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21 WILLOW AVE - BUILDING INSPECTION RECEI Ile Commonwealth of Massachusetts A s �N$PECT��N f Building Regulations and Standards CITY O a � ts State Building Code, 780 CMR `s:_,r Revised Mar 2011 R'cV p t n To Construct,Repair,Renovate Or Demolish a 'or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: �Building Official(Print Name) Signature I Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1f WIl1AW j (�sy(` 1.to Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: IA Property Dimensions: Zoning District Proposed Use Lot Area(sq tt) Frontage(R) 1.5 Building Setbacks(it) 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❑ Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: a ' 6) ;it ' C' ZD Na;mee,(,,Priint) City,State,ZIP ' Not Stet Telephone d Email Address 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 : - SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials Official Use Only I.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 (I-[VAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ go• ❑Paid in Full ❑Outstanding Balance Due: C31 13 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) !Do IL-fl & --� - �� I� � n License Number Expiration Date Name CSL Ho der Z� List CSL Type(see below) J7L - 3a)<_u s�rus-� No.and Street Type Description U Unrestricted Buildin s u to 35,000 cu.ft. MAR Restricted 1&2 FamilyDwelling City/Town,State,ZIP zl 5 M Masonry \ Roofing Covering S Window and Siding SF Solid Fuel Burning Appliances 1 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) H HIC Company Name or HIC Registrant Name IC Registration Number Expiration Date No.and Street Email address City/Town,State,ZIP 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...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize. K r La-Ho Qom. io CL r-& to act on my behalf,i Il matters relative work authorized by this building permit application. G /4/ Print er's NimeyElectronic Signaturel 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 We and accurate to the best of my knowledge and understanding. ©a2— cgl Y Owner's thori ed A s Name(Electronic 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.ntass. ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss 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"may be substituted for"Total Project Cost" J , ROOFING CONTRACTING �J� Monday, June 16, 2014 CONTRACTING#3088 ATT: David William 1. PARTIES TO THIS CONTRACTING: A. Contractor Marcello roofing and gen.service 617-607-17031617-206-7862 Name Phone 20 Augustus st Revere.ma 02151 Address HIC LICENSE# 153852 CS SL LICENSE# 100141 B. Home owner: David William 978-7440279 Name Phone 21 WILLOW RD, SALEM, MA Address 2. LOCATION WORK: 21 WILLOW RD, SALEM, MA 3. Completion dates: A. Estimate date of commencement 07 109 I 2014 B. Estimated date of completion 07 1 11 1 2014 4. Contracting price: $ Lump sum amount$8 480 00 Eight thousand four hundred eighty dollars Include all labors and materials. S. Method payment: 50% initial payment at start of work and another 50%when all lob finished 6. Descriptions of the work: ROOFING: IN THIS CONTRACTING WE INCLUDE: 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 $2.25 per foot. 4)Apply"grace ice&water shield" barrier to the first six feet of the roof deck. 6) Remaining roof deck will be coverage with a tri-flex underlayment paper. 7) Re-shingle roof using a selected (Architectural high definition shingles life time )With Lifetime Limited Warranty. Shingles will be hand nailed only. (Fifteen years workmanship warranty). 8)All pipes and chimney will be receive new flashing. 9) House will be vented along the ridge with CertainTeed shingle air vent. 10)Owner will be notified 24 hours in advance of all work actives. 11) Include costs for permitting and parking if required. 12)All work to be complete in accordance with local building codes. 13)Submit shingle specifications and colors options for owner approval prior start. 14)Color# *Gutters: 1) Cleaning gutters Marcello Roofing and General Service will be responsible for all materials,disposal& permits for the roof project. 7. Warranties: Fifteen years workmanship warranty. 8.Additional provisions: r 9. Marcello Roofing and General Service will be responsible for all materials, disposal & permits for the)roof project. _% 10. Contract acceptan Signature: Date/ Home o Signature: Date Contractor 06 , 6_ call CITY OF S.U.EX4 AANSSACHUSETTS BUILDIING DEPART.