25 WILLSON ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, T"edition OF SALEM
Revised Januury
Building Permit Application To Construct, Rep�if�Renovate Or Demolish a 1. 2008
One-or Two-Family D e!!i g
This Section For Offi'ial U�e Only
Building Permit Number: !� ate pp
� tfJ J
Signature:
Building Commissioner/Inspector of Buildings ' Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 essors Map& Parcel Numbers
;z5- W , IISo^ S-lr
I.1 a 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 11) Frontage(tl)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check ifyes❑ Municipal❑ On site disposal system Cl
SECTION 2: PROPERTY OWNERSHIP'
1 Owner of Record: pp
Name(Print) Address for Service: � ^
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(sy[f Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed yvork':
UT4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
-. Electrical
❑Standard Cityli'own Application Fee
� S
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (11VAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S �'7 S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
/5.1 Licensed^Construction S/u�p�e�rvisor(CSL) 9 �Q "
RQ 4 rran rl T t'r2�"' I .iccnse Number F:xptmtion U to
rof CSl.I folder List C'SL Type(see below)
NJ rS-SrU C-t;- a T,pe Description
Address U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature 0,/ M Mason Only
'79 1 �7S 4 RC Residential Roofing Covering
I'clephone WS Residential Window and Siding
SF Residential Solid Fuel Buminst Appliance Installation
D Residential Demolition
5.2 Regi3tereftHpate I prrovernept Cant�acfor(NIC) �� -1
F ��yl++ram �Xr-,C 1 n c �.
it 'Co any Name or HIC i3trant NCane Registration Number
T ,�C " 1 /"
Address7Zr _W-o Ed CF Z Expiration 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...........❑
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 to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,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
(Signed under the pains and penalties ofperjury)
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("IC)Program), will have access to the arbitration
program or guaranty fund under M.G.L. c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 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"
Y. w^.$� CITY OF SALEM
PUBLIC PROPRERTY
\y`�a
DEPARTMENT
IJ\r lt.`R IA:y URISCU I.I.
41 A rt tR 12C W AsHING I ON STR ELT o S.LLIEM,Massnci a sr:Ir is 01973
Tv.l.:978-745-9595 • i'ax:978-740.7840
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
-\ mlicant Information Please Print Legibly
V:Imt: (nu<inc+s/Or�aniratinn/lntlivi<luull:�l�-C7'�'fr� I� ��"Set���t �� �'���IZ� �f1('
Address: (0 J ��
Cityistalc %ip: Sa ( a Phone .' 1
Are you an employer? Check the appropriate box: 'Type of project(required):
I..E3�'Fam a employer with 1 4. ❑ 1 am a general contractor and 1 6. ❑ new construction
em 7.ployees(full and/or part-time).• have hired the"sub-comractors El Remodeling
2.❑ 1 ten a sole proprietor or partner- listed on the attached sheet. :
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'cote insurance S. ❑ We are a corporation and its
1 P•
required.] of 10.❑ Electrical repairs or additions
officers have exercised their
right of exert pe
r r MOL 11.[] Plumbing repairs or additions
3.❑ I am a hrnncuwncr doing all work S P P _
myself. [No workers' comp. c. 152, y 1(4),and we have no 12.0 Roof repairs
insurance required.] t cinployees. (No workers' 13.0 Other
comp. insurance required.]
-nay::pplieunl that checks box ill must also rill cut the seclion Ixluw showing{their workui cumpensaiioo pulicy inlinmatiun.
'I lumeuwnen whu submit this affidavit indicating they are doing all work and then hire outside corurnctors most auhmil a new al'rdavit indicating such.
-C'onrracturs thus check this box mull anxhod an additional sheet showing mto nano of the sub<ontraciom and their workers'comp:policy information.
l our an employer that is providing workers'compensation insurance for my employees. Below is the policy and job silt
information. L f
Insurance Company Name: M 45 5 wlC_...Ra;�C A_ Uj'a-(Id kr 2�li I g
r q
I'olicv A ur Self-ins. Lic.r'.':" t o f 'U 7•-� _-{- .._. . ._...___.._ Expiration Date:
Job Sim :\ddress;'t—� (/t/ 2 1
US' Ott � S0&M Cityislateizip: 0117 y
Attach it copy of lite workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A uf.N lGL c. 152 can lead to the imposition of criminal penalties of a
line 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 S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Investigolions of the DIA for insuru:ce coverage vcrilicatiun.
l do herehli,certify undler the pains enaft�perjh�t the luforination provided
above is true and correct.
Sie:laorre: Date' t I l T I y
I It r c i / $I -7
official rise only. Do tint write in this area,to be completed by city or town official. '
City or 7'ow•n: Permit/Licensc X_---- -- --_-------
Issuing Authority(circle one):
I. Board of ilcalth 2. Building Deparuncul 3.Cil,tTfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: __— Phone S:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an einpforee 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 oI :n 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, bIGL chapter 152, §25CM states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract ter 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 Offlclals
Please he 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 Irivestigations has to contact you regarding the applicant.
