5 WOODSIDE ST - BUILDING INSPECTION (2) AEC€IvED Commonwealth of IV[assachusetts
`iSPEC IONAE SERVICt�
Sheet Ntetal Permit
1016 MAY 1
J Date: S—/ — / ' 9 Permit #
lw Estimated Job Cost: S f8, cc)l) . 0o Permit Fee: $
Plans Submitted: YES NO —' Plans Reviewed: YES NO
Business License # 13 Applicant License #
1
Business Information: Property Owner/Job Location Information:
Name: �9l�/7i�J G Q>�� Name:
Street: / Street: 5 6UDO $1 ND C
City/Town: City/Town: S >It
"Telephone: :2 UI— �W q4-63 Telephone:
Photo I.D. required / Copy of Photo LID. attached: YES NO
- 11J rr tllllllll
J-1 1-unr ;trictcd license
J-2 / DI-2-restricted to dwellings 3-stories or less and commercial up to 10,000 sq. ft. / 2-stories or less
Residential: 1-2 family Multi-family Condo /Townhouses Other
Commercial: Office_ Retail Industrial Educational
Institutional Other
Square Footage: under 10,000 sq. tt�-- over 10,000 sq. ft. _ Number of Stories:
Sheet metal work to be completed: New Work: Renovation:
H VAC _ Metal Watershed Rooting_ Kitchen Exhaust System
Metal Chimney/ Vents Air Balancing
Provide detailed description of work to be done:
6n�5Ti9f�",t.G /t,(` 3 y) /]G ✓� �'cr• c7 s
ccJD N.�ST�tLL� 'iALS� -
M1� I.Cr I C'61-7���e
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements.of M:G.L-AChv112 -,'--Yes d'rvo ❑
If you have checked Yes, indicate
, the type of coverage by checking the appropriate box below:
A liability insurance policy L-th Other type of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
� �✓ Owner Agent ❑
Signature of Owner or Owner's Agent
By checking this box[],I hereby certify that all of the details and information I have submitted(or entered)regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and installations performed under the permit Issued for this application will be
in compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct inspection required prior to insulation installation: YES NO
ProLTress Inspections
Date Comments
Final Inspection
Date Comments
Type of License:
By ❑ Master
Tine ❑ Master-Restricted
City/Town
❑Journeyperson Signature of Licensee
Permit#
❑Journeyperson-Restricted License Number: 64 3 3 _
Foe S ❑
Check at www.mass.gov/dpl
Inspector Signature of Permit Approval
Ur
OMMONWEI1LTFi OF MA S3ACIius"
• • • •
HRAHp of
SHEET'Mf:TA'L WORKERS ,
'ISSUES TH FOLLOWING LICENSE AS A W t'
MASTER UNRESTRICTEDf `':cr
t
',DAMES F O'BRIEN a
5 ARCHER'ST'
SWAMPSCOTT,MA 01907 1fl79, "^ z
w
233 02@8&Z018 14479
The Commonwealth of Massachusetts
t Department oflndustrialAccidents
1 Congress Street,Suite 100
Boston,MA 02114 2017
www massgov/dia
wworkers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
A licant Information Please Print Le 'bl
Name(Business/OrgamTationQndividual): 3{97*) C) is �� 14vq{
Address:-
City/State/Zip: Phone M
Are you an employer?Check the appropriate box:
1.❑I am a employer with employees(full and/or part-time).' Type of project(required):
7- ®-New construction
2.Z�1'�am a sole proprietor or partnership and have no employees working forme in
any capacity.[No workers'comp.insurance required] 8. Remodeling
I E]I am a homeowner doing all work myself[No workers'comp.insurance required]1 9. ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 Q Building addition
ensure that all contractors either have workers'compensation insurance mare sole 11.E Electrical repairs or additions
proprietors with no employees.
5.O I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plwnbing repairs or additions
These sub-contractors have employees and have workers'comp.insurnamt 13.❑Roof repairs
6.Q We are a corporation and its officers have exercised then right of exemption per MGL c. 14.Q Other
152,§I(4),and we have an employees.[No wmkes'comp.insurance required.]
'Any applicant that checks box#1 must also till our the section below showingtheir wmkes'co
t Homeowners who submit this affidavit indicatingtheyare do' Outside
compensationmust
policy information.
ubmit a new affidavit indicating such.
tContractors that check this box most attached an additional sheet showing the name k and them of�rb-contractors and state whether or Out those entities have
employees. Ifthe sub=contractors have employees,they most provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance jar my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/Statr/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required wider MGL c. 152, §25A is a criminal violation punishable by a fine up to$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$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 cer[ify under the pains andpenalties ofperjury that the information provided above is true and correct
suture, - Date S A �C
Phone M -7 S(-- '2/D -- eteW6 —i
OJftcial use only. Do not wrke in this area,to be completed by city or town o�ciai _
City or Town: Permit/License#
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#'
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 then 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 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 Officials
Please be 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 Investigations has to contact you regarding the applicant.
Please be sure to fill in the pernut/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 permit to bum 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 1 4-20 1 7
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
^7 �a� GK l030
The Commonwealth of MassachusettAE,CE,V .4 CITY OF
W
SERV ICE$
Board of Building Regulations atl�, @T !�- SALEM
Massachusetts State Building Code,7,80 CMR ` -} Revised Mar 2011
Building Permit Application To Construct, Repair����tt✓�1(e UODAoli e
One-or Two-Family Dwell1 ". .
L This Sectdon For OtRcial Use On#
t Building Permit Number Date Applied: T
13mlding�5fficial(Print Name) Signatures Date
SECTION 1:SITE INFORMATION
1.1 Property Address: r ��. 11 Assessors Map&Parcel Numbers
tr 3�, f Je. l
I.I a Is this an accepted street?yes •no Map Number .Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
6 •
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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? Municipal❑ On site disposal system ❑
Checkifyes❑
2.1 Owuer'of ecord:
SECTION 2: PROPERTY OWNERSIIIP1
�. . . .. . .. .--
ame 'n[) - City,State,ZIP
=S �,e &A"I- S�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Descr'ption of Proposed Worl2: Re
L '
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ rf� 1. Building Permit Fee:$ Indicate_how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cose(Item 6)a multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Su ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 9 Y� 4M ❑Paid in Full ❑Outstanding Balance Due:
.,:-,SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervrsor,tic,' sei(CSL).. License Number E irah- nDate
Name of CSL Holder " a.
.•� / 13 `lug List CSL Type(see below)
d�af9/lbrf xy "
No.and Street XIInsulation
Description.-
�f stricted nildin u to 35,000 ca.11.)
I� A r d ! �� ricted 