%MNT • p 120 WASHLNGTON STREET,3aa-FLOOR °j Ili (978)745-9595 FAX(978) 740-9846 KlJIBERL EY DRISCOLL MAYOR THOMAS ST.PtERRE DIRECTOR OF PUBLIC PROPERTY/BUILDDZG COMMSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name tHusitns .UrganizationIndividual): .^ M T L// 0 [ C✓�J Address: // L2 CJ &W`--�) S City/State/Zip: CG (-)6(Z6 Phone#: 6 z S o 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑- 1 am a employer with 4..Q 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.0 1 am a sole proprietor or partner- listed an the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have - S. ❑ Demolition working for me in any capacity, workers'comp.insurance. q. ❑Building addition [No workers'comp.insurance 5. El We are a corporation and its required.] officers have exercised their ME] Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs insurance required.)t cmployces. [No workers' 13,(�Other comp. insurance required.] •Any applicant that cluxks box#I most also fill out the—firm below showing their workers'compensation policy information. t I hxneuwren who submit this affidavit indicating they am doing at l work and then him outside contractors most submit a new affidavit indicating such. :C:nmmctors chat clack this box mint anached on additiorad sheet showing the name of the avb­cmuractors and their workers'comp policy infom nim. I um an employer that is providing workers'compensadon insurance for my employees. Below is the pollcy and job site information. insurance Company Name: / gnr�l / c,�� (f e r y.4✓" Y Policy#or Self-ins.Lic.#i-& 2 W� -5- 1_L//� ��1 / Ex 2piration Date: O3" 26— C? Job Site Address: ( [�� �. w /�Yi City/Slate/Zip: 5/tZ6e/`i 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 orMGL c. 152 can lead to the imposition of criminal penalties of fine up to S 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 S250:00 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 certify under the painissand penaa ties of perjury that the information provided above is true and correca Signature: 6 `).�!' c' .. c Phone#: Official use only. Do rent write in this area,to he completed by city or town ojjleiaL City or Town: Permit[Llcense# Issuing Aulhority(circle one): 1. Board of Ileallh 2.Building Department 3.Cityff own Clerk A.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: _____ Phone#: r'r��r• (P WIIIOIIOrvll�l� r� rl.lir/r'tion 1 i Office of Consumer Affairs&Business Regulation OME IMPROVEMENT CONTRACTOR Type; egist2tlon: 174902 DBA .,Expiration: 312 712 01 5 MARCELLO ROOFING AND GIS MARCELO DE SOUZA 20 AUGUSTUS ST ��. MA 02151 Undersecretary # REVERE, +. 1 Mas s achuse s DePart tis _ C°n�n Building Reicti galement of Public Safety license:SuPcrrierr Specmll,^d Standard �. CSSL_100 141 M'4RCE 2 L0 DESO ��`_r I r• � 4, AUGUS I US ST UZq ' Revere iyq 0215f REET - Commis sooner E F X ration 06/0 7/2016 r CITY OF S :1I.E;b[, ,tiG1SS:ICHUSETTS BULDLNGDEP.IRTJL&NT 20 \U.ISHLNGTON STREET, FLOOR T EL (973) 745-9595 KlUBERLEY DRISCOL.L FAX(978) 7-9)-934,5 NLAyol 'rci JLisST.PIF-Ua 017ECTCIR OF PUBLIC PROPERTY/8E:=LYC COSWISSIONER Construction Debris Disposal Aftldavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CDr section l l I.S Debris, and the provisions of rMOL e 40, S 54, fR Building Permit 4 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 GL c l It, S i 50A. The dehris will be transported by: y 269�2 o /c (nuntc urltaulcr) fhe dchris will he disposed ot'in : (name of facility) —' —_-----(..rJlress of'riiulity) . I siyn� rut permit.rppficant --. L I ?� I LP CAUL --p CO rv-rr-(Ac.-(-O(F- r ,C to rJ c NE � c� N T C�2itfG C.6��K � ( zy off. M�VI— lalth of Massachusetts of Salem Floor Salem,MA 01970(978)745-9595 x5641 g Division for Certificate of Occupancy LEM BUILDING PERMIT E POSTED IN THE WINDOW PECTION RECORD 1 DATE I (DEastern Bank RE6L­.t 4 JUL- 1 2014 MASURER'S OFFICE CITY OF SALEM GENERAL ACCOUNT ZBA — ATTN TREASURERS OFFICE Date: 07/14/2014 120 WASHINGTON ST 2ND FL SALEM MA 01970-3527 Account: 9123881 We are charging your account for items returned unpaid as listed below. 