18 VERDON ST - BUILDING INSPECTION Lt (e2-
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
t i
0!!� Nassachusetts State Building Code, 780 CNIR SALENI
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised blar 2011
i, One-or T1Vo-Fnm11y Dwelling
Number:
This Section For Official Use Only
Building Permit '
? Date Applied:
[3udJing OtTtctal(Pnnt Name). — `-Yfl JZ_Z�—�
" . dress:_ � Signatures � Date
SECTION I:SITE INFORt�fATION`
L1 Property A�1d
f 1rt`fin yU J 1.2 Assessors IIap S:Parcel Numbers
I.[a Is this an accepted street?yes_ no Map Number ,
— I arcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Ua�—
LotArea(sy It) Frontage(II)
1.5 Building Setbacks(ft)
uireJ
Re
Front Yard Side Yards
q Provided Required Provided Rear Yard
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 ifyes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner 0,1,
Np,�,e(1rmt).,/ y/, r % J,l//1% > 5"w" 479 . O/ � 70
ie S` City,State,Zip ` �y
No.mid Strut - 6/o J'3 !�
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED 1VORK*(check all that apply)
New Construction❑ E.xis1 Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ I Number of Units
Brief Description of plop York=: Other pecify:
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Iten, Estimated Costs:
abor and Materials Official Use Only
I, Building $ �() I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/TownAppheation Fee
3. Plumbing $ ❑Total Project Costa(Item 6)x multiplier x
2. Other Fees: $
4. ch ird (F AC) $ List: �, x
S, M\(echa nical Fire '
Suppression) $ Total All
6. Total Project Cost: :S /� ) Check No._Check Amount: Cash Amount:_
❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
s !apt
5.1 Construction Supervi or License(C%)) �— E, iration Dale
License Number P
Na,,,ol'CSL Holder List CSL'rype(tee below)
Type - ,`. Description -
/ U Unrestricted Bottom s u to 35,000 cu. tl.)
No.and Sjl
R Restricted 1&2 F Imily Dwelling
Mason
city/Town,State,ZIP RC Rootin Covering
WS Window and Sidin
SF Solid Fuel Btiming Appliances
77YnG7 7 1 Insulation
�(J V p Demolition
Tale bon Email address i,/
52igi ¢Flome/I n�ptroveme nttGs t�A(HI,C) 2
!rK/ �a°r)FTt%L, /� RICRegist r �LExpiation Dale
HIC Cum ' Nam-or IC iegtslra�trNrJme �J us�� �/�
Email address
G
No.and Stree)ml { G-. U 017
t
(TCJ J Tele hone
Cit /Town,State,ZIP
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.1 25C( ':.
Workers Compensation Insurance affidavit must be complete submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of Ili uilding permit.
No...........❑
Signed Affidavit Attached? Yes ..........
ON 7a:OWNER AUTHORIZ ATION TO BE COMPLETED W
SECTI MI
OWNER' R APPLIES FOR BUI DING PERMIT
S AGENT OR CONTRACTO
1,as Owner of the subject property,hereby authorize /
tal act on my behalf,in all matters
/relative to work authorized by this building permit application. 2 3! 3
Dale
print Owner's Nmne(Electronic Signature)
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 d accurate the bps}of my knowledge and understanding.