Please be,sure to till in the pennittlicense number which will be used as a reference number!' In addition,an applicant
that must submit multiple permitilicense applications in any given year;need only submit tine affidavit indicating current
policy information"if necessary) and tinder"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 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he OI'lice of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please do 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 I '
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05 Fax #617-727-7749
www.mass.gov/dia
{ CITY OF SALEM
Ay �alt
PUBLIC PROPRERTY
DEPARTMENT
\C.\iI II\t.:i GCS IN I:I T • }.\I I V. N1.\li\( :Il (i I
TrI: v78-N;9;93 I'.\s: 9-8 N 9846
Construction Debris Disposal Affidavit
(rcaluired lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 CMR section 1 1 L5
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 he disposed of in a property licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:,
titanic of hattler)
'I he debris will be disposed of in
(name of facility)
(address of facility)
sienaturc of prnnit applican
rd
,laic
dchi
CERTIFICATE OF LIABILITY INSURANCE
07/13/2010
THIS CERTIFICATE 13 ISSUED AS A INTTI:R OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVt3Y OR NEGATIVELY AMEH0. EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS, CERTIFICATE OF INSURANCE DOES NOT CONS RM A CONTRACT BETWEEN THE ISSUING INSURM", AUTHOR®
REPRESENTATIVE OR PRODUCER AND THE CER71RCATE HOLDHt
WIFORTAml: t1e Is at ( SUBKOrATICIN IS WAIVED, yau�.rbpot W
the tams MW con6tlmis oT the polky, ce lah PaBtlsm waT ra dm aneoaoRsamiaL A eta small ea d is cd9fitab dOeb not cwdw hy to the
CKWIcaa holler Mn Ran of such erldorhonmrs(s).
FROmxTR RAtlse
Richard Bertolino Jr Insurance Agency PRONE
1200 Salen St a121
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Lynnfield, ROL 01960 smlame:
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oahllEn mahm3lAArbella Protection
Fitzgerald Construction Services II®I�eMa99 Workers Comp Rating Bureau
2 Orchid Circle Nftmetc Comeroa
Burlington Vase 01803 sou g.
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COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE SEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUREMENT. 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 PAD CLAIMS.
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A 'LL UAeun 8 8500027957 04/27/201 04/27/2031 II $1,000,000
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X; alasMODE ❑alrlB M®W V".P." $1,000
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aBHeuLAILwIEOAne $2,000,000
GoaAGORECATE LIMTIPRIF3PFA: iPRowhcns_cOM 0CG 41,000,000
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'r^'A11fO 'BODILY INATY 0�Q,mp s 500,000
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aNaI9IATroHs hsn. EL aI�ASE-PoDaY UMn s 100,000
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Separate Cart Has been ordered for holder Mass Workers Comp Bureau
Automoblie is registered to Raymond Fitzgerald
CERTIFICATE HOLDER CANCELLATION
Rene and Margaret Boulanger
25 Wilson Road SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEDeEwRE
THE EOPR TON DATE THEREOF. NOTICE nm1 BE DELIVERED IN
Salem Mass 01970 xD°RDANcl:wmTE POLICY PROVISIONS
97B-233-0636
Auna®sFsnFsartATME
01986-2009 ACORD CORPORATION. At rights reserved.
ACORD 25(2009109) The ACORD rmnm and logo are registered na11L5 of ACORD
z 'd BILOTES8L6 aC ouTTo-4-jaa P,leyo1a dLa :21 01 61 inC
guard of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
_ Registration$ 161897 T 279731
Expiration- 121912010 f*•.
Type: Private Corporation
FITZGERALD CONSTRUCTION SERVICES INC.
RAYMOND FITZGERALD_ I
2 ORCHARD CIRCLE, - Admmtstrutur
BURLINGTON.MA 01803...-• _ _ /'
.A14ssachusetts - Department or Public Saret$
Board of Building Rl-,1113 lorls MW Standards
Construction Supervisor License
License: CS 39692
Restricted to: 00
A p
RAYMOND H FITZGERALD i
2 ORCHID CIR
BURLINGTON, MA 01803
o—
=-*f� Expiration: 9/29/2011
r'ommisri"nef Tr#: 6136
FitzGerald FitzGerald Construction Services, Inc. Proposal/Contract
roxmmcrine
6 Nursery Street
Salem, MA 01970 DATE ESTIMATE NO.
7/13/10 351
-NAME/ADDRESS Phone Alternate Phone
Rene and Margaret Boulanger 978-744-8085
25 Wilson Read-- ,
Salem,MA 01970
PROJECT
Front stairs
DESCRIPTION TOTAL
Obtain building permit. Construct new 3X6 platform to support new set of stairs and railing system. Framing lumber 2,675.00
will be pressure treated. Platform will come off closed in porch,3 1/2 to 4 feet.out and 6 feet wide. Composite lumber
will be used for platform and steps. Stair treads will be 5'6"wide and will extend past the existing bottom step. Railing
system will be PVC. Originally quoted system is no longer available. Price maybe adjusted slightly based on what we
can find for similar PVC railing system_
$1,200 deposit.
$975 when framing complete
$500 final payment.
TOTAL $2,67s.00
Acceptance of Proposal
Phone# Fax# E-mail
781-750-8042 978-233-0636 Fit7Gerald.ray@verizon.net