1 Returned Item Notice Account Amount Description 9123881 58.00 Chargeback Item 1326616096 58.00 Returned e osi e m Summary of Account Charges Number Amount Debit Total 1 58.00 TotalAccount Debit *011301798* 07/14/2014 s �onrnID 102 18116378 MARCELOGREGORtODESOUZA G 20 AUGUSTUS ST. PN./17411*7862 /n� u This is a LEGAL COPY of your ru REVERE,MA 02151 MTE D D.C. f✓7 check. You can use it the n same way you would use the ..0 check. 0" G original C3 vArrornE i{y OE'' S 6h $ SQ • a RETURN REASON-A 17 C3 O ov 11 NOT SUFFICIENT FUNDS o � �• r<i Q 8 C soxw o r- �t Nok 0 oo\/y �A r MEMO r 2110�01 s�: 1 3 266 16096w 02 41: 2 L LID 70 L 7 St: I, 3 266 L609611.0 LID 2 "000000 S800.1' 195 Market Street • Lynn, MA 01 901-1 508 • 1-800-EASTERN (327-8376) •www.easternbank.com EBF-1175 y "°" Commonwealth of Massachusetts ' City of Salem C Inspectional Services 120 Washington St,3rd Floor Salem,MA 01970 Phone'.(978)745-9595 x5641 RECEIPT Application For Building Permit (One- or Two- Family Dwelling) Termlt No# B 14 1154 .,,' i1$ ' Date Applied p7/2/2014„ ',e° i° � S' ' "......... + T te' .....,,. Y'Rtn tu,f(`m {� A GrW: Mm';4'hWrafrN1"1 �;, 1� 1�I 1N /3/2014gJBullding Official (Print Name) uti + Signature"!' f kafe Issued.G .+!!!G! .�. ,r. . +9+" :Ittxt t+n?'Y4e, ffi t?k.�x;�t_ H.. �t 'a v"' + 9 l+ SECTION 1: SITE INFORMATION 1.1 Property Address 1.2 Assessors Map&Parcel Number 21 WILLOW AVENUE 33-0621 1.3 Zoning Information 1.4 Property Dimensions R1 2960 Zoning District Proposed Use Lot Area Frontage(ft) 1.5 Buidling Setbacks(ft) Front Yard Side Yard Rear Yard Required Provided Required Provided Required Provided 15.00 0.00 10.00 0.00 30.00 0.00 1.6 Water Supply: 1.7 Flood Zone: Outside Flood 1.8 Sewage Disposal System Zone? Check if Public Zone: yes_ Municipal SECTION2PROPERTY!OWNERSFIIP 6lnir .G:�S _ ., .,hi_�.,.,::: ­,., ,m, � .. �x�—_.xt3,3+ + ,;.n .:::.:. Owner of Record WILLIAMS DAVID WILLIAMS 21 WILLOW AVE SALEM MA 01970 Name Address Phone Email e.P rin�i,� ! + '�I;wt«x� ! t�fi� -a SECTION'S a DESCRIPTION OF PROPOSED WORK,. !'!!T, � y�u,+l " lip+ '�g3i�#�'o Permit For: Roofing Brief Description of Proposed Work: STRIP AND REROOF �n,�r�� #n SECTION 4 ESTIMATED CONSTRUCTION COSTS/PERMR FEES Ili+ + lt! 1 f - .Hj4+T.n � `' ,.. .�, a ,, ._ _..---�.. , .,,�r;p m. eew atma +y +rtxu+, ,+ ' r u'ft+I t I ,,,.,I,+i, Total Project Cost: $8,480.00 Payment Date Amount Paid Check No Total Permit Fee: $58.00 7/3/2014 $58.00 102 Total Permit Fee Paid: $58.00 Commonwealth of Massachusetts .�.`sa.. yT City of Salem F Inspectional Services 120 W ashington St,3rd Floor Salem,MA 01970 Phone:(978)745-9595 x5641 RECEIPTS: Building Type: Two Family Existing Proposed No.of Floors/Stories(include basement levels&Area Per Floor(sq.ft.) 0 0 Total Area(sq.ft.)and Total Height(ft.) 0.00 0.00 0.00 0.00 SECTION 5 `CONSTRUCTION SERVICES li yE au` ;; iY' -Y -IN' +i TAMISECTION 6'WORKERS' COMPENSATION INSURANCE AFFIDAVIT 'r �yr+•'i h.....,n,.Ln��, ��R 4 Il.i.a=:: �i.e + ra:..,..,rre++.Y,+: i:,Vf3tY[t k ' ,.S rv•tN{iSi.t,§ r'.tu� .�xna�.,N•.r..mucxm.w.+am 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 On File? ' �, SECTION 7a`OWNER AUTHORIZATION'TO BE COMPLETED WHENHE ' ?' t rl OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIIT" °,,,,; finer' I, as Owner of the subject property hereby authorize Marcelo Roofing &General Services, Marcelo DeSouza to act on my behalf, in all matters relative to work authorized by this building permit application. 1 WILLIAMS DAVID WILLIAMS VITALINA 7/2/2014 Print Owner's Name(Electronic Signature) Date Submitted E t a,fId SECTION 76-.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 and accurate to the best of my knowledge and understanding. WILLIAMS DAVID WILLIAMS VITALINA 7/2/2014 Print Owner's Or Authorized Agent's Name(Electronic Signature) Date Submitted e r t c '" t r+1t —ail; +3YA r¢"'i'k �Yvt:.' u _YY '� IY'i t ".G1,t+ffibd 'YP ft6lN,i i SAY fait(Jt-+� r�+�aa t NOTES: i fil!i3"I" ;�u(06!i:.,u. � �"3_ ll`'.. ....,,, .u: .. ,.u,�,. . . ...-a 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 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps When substantial work is planned, provide the information below: Total Area (sq.ft.) 0.00 Type of Heating System Number of half/baths Gross Living Area (sq. ft.) 0.00 Type of Cooling System Number of decks/porches Number of Fireplaces Room Count Enclosed/Open Number of Bathrooms 0 Number of Bedrooms 0 '+5;m*^wR�R Y^; t=ea;.aaem•vei$ ._-„ Y*¢ x,2'{•I,, mt :'Ae"aae�'xYs a m i R "�'+r� Mrz rb THIS IS"NOT+t�' PERMIT`¢; ,41 `,