/n Date
Print Owner's orr Authorized Agcnt s Name(LI arum Signature)
NOTES: gistered
I. res an
An Owner who obtains a building permit to do his/her own work
rogg,or)toll n rt haovetac ess tot the arbitration tmuor
(not registered in the Home Improvement Contractor(HIC) Pro mm),
ty fund bConstruction Other infor ation on the
a wProg,am can Il at
program oopeform on on he supervisor ense be fondt wls'
as' a : ln
2. When substantial work is planned,provide the information i uinglgarage,finished basement/attics,decks or porch)
Total floor area(sq. ft.) Habitable roam count
Gross living area(sq. ft.) Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches
Type of heating system Enclosed—.-._--_---Open
'type of cooling 'system
3. "lbtal Project Square Footage"may be substituted for"rota) Project Cost"
CITY OF SALEM, NLNSSACHCSETTS
BUILDING DEP 1RTME.NT
4 k Ylk Jr 120 WASHIINGTON STREET, 3ra FLOOR
T EL (978) 745-9595
F.kx(978) 740-9846
KINfBERLEY DRISCOLL
'I"
iAYOR ontA6 ST.PtireRs
DIRECTOR OF PUBLIC PROPERTY/BUADING CONMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A p tlicant Information Please Print Legibly
Name (Business Organization'Individuaj: y_
Address: /y1, / C , V l /�,/ �j�
City/State/ /0/iLTU� dn0?e #: 77— /—r�1S ?r0adr)—
A e yn n employer?Che the appropriate box: 'rype of project(required):
I. am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ 1 ana a sole proprietor or partner- listed on the attached sheet.t 7• ❑ 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 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself.(No workers'cutup. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. (No workers'. . l3.❑ Other
camp.insurance required;]
'Any applicant that checks box at must also fill out ate section bdowshowing Theirworkm'compxnsmion policy inl'unnation.
'I b+mcomrrs who submit this of icibivit indicating they arc doing all work and then hire outside contmetors mint submit a new afrdavif indicating such.
K:eomwmn shut chuck this box must attached in additional Asel shuwing The mmne orthe subeantncton and their workers'comp.policy inrotmation.
I one an entplayer that is pruvfdi og worker 'conepeasadon insurance for my eatplo3,ees. Below Is the policy and job sire
i ifonuutiun.
Insurance Company Name: A
PolicyAurSelf-Tuts. Lie.N: Vc l—� Expiration Date:_.q ��,,��/y/� q—�
Job Site Addruss: LO 6�4�G�� T_ City/State/Zip;,::;4 ✓ „' I , Gf< �v
mtacb a copy of the workers'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
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to SM.00 a day against the violator. Be advised that a copy of this statement may b:forwarded to the Office of
Invesligations of the DIA for insurance coverage verification.
I do hereby certify un/derethe paths and penalties/o�fpperrjju/y that
the infurnr ov' ab v Lv�up a�rrecL
/
llen;IlllfC: / �� (�7/�J' ✓ (� t/e 1 C—rl^`L�'y
Phone
Official rise only. Do not write in this area,to be completed by city or fawn offieiul
Cityor7mva: _ .__ Permit/i.lccnsep
I.ssuing,%ulhurily(circle one):
I. Board of Health 2. Building Department J.Citylfuwu Clerk A. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone tt:
1,y1 Massachusetts -Department of Public Safety
�f Board of Building Regulations and Standards
C e : Supen'ieor
License: CS-102403
WIISON R VALD)IZ . .. .,
151 MAIN STREET -
MnSORD MA 0757
n iv`s Expiration
��
commissioner 1112012014
r.HRcr of Consumcr.\[fairs&Ruiinexs Re�ulnoon
HOME IMPROVEMENT CONTRACTOR Type:
Registration: 150577 PP
'-• Expiration: 4111,12014 DBA
MA.STERROOF
WILSON VALDEZ
151 MAIN ST - �•
MILFORD.MA 01757 1 ndersrcretarr
i
it
i
I
I
i
v �vr YIIVOUMLLYUL'HIIYCNYI
yALDEZ,WILSON DBA MASTER ROOF&UMENVIOUS-MA INSURERS:
INSURER C:
INSURER D:
PO BOX 83 INSURER E:
MILFORD,MA 01757 INSURER R
COVERAGES CERTIFICATE NUMBER: REVISIIIN NUMBER:
THIS 13 TO Cl
RTIF I O IF—tAWd9rWTEDBELOW HAVE IM ISSOED TO THE INSURED NAMED ABOVE FOR THE POLICY PEI I OD INDICATED.
NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT Wn H RESPECT TO WHICH THIS CERTIF(:ATE MAY BE ISSUED OR MAY
PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,EXCLUSIONS AND CONDITIONS OF:;)CH POLICIES. LIMITS SHOWN MAY
HAVE BEEN REDUCED BY PAID CLAIMS.
INSR ADD BUS POLICY EFP DATE POLICY EXP DATE
LTR TYPE OF INSURANCE L R POLICY NUMBER (MMIOMYYYY) (WAOMYYYY) UNITS
GENERAL LIABILITY CHOCCUPItENCE $
COMMERCIAL GENERAL LIABIUTY
AEMI ETOIIENTED $
CLAIMS MADE M OCCUR REMISES(E I atwrlerae)
ED W(Am Dne Person) S
ERSONAL&.OV INJURY S
GEN'L AGGREGATE LIMIT APPLIES PER ENERAL AG:REGATH $
POUCY PROJECT�LOC RODUCTS-:OMPIOP AGG S
AUTOMOBILE LIABILITY COMBINED SI'IGLE $
ANY AUTO LIMIT(Ea acdi I m0
ALL OWNED AUTOS BODILYINJUET S
SCHEDULE AUTOS (Per parson)
HIRED AUTOS BODILYINJUF�/ S
(Per wddent)
NON-OWNEDAUTOS PROPERTY D:MAGE $
(Pw uddent)
-- -- .UMBRELLA UAB _ OCCUR - - ... EACH OCCUR
$
EXCESS LIAS CLAIMS-MADE AGGREGATE $
DEDUCTIBLE $
RETENTION $ $
A WORKER'S COMPENSATION AND X WC STA'UTORY OTHER
EMPLOYER'S LIABILITY YIN UB-4505PS74-13 03I15fm13 03115=14 UMITS
ANY PROPEAITORIPMiNEWEXECUTIVE y❑ NIA E LEACH AC :IDEM $ 100 000
OFFICERIMEMBER EXCLUDED?
(Mandatory In NH) EL DISEASE-EA EMPLOYEE $ 100,000
If yoa,ducd6a andar E.L DISEASE•POLICY LIMIT $ 500,000
DESCRIPTION OF OPERATIONS below
DESCRIPTION OF OPERATIONSR.00ATIONSNEHICLESIRESTFOCTIONSISPECIAL ITEMS
7 11S REPLACES ANY PRIOR CER73F ICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE.
THE WORKERS'COMPENSA110N POLICY DOES NOT PROVIDE COVERAGE FOR VALDE7,WILSON.
CERTIFICATE HOLDER - CANCELLATION
COASTAL WINDOWS AND EXTERIORS SHOULD ANY OF THE ABOVE DESCRIBED P(I LICIES BE CANCELLED
I00 CLRv1I1�iGS CENTER SUITE 235-H BEFORE THE EXPIRATION DATE THEREOF,117TICE L B WIL DEW D
IN ACCORDANCE WITH THE POLICY PROV I
BEVERLY,MA 01915
AUTHORIZED REPRESENTATIVE
�
ACORD 25(2010I06) The ACORD name and logo are registered marks of ACORO 1988.2010 ACORO CORPO :%I . A ng reserved.
