2 WEST CIR - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7°edition R v SI ed aJ nuary
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit N be Date Applied:
Signature:
Buildid Commis tuner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Z WteST al"tto shle +
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(11)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Chcck if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Re ord:
1<_�rpi FDI Recc,a 2 wur eaveacc
Name(Print) C Address for Scrvicc:
Sigdature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check 9 that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) &I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief escription of Proposed Work2:
�EPL t° l64af ON it3!
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ `l .0*. • r 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $_
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check ount: Cash Amount:
6.Total Project Cost: $ 7PD0. 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) / //3 5' 74 1 L
(fMILY fot'WSS License Number Expiration Date
Name?f CS Holder q T
C 1V CM1. (`OjIQ t 6 epsf lCLO List CSL Type(see below)
Ad Type T Description
U Unrestricted u to 35,000 Cu.Ft.
R Restricted 1&2 FamilyDwelling
Si a M Masonry Only
131Y-4 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5. R inter Home Improvement Contractor(HIC) /
A Y MAm oe" wwaw L F3o3FT
HIC Compan Name or HIC Re r tName Registration Number
t1eA- rDxfId4b u�
Addre 976-31Y-65($ Er irmlbn Date
Signature Telephone
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...........O
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, KCv e--4 q 1 (" as Owner of the subject property hereby
authorize P A11Y 74 s -) to act on my behalf,in all matters
relative to work authorized by this building permit application.
e b-l7lo
Signature of Owner IDate
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
I,w( Jo-(Vwx-✓ ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. _1
Print Nam /
Signature of Owne or orized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1IO.R6 and I IO.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
,/ft¢ �FbL)n0!),I/J26G9L 6f.11'[O3XLL�U6F,�u' .. .
Board of Building Regulations and Standards - License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration dale. If found return to:
Board of Building Regulations and Standards
Al". Registration: 163038 One Ashburton Place Rin 1301
' Expiration: 5/4/2011 Tr# 283773 ' Boston,Mo.02108
- Type: Partnership
OPEN MEADOW HOMES LLC.- n
u
CARY JOHNSON _N.�,
15 RIVER RD nat
No valid ' ithout sigure
TOPSFIELD, MA 01983 Administrator • .
NLu>achusctt> - DePar'llnent nl Public S:ifetA
Board of Buildin, RC,lll:ttions and .
Construction Supervisor License
License: CS 96663
Restricted to: 00
CARY JOHNSON
15 RIVER ROAD
TOPSFIELD, MA 01983
Expiration: 5/21/2012
Tr---: 27683
I.LULAHA i IUN VAli
w , 62UINCY MUTUAL FIRE INSURANCE COMPANY
57 Washington Sheet
Quincy,MA 02169
WORKERS COMPENSATION POLICY
RENEWAL POLICY
MA TAXPAYER ID NO: 201108512
NCCI NO: 32247 PRIOR POLICY NO: WC 000699
•® ^e - ee
MOMM
WC 000699 02/03/2010 02/03/2011 QUINCY MUTUAL FIRE INSURANCE COMPANY 01936
- 0 ;.
a e gee=
I • OPEN MEADOW HOMES LLC DOOLEY INSURANCE AGENCY, INC.
15 RIVER RD 2 CENTRAL STREET
TOPSFIELD MA 01983-2108 PO BOX 264
IPSWICH MA 01938-0264
(978) 356-0581
NAMED INSURED IS: LIMITED LIABILITY CO (LLC)
OTHER WORKPLACES NOT SHOWN ABOVE: ON SCHEDULE ATTACHED IF APPLICABLE.
FEDERAL ID NO: 201108512 RISK 10 NO:
2. POLICY PERIOD: FROM 02/03/2010 TO 02/03/2011
12:01 AM STANDARD TIME AT THE INSURED'S MAILING ADDRESS.
3.A. WORKERS COMPENSATION INSURANCE: PART ONE OF THE POLICY APPLIES TO WORKERS
COMPENSATION LAW OF THE STATES LISTED HERE: MA
3.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 $100,000 EACH ACCIDENT
BODILY INJURY BY DISEASE $500,000 POLICY LIMIT
BODILY INJURY BY DISEASE $100,000 EACH EMPLOYEE
3.C. OTHER STATES INSURANCE: PART THREE OF THE POLICY APPLIES TO THE STATES, IF ANY,
LISTED HERE: ALL STATES EXCEPT ND, OH, WA, WV, WY.
