposit due upon signing contract: ' $ o?, I00 113 payment due upon start of job: $ 113 payment due upon completion of job: $ Total Amount Agreed To Be Paid: $ Work Scheduled to�Begin: TBD Job expected to be completed elect within 60 days of actual start date. Warranty:Winter Hill General Contractor Inc.guarantees all work performed for a period of ten(10)years.N any problems occur we will cover the cost of all labor and material to correct the problem and meet the customer's satisfaction. r cY:L.w W rY� -51 Robert Winters,Project Manager Gerald Raymorat7e.. Winter Hill General Contractor,Inc. Date Date 71Z,115 CITY OF S.U.EINI, iNDLSSACHUSETrs BUIIDIING DEPARTNMNT 130 WASHINGTON STREET, 3ia FLOOR ` TEL (978) 745-9595 FAX(978) 740-9846 KI1tBERI.EY DRISCOLL MAYOR T HomAs ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUILDING COJL\JMIONER 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: to TC 3 t,s(ao 501, (name of hauler) The debris will be disposed of in : (name of facility) (address of facility- _ signature of permit applicant oUty (�� date The Commonwealth of Massachusetts Department oflndustrialAccidents Office of Investigations UIF 600 Washington Street Boston,MA 02711 www.massgov/did Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information r Please Print Legibly Narne (Business/Organization/Individual): Address:, 11`0 /IA/" ( &--,� S City/State/Zip: /V• I°`—"r'�' 1 Phone #: w l 3 Z 4 Agree you an employer?Check the appropriate box: Type of project;(required): 1� 1 In a employer with J___ 4. ❑ I am a general contractor and I employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction 2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, employees and have workers' 9 ❑ Building addition [No workers' comp.insurance comp.insurance.1 required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself, o workers' cou right of exemption per MGL Y [No P� 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no employees. [No workers' 13.❑ ,Other comp.insurance required.] *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. *Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'"compensation insurance for my employees. Below is thepo/icy and job site information. �i Insurance Company Name: U', �� Policy#or Self-ins.Lic.#: WC- S —'ZO _ 00 iration Date: j�Z 4- I I� Job Site Address: _�_l Va An ST City/State/Zip: !�a(rev--N Attach a copy of the workers' comp nsation 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 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 certifyj�nde :e pq ns and penalties ofperjury that the information provided above is true and correct. Signature: CJ' amy Date: %1 er�Phone#: W 1 J Z t I g 9 1 Official use only. Do not write in this area,to be completer)by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: hforu aflon and Ensti °�uc��tRons Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee 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,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 who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL 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-contractor(s)name(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 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. Please be sure to fill in the permittlicense number which will be used as a reference number. In addition, an applicant that must submit multiple permit/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 :own)."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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. the Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, 3lease do not hesitate to give us a call. 'he 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 ,ised 4-24-07 Fax# 617-727-7749 www.mass.gov/dia f WINTE-2 OP ID:JJ ,a►`o/ty CERTIFICATE OF LIABILITY INSURANCE DATE 0318/2118120/115 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies)must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endomement(s). PRODUCER CONTACT Bradly S.Michals Insurance PHONE Crown Insurance Agency,Inc. Fax Agency,Inc. ac NeEe:617-924-1100 ac No: 617-926-2162 Main Street E-MAIL Watertown,MA 02472 ADDRESS: Crown Insurance Agency,Inc. INSURERS)AFFORDING COVERAGE NAIC N INSURERA:Acadia Insurance Company INSURED Winter Hill General Contractor INSURER B:Essex Insurance Company Claudio Mcuhna Araujo 170 Main St INSURERC:Arbella Insurance Co. 17000 North Reading,MA 01864 INSURER D: INSURER E INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INLICY EXP T TYPE OF INSURANCE L U POLICY NUMBER MMIODYNYVY MM R IODNM LIMITS B X COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000 CLAIMS-MADE OCCUR 3DX7960 02I1312015 02113/2016 PREMISES Ea accunence $ 100,00 MEO EXP(Any one person) $ 5,00 PERSONAL S ADV INJURY $ 1,000,00 GEN'L AGGREGATE LIM IT APPLI ES PER: GENERAL AGGREGATE $ 23000,000 X POLICY JEST LOC PRODUCTS-COMP/OP AGG $ 2,000,000 OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLELIMIT $ 13000,005 Ea accident C ANY AUTO 1020001551 04109/2015 04109/2016 BODILY INJURY(Per person) $ ALL OWNED X SCHEDULED BODILY INJURY Per accident) 4 AUTOS AUTOS ( I X HIRED AUTOS X NON-OWNED PROPERTY DAMAGE $ AUTOS Paramount $ UMBRELLALIAB OCCUR EACH OCCURRENCE $ EXCESS LIMB CLAIMS-MADE AGGREGATE $ DED RETENTIONS $ WORKERS COMPENSATION PER TH- AND EMPLOYERS'LIABILITY X I STATUTE ER A ANY PROPRIETOR/PARTNERIEXECUTIVE YIN C-20-20-003174.01 03/26/2015 03126/2016 E.L.EACHACCIDENT $ 500,00 OFRCER/MEMBER EXCLUDED? N❑NIA (Mandatory in NH) E.L.DISEASE-EA EMPLOYE $ 500,00 If yes,describe under DESCRIPTION OF OPERATIONS below EL DISEASE-POLICY LIMIT $ 500,00 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,Additional Remarks Schedule,may be attached H nwnt space is required) RE: Operations of The Named Insured CERTIFICATE HOLDER CANCELLATION XXXXXXX SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE FOR BIDDING ONLY THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN FOR BIDDING ONLY ACCORDANCE WITH THE POLICY PROVISIONS. FOR BIDDING ONLY FOR BIDDING ONLY AUTHORIZED REPRESENTATIVE FOR BIDDING ONLY FOR BIDDIN 01988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014/01) The ACORD name and logo are registered marks of ACORD