CERTIFICATE OF LIABILITY INSURANCE 3/7/2013
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 AF!'ORDED 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: It the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an emloraemeM, A statement on this carlitle to I Ices not confer rights to the
cerlificate holder in Ileu of such endorsemen s. ,
PflOOUCPA R AC Thomas Murray
Marketing Associates insurance Agency, Inc. PHONE (617)964-5340 FAX .(s17)9a5-1e43
150 Wells Avenue I, tmurra @telamonins.com
INSUR AFFORDING COVE3tADi NAICS
Newton MA 02459 INSURERA:Rautilus Insurance Co21 an
INSURED NsuFTER9,Safety Insurance
Wilson Valdez, DBA: Master Roof WMRERC:
P.O. Box 83 INSURER D:
151 Main Street INSURER E: -
Milford 14A 01757
COVERAGES CERTIFICATE NUMBERCL133110681 REVISION NI;MBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED AS 0VE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT V I TH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS !iUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
Ns Uc 0 C $
TYPE OF INSURANCE PauCY NUMBER MM , LIMIT
OENEAAL LIABILITY EACH OCCURRI:%ICE Is 1,000,000
DAMAGE TO M TED
COMMERCIAL GENERAL UABIUTY s 50,000
A CLAIMSMAOEQOCCUR 20718 /10/2013 /10/2016 MEO�PA ,RE
,,pomen) S 3,000
....... -- --------. . _..--------
PERSONN-B,A[I r INJURY-- S-----
GENERALAGGT1iGATE S 2,000,000
GENLAGGREGATE UMRAPPUES PER PRODUCTS-CCI IMP AM $ 2,000,000
$ POLICY PRO• L� s
AUTOMD9ILEUASILTY NE 31M.
U
B ANYAUTO BODILY QUAKY;lu W=) S 100.000
ALL OWNED M ASC�IMMED 203733 /29/2013 /29/2014 BODLYKWRY ;+eratcWero) 3 300 000
WREAAUTOS NON-OWNED
ON- �AUTOi 1 PROPERTY s S 300 000
s
UMBRELLA UA13 OCCUR EACH OCCURRE I ICE $
EXCESS LIAR CLAIMS414DE AGGREGATE $ ..
O S $
WORKERS COMPENSATION ill be issued under YJC 5TA7U;
IM
AND EMPLOYERS-LIAINUTY
ANY PROPRIE70RIPARTNERIPKECUIIVE Q NIA Aerate cover within EL EACH ACD[I iYT $
OMCERAMEMSER EXCLUDED? 4 to 46 hours. ELOISEASE-E- EMPLOYE S
Vdandat3ry In NH)
Uyyeass,,ducfto odor
DESCRIPTION OFOPERATIONS hebw E.L.DISEASE-P;UCY UMiT S
:="ONOFGPERATIONB/LOCATIONSIVOUCLES(AUeaEACORD/01,AddDlonWRametls SnMtldalt=MSPxalsreWNad)
ea attached for additional information.
iding Installation is subject to $500 deductible per claim.
cofing is subject to $2,500 deductible per claim.
ERTIFICATE HOLDER CANCELLATION
pfontas@aol.CCM SHOULD ANY OF THE ABOVE DESCRIBED POL I:IES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTION WILL BE DELIVERED IN
Coastal Windows and Exteriors ACCORDANCE WITH THE POLICY PROVISIONS
100 Cummings Center AUTHORRED REPRESENTATIVE
Suite 236-H
Beverly, MA 01915
'?RD25(2010/OS) 019W2019ACORDCORP0IIATION. All rightsreBetved.
1196nmmslm Thnernnn�nrwed,awr..ore.daeie.m+w.a.l,e Ar`nQn
CITY OF S.1LEl t, 1rW&ICHUSETTS
tt " Bt MMNG DEPAJITMENT
120 TASHNGTON STREET, 3AD FLOOR
TFL. (978) 745-9595
KIMBERI EY DRISCOLL FAX(978) 740-9M
iNLAYOR THOHAs ST.Pmus
DIRECTOR OF PUBLIC PROPERTY/BLILDD4G CONNISSIONER
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 1 l 1.5
Debris, and the provisions of NIGH, c 40, S 54;
Building Permit # is issued with the condition that the debris resulting Cram work shall be
l l I, S I SOA. disposed of in a properly licensed waste disposal facility as defined by MGL c
The debris will be transported by:
y_
(name of hauler)
The debris will be disposed of in
(name offacility) /yam' I
(address of facility)
64
signature of permit applicant
(late
khn.a u'•b:c