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8 WOODBURY - BUILDING INSPECTION The Commonwealth of Massachusetts r 4'PEe W Board of Building Regulations and StandardsI Massachusetts State Building Code,780 CjvIR,- , SALEM L2016'Julrse M r 2011 Building Permit Application To Construct,Repair,Renovate(Or DW6'lish a 138 One-orTwo-Family Dwelling This Section For Official Use Only, Building Permit Number;. Date Ap edk t Building Official('Print Name) Signatures - - Date SECTION 1:SITE INFORMATION ' 1.1 Property Add ss: 1.2 Assessors Map&Parcel Numbers ��111 �' ldooclbu ry . 1.1 a Is this an accepted str et?yes no Map Number Parcel Number 1_ 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rem 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? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' S 2Jp err of Record:kl /1/ . S'Oy/em dt,IGSS Name(Print) / City,State,ZIP �•� g UJDDe , ar`4 7�/-7/1- 0/ No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify: Brief Description ofProposedWor : _ t' move a Id UJOD /n� SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 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 $ Total All Fees: Su ression - �1 yy��, Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ PD®, V ❑Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES ' 5.1 ,Cou"stru&i6 Supervisor License(CSL) ! �a License Number Expiration Date >Narne`of CSy Holder ,p •'� ,{, �� //�� / �� List CSL Type(see below) C/- ° No.and Sir et U Unrestricted(Buildings up to 35,000 ca.ft. J!Y Ll7J 7 < Restricted 1&2 Family Dwelling City/1'owa,State,ZIP - M Masonry RC Rooting Covering WS Window and Siding ,._. y (� SF Solid Fuel Burning Appliances 2�O I 1 Insulation Telephone Email address D I Demolition 5.2 Registered LHome Improvement Contractor(HIC) 173911 1 HIC Registration Number Expiration Date HIC Com Name r C Re t Name Email address Ci /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........... ❑ SEC`ITON 7a:OWNER AUTHORIZATION TO BE COAOLETEI)WHEN OWNER'S AGENT OR CONTRACTyORR APPLIES FOR$UMDING PERMIT I,as Owner of the subject property,hereby authorize i-�a Z- &'� w to act on my behalf,in all matters relative to work authorized by this building permit application. wwl?Cg i Z Al 2 0---) Print Owner's Name(Electrdnic Signature) Date 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 containe thiWAutjorind ion ' true and accurate to the best of my knowledge and understanding. Print Owner's or Agent'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.mass. oa v!oca Information on the Construction Supervisor License can be found at www.mass. ovg /dns 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" LILIA-1 OP ID:JHG ,atc/oirfl CERTI ICATE OF LIABILITY INSURANCE DATE(MMMQ""Y) 0 610 212 01 6 THIS CERTIFICATE IS ISSUED AS A MA ER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS CERTIFICATE DOES NOT AFFIRMATIVE Y OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES -BELOW- THIS CERTIFICATE OF INSU CE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER,AND rHE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder ISO ADDITIONAL INSURED,the policy(les) must be endorsed. if SUBROGATION IS WAIVED,subject to the terms and conditions of the policy, in policies may require an endorsement A statement on this certificate does not canter rights to the certificate holder In lieu of such endorse e s. PRODUCER GQ0'rCT John J Doyle Insurance Agency PHONE John J.Doyle Insurance FAX 85 Constitution Lane Ste 2Fi 978-777-6344 No):978-777-9804 Danvers,MA 01923 ADsa,kevtn@doyleinsurance.com Kevin C Lawrence -- MURER(S)AFFORDING COVERAGE NAIC0 INSURER A:Safety Insurance 39454 _ INSURED - Lilian Mendez INSURERG: Mendez Home Improvemen INSURER C: 16 Walden Street Lynn, MA 01905 INSURER D: - INSURERE: INSURER F: COVERAGES CERTI ICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES O INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCY PERIOD INDICATED. NOTWITHSTANDING ANY REO IREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PEftTAJN, THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POPCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. ILTR ._ ,.. _ TYPE OF INSURANCE ._ POLICY NUMBER WD�EFP M $XP LIMITS .GENERAL LIABILITY EACH OCCURRENCE E 1,000,00 LC A r X WMERCAL GENERAL LIABIUTY BMA0019296 04/0812016 04IM2017 -PREMISE Ea owarenn E 100,00_ r I iCLAIMS-MADE rXlj OCCUR MED EXP(Any one person) S 10,0 PERSONAL EADV INJURY S GENERAL AGGREGATE $ 1,000,00 GEN•I AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOPAGG E X POLICY� PRo- LOC E AUTOMOBILE LIABILITY EOMDIINED SINGLE LIMIT ANY AUTO BODILY INJURY(PW paean) E i I ALL OWNED UTDS O ! �SCHEDULED AU BODILY INJURY(Per accident) E 1HIREDAUTDE AUTOS ED ITOS A PERA I�EI"M"` E E i11eBRELLA DAB OCCUR EACH OCCURRENCE E i - EXCESS LUIB L_LCLAIMS-MADE AGGREGATE E ..DED F RETENTIONS - ' E - WORKERS COMPENSATION WC STATU- OTN- AND EMPLOYERV LABILITY - �ANYPROPRIETDRTARTNERrHXECUTIVE Y® TBD _ 06/01/2016 06/01/2017 ELEACHACCIDENT E OFHCEWMEMBER EXCLUDED? NIA a:"-"" --- -- �(Mendetory In NH) - - -' E.L.DISEAEASESE-EA EMPLOYE E 11 yyaae doecr unct - •DESGRIPTIONOFOPERATIONSOeIoe E.L.DIS -POLICY LIMIT 1 E DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICL (A1hch ACORD 401,Add1BaW Remab BahWuh,N mere epf Is nRuRWI CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE Skomurski THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. PO BOX 2009 Danvers, MA 01923 AU HORMED REPRESENTATIVE Kevin C Lawrence ®1989-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD Licensed 6lnsured Estimate "The Nght hand for the job" Date Estimate# how "M M.0 