3.D. THIS POLICY INCLUDES THESE ENDORSEMENTS AND SCHEDULES:
WC 00 00 00 A WC 20 03 02 A WC 20 03 03 C WC 20 03 06 A WC 20 06 01 A
WC 00 04 20 WC 20 01 01 WC 20 03 01 WC 20 03 02 WC 20 04 05
WC 20 06 04
4. THE PREMIUM FOR THIS POLICY WILL BE DETERMINED BY OUR MANUAL OF RULES,
CLASSIFICATIONS, RATES AND RATING PLAN. ALL INFORMATION REQUIRED BELOW IS
SUBJECT TO VERIFICATION AND CHANGE BY AUDIT:
PREMIUM BASIS RATE PER
TOTAL ESTIMATED $100 OF ESTIMATED
CLASSIFICATIONS CODE ANNUAL REMUNERATION ANNUAL
NO REMUNERATION PREMIUM
(SEE EXTENSION OF INFORMATION PAGE)
TOTAL ESTIMATED PREMIUM $276.00
DIA ASSESSMENT ( 7.200%) $8.00
TERRORISM RISK INSURANCE CHARGE ( 3.000%) 9740 $36.00
MINIMUM PREMIUM $186.00 TOTAL ESTIMATED COST $320.00
DEPOSIT PREMIUM $320.00
AUTHORIZATION : DOOLEY INSURANCE AGENCY, INC. 01/14/2010
CONTINUED ON NEXT PAGE
WC 00 00 Ol 8
INSURED
CITY OF S�U EN1, ,'LkSSACHUSETTS
BI:ILDLNG DEPAMCLNT
• 12O WAsmNGTON STREET, Sao FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KiNiBERLF-Y DRISCOLL
hiOMAS ST.PIERRI3
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BC111ILNG CO%L%MIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Ant i1�, Please Print Leeibly
Name(BusinesslOrganizationtindividual): n D_ Pe J A t ri 4r wny
Address: 4.!�— A reet-
City/State/Zip: I o PSf7 P":>614 Phone #:
Are yo an employer?Check the appropriate box: Type or project(required):
1.0 1 am a employer with_� 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(felt and/or part-time).' have hired the sub-contractors
2.❑ 1 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. workers'comp.insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their (0.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I EI Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12. /Roof repairs
insurance required.]t employees. [No workers' ME]Other
comp.insurance required.]
•Any applicant that chocks box 91 most also fill out the section below showing thew workers'comprnnuon policy information.
I Iomeawren who submit this affidavit indicating they am doing all vaut and then hue outside contractors must submit a new affidavit indicating such
:Contractors that check this lox mug anachod an additional short showing the name of the subcontractors and their workers'comp.policy information.
I am an employer that is providing workers'compensation hisuronce for my employees. Below Is the policy and Job Me
information. G
Insurance Company Name:
Policy#or Self-ins.Lio.#: 4006 C1 Expiration Date- Z�3 •f/
Job Site Address: 4 City/State/Zip: S tl r"'l is
Attach 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 a
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$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 cerdfy wider the pal sand penahes of perjury that the byormadon provided above is true and correex,
Simature, Date:
Phone#: q7 0 Q'- G ,3 Y 6�
Oficial use only. Do not write in this area,to be completed by city or town official,
City or Town: Permit/I.1cense#
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#:
Estimate
Open River Road Date Estimate #
15
TODSfield, MA 01983 6/11/2010 5142
Name / Address
Karen Dirocco _ 6
2 West Circle Project {
Salem, MA01970
.,�. "' —.-•^� Roof
_Description Total
STRIP AND REROOF I
a
*Building Permits: ALLOWANCE'' - 100.00
v,
*Roofing Labor & Materials: Project: Strip and reroof both the house and garage labor and materials. 7,500.00
The following is a brief description of all proposed work to be completed.
1.Remove and dispose of 2 layers of asphalt shingles
2.Apply ice and water shield on lower 3 feet of roofs V.
3.Apply 15 lb felt paper on remainder of exposed sheathing
4.Install white aluminum drip edge on perimeter of roof
5.Repair/replace any flashing as needed
6.Install Certain Teed 30 year architectural shingle
7.Grind out lead/mortar joints, install new lead and reseal joints
8.Cut in ridge vent and install ridge vent
GARAGE IS AN ADDITIONAL $1700.00 IF DONE AT SAME TIME AS HOUSE.
-The Estimate is valid for 10 days. 1
- A twenty percent (20%) downpayment is required upon acceptance of this Estimate. It is j
3 _ anticipated that there will be 1 additional payment. Based on our current work load we can start your t j
roof on or about June 28, 2010 subject to weather conditions.
- Subject to receiving a signed copy of the Open Meadow Home Improvement Contract and the i
downpayment.
- This assumes that there is no rot that we have to repair. Any such work will be at $50 hour +
materials.
- Should an item increase by 10% from the estimated cost of the same item, then Open Meadow
Homes LLC may pass along that increased item cost onto the OWNER. — :f
All materials and services are supplied through Open Meadow Homes LLC with the exceptions of
those listed above as PROVIDED BY OWNER: i
� I
I �
All work will be done in a professional manner and satisfactory to you!
Total ' $7,600.00 1
c
Phone# Fax# E-mail Signature:
978-887-2196. 978-887-2165 cary@openmeadow.com
Daze::