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19 WILLOW AVE - BUILDING INSPECTION (2) is The Commonwealth of Massachusetts Board of Building R tions and Standards Town of Wilbraham \\ Q Massachusetts State tiding Co 780 CMR, 7"edition Building Dept `l Building Permit Application To Construct, epair,Renovate Or Demolish a 413-596 2800 111"` ne-or 7 ivo-Fdoidy,/hvelltng Ext 118 This 9&fion Fo Official Use Only Building Permit Number. Date Applied: ( O v Signature: Building Co issioner/In for o . ings Date SECTION 1:SITE INFORMATION 1.1 ProFerty A>id 7%v % 1.2 Assessors Map& Parcel Numbers 1.la Ithis saann accepted street?yes no Map Number Parcel Number - 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq it) Frontage(it) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System: - Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: /o;; / /��G� A✓ Name(Print) Address for Service:" /7"! Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify: Brief Description of Proposed Work 2, r9 G p JrAt f v 6' SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Casts: Official Use Only Labor and Materials Y 1.Building $ 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 Su ression $ Total All Fees:$ ,�t/ Check No. Check Amount: Cash Amount: 6.Total Project Cost: . $ ��� f% 0 Paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES n 2 5.1'Licensed Construction Supervisor(CSL) 1-tifittea u 06 s " 2A License Number Expiration Date Name of CSL-Hal rr �/ List CSL Type(see below) Addre T Description /i s �(j/'/G/�� U Unrestricted(u to 75,000 Cu. FtJ 7 C.JJ R Restricted 1&2 FamilyDwelling Sigmrmre M Maso Only RC Residrntial Roofin Coverin eleph WS Residential Window and Siding ^ �R /' �n SF Residential Solid Fuel BurningAppliance Installation rt V0i v[ D Residential Demolition 52 Re istered Hgme Improvers Contr,�ctor(HIC) �-3 ()J!"� ��J2-�rSLLIJ . 0 y Y��^'r Z,.Registration Number MW7 RegelS,ULS/ZC` �2/5^ Ex iration Date 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 ..........T No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby authorize �/ �/` � C f_•,CGi IV77- to act on my behalf' in all matters relativ%Iov ork authorized"'by this building permit application. n — �P� �1 t/fGy/ . /N t� Si atuYe ofOw%ner % Date SEC1I6N 7b: OWNER'OR AUTHORIZED AGENT DECLARATION l ,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. Print Name Signature of Owner or Authorized Agent Date Si under the ins and nalties of 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 fRI 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 110.R6 and 110.115,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 cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" MCITY OF SALEM lei PUBLIC PROPRERTY DEPARTMENT :,I]ttl:R!ifY JRISCd n.1 >!'�d"t 12CWASH1NG10NSIREL'T • SALEM.MASSA rlrsl;lIs0197C '11.1.;978-745-9595 ♦ P:yx: 978-740-9846 Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aoolicant Information Please Print Leeiblv Name l9usiiw%siorgaai7atioNlndivicluap: Address: 3 ( C 5Se--K City Statci/..ip: /2661G/2G'' I is ./ /l Phone /':5/ :kre you an employer:'Check the appropriate box: 'Type of project(required): 1. 1 am a employer with zl- 4. ❑ I am a general contractor and 1 G. ❑ New construction employees(full and/or purl-time).• have hired the still-contractors 2.El sun a sole proprietor or partner- listed on the attached sheet. �• ❑ Remodeling ship and have no cmployces These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition 'No workers'com insurance 5. ❑ We are a corporation and its I P• 10.❑ Electrical repairs or additions required.) officers have exercised their 3.❑ 1 ant a homeowner doing all work right of exemption per MGL I LE) Plumbing repairs or additions myself. LNo workers' comp. c. 152, j 1(4),and we have no 12.❑ Roofrepairs insurance required.) r employees LNo workers' 13.0 Other comp. insurance required.) 'Any:gyp plicmtt that checks box fit must also till out the seCtiml beIPW showing their workus'cumpenvdiun pulicy intiamatioo. ' I lumeuwrters who submit this affidavit intlicanng they are doing all work and then him outside contractors must aulmtit a new affidavit indiuling.etch. �Comnctors that check this box must.anachdd:m additional sheet showing the name of the sub�ontracturs and their workers'comp.policy information. l ant mf employer dint is providing workers'c•ompelfsation insurance for my employees. Below is the policy and job site information.Insurance Company Name: L pG ke'CA _ZU q A L' 5 - ----- p Policv 4 or Sclf-ins. LLiic.t%: ©S/O y/ Sb_ - .._ _..._____ Expiration Date: yf9 OD Job Site Address: f LA-'r 210 LA/ - City/Slate/Zip: `'p� 1 Attach It copy of Ilse workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of.`QGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1.500.00 and/or one-year imprismmncnt,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Ile adviu:d that a copy of this statement may be lurwarded to the Office of Investigations ul the MA for insui:mcc coverage vcriliauion. d du hereby certify under nthe/painss nerd penudries of parjary that the information provided above is true and correct. Sic:lamro:Z,/tW ,y/ /f/ / Datc' Phone:s: ell Official use only, Do Ifni ivrire in this area, to be completed by city or town official. City or Town:_-__.-- - -- Pcrmit/Liccnsc d.- .__.- .... Issuing Authurily (circle one): 1. Board of Ilealth L Building Mparunent 3.Citylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector G. Other contact Person: _.... -_ __— Phone q: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their eniploiyees. 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 perfonuance 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) 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 confinnation 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom or the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant. Please be.cure to till in the pennitllicense number which will be used as a reference number. In addition,an applicant that must submit multiple pennidlicersc 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 Town)."A,copy of the affidavit that has been officially stamped or marked by the city or towh 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 tilled 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he Ol licc of Investigations would like to thank you in advance fur your cooperation and should you have any questions, Please du 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 Revised 5-26-05 www.mass.gov/dia CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT Construction Debi-is Disposal Affidavit (ICLIL[iied lor all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CNIR section If 1.5 Debris, and the provisions of.MGL c 40, S 54; Building Permit it-__ - is issued with the condition that the debris resultingfrom 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: Viff 1 O 's-fil jifinic ot'hauler) 'file debris will be disposed of in (came ul facility) (address of facility) S1911atul C;o- Iliit aill Icant 1 -,-7, e4` (late Massachusetts - Department of Public Safct� Board of Building Rc_ulatiorts and'Standards �f Construction Supervisor Specialty License License: CS SL 100141 Restricted to: RF - MARCELO DESOLIZA 34 ESSEX STREET REVERE, MA 02151 Expiration: 6(7/2012 ('nnmisrinnvr Tnt: 100141 ✓lee 1°iaminararieall�e o�✓`fadlac�zttd✓.dd Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration: 153852 Expiration: 1/18/2009 Trp 253907 Type: DBA MARCELLO ROOFING&GENERAL SERVICES MARCELO DESODZA 46 GLANDALE STREET EVERETT.MA 02149 Administrator ROOFING CONTRACTING Marcello Roofing and General service Registration# 153852 34 ESSEX ST Exp: 01/18/2009 REVERE,MA Tr: #253907 Owner: Marcelo De Souza Saturday, November 08, 2008 ATT: TIERNE ,JAMES 19 WILLOW-AV SALEM,MA IN THIS CONTRACTING WE INCLUDE : ROOFING: 1)Tarp house and bushes to project from failing debris. ( Magnetic sweep performed daily). 2) Remove and disposal existing layers of roof shingles. 3) Inspect re-nail and replace rotted roof board replacement over 100 feet will be an additional $ 4.00 per foot if need. 4)Apply"grace ice&water shield" barrier to the first six feet of the roof deck. 5) Remaining roof deck will be coverage with a tri-flex underlayment paper. 6)All roof edges will receive an eight-inch aluminum drip edge. ( white) 7) Re-shingle roof using a selected ( 30 YEARS ASPHALT SHINGLES )with carries 30-years warranty. shingles will be gun nailed only.( Fifteen years workmanship warranty). 8)All pipes and chimney will receive new flashing. 9) Install CertainTeed ridge vents . SKYLIGHT: Iviarceliu Ruumig And Geneiai Service will be rebpuiisibie fur ail ruaileia—B, dispusai & Pervnits fur the roof project. Priceroofing ............................. ............................n.......................$ 8000.00 y - - = - - M---- ARCEL SOUZ GUSIONIER /