5/6/2016 563 271 Western Ave Suit#211D Lynn MA 01905 Name/Address Project Address Mandee Spittle 8 Woodbury Court Salem MA 01970 DescriptionTthe The following Estimate for the property located at above address. The following paragraphs explain the work that Mendez Contractor will carry out. SCOPE OF WORK:INSTALL NEW VYNIL SIDING •Strip old shingle siding •Re-nail any loose clapboard. •Repair substrate flaws or defects before applying siding •Install 3/8"insulation •Install Vinyl siding •Siding to be installed according manufactures specifications.Siding most be installed t expansion and contraction by matching color siding,and accessories blocks and flashing for all penetration light block exhaust vents, intakes,etc.,Shall be provided. • All penetrations shall be properly sealed. •All seams to facing the rear away from the street so seams are not seen. Wrap fascia and trims from doors and windows with Cole aluminum Install New vynil soffit TOTAL FOR LABOR AND MATERIAL 200.00 NOTE:Extra for dark color material 0 -Remove extra clap board siding 1,200.00 Payment temis: $4,000.00 down payment $3,000.00 upon the job is in progress $4,150.00 upon the job is completed Total Page 1 Estimate Llcansad Elnsated "The fight hand fa the job" Date Estimate# 74"MM 5/6/2016 563 271 Western Ave Suit#211D Lynn MA 01905 Name/Address Project Address Mandee Spittle S Woodbury Court Salem MA 01970 Description Total c n for ome weer r n z- ales Manager www.mendezontractor.com NOTE: Any alteration will be approve by all parties before is done Total $11,150.00 these may result an extra charge. Page 2 r q �o� QYYOFSALEA ALMA(HLBEM BUZDMDBPAMn' 120 WAstmNcTMSVJE7,Y*RD e UL(M)745.9595. KDAERLEYDA O ' FAx 740.98t6 MAYCR Ma ASST.PM Construction Debris DisposaiAffidovit (required for all demolition and.renovation work) In accordance with the sbxth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of A4GL M,S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 311,S 150A. TTh^e' debris will be transported by: r�-5 (name of hauler) The debris will be disposed of in: ✓1 ►1 (name of facility) (address of facility) Signa u f applicant ate The Commonwealth of Massachusetts Department ofInduslrialAccfdents 1 Congress Street,Suite 100 Boston,AM 02114-2017 www mass govldia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PER1WMING AUTHORITY. Applicant ln[ormatio _ Please t I.e 'b ly Name(Busiuft—JOrgamzationQmlividual): Cam- E/�//1 E ---- Address:_ ?11 &k� City/State/Zip: ff O Phone#: Are you ao employer?Check the appropriate box: ,yp_ FE10ther project(required): I. am a employer wiN �/ employees(full and/orpart-lime).• ew construction 2.Q lam a sole proprietor or partnership end have no employees working forme in any capacity.[No workers'comp.insurance required.] emodeling 3.❑1 a n a homeowner doing all work myself[No workers'comp.tnsreancc required.]t molition 4. I am a bomeowrear and will be h'' contactors to conduct all work m ilding addition 8 my .property. 1 will eosme that all contactors either have workers'wrnpensation insmmr"or are sale ctrical repairs or additions proprietors with no employees. mbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. These subcontractors have employees and have workers'comp,immmml ofrepairs 6.Q we are a corporation and its officers have exercised their right of exemption per MGL c er 15Z§1(4),and we have no employees 1No workers,comp.insurance required.] 'Any applicant that checks box#1 must Rho till one the section below sho wing that wmkcs'compansatien policy infororatim. t Homeowners who submit this affidavit indicating they ere doing as work and than hire outside contactors must submit a near a11-idaeit indicating such. tCt ntrsotors that check this box must attached an additional sheet showing the Dame of the sub-contactors and slate whether m not those entities have employees. Ifthesnb=contractors have employem they must provide their workers'comb.polity number. lam an employer,that is providing workers'compensation insurance for my employees Below is the policy andjob site Informadon. Insurance Company Name: • ,./ / ` Policy#or Self-ins.Lic. Expiration Date: DL Job Site Address: (4)6 j f (i GSty/3tatelZip: s d I Ems/ G Q��D Attach a copy of the workers'compensa oBcy declaration page(showing the policy number and expiratio date). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00 andlor 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby ce sunder pains and penalties ofperjury that the information provided above ' ttr�ruell and orreeL Si store: - ate: (!n .N 7C.. . Phone#: Official use only. Do not write in this area,to be complded by city or town oricrai City or Town: Permit/License# 1[6. ssuing Authority(circle one): .Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector Otherontact Person Phone#: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. 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,§25g7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for 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 Lirrrited 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 approj ate lime. City or Town Officials Please be'sure that the affidavit is complete and printed legibly. The Department has provided a space it the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. in addition,an applicant that must submit multiple permit/license 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 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.a dog license or penit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02 1 14-20 1 7 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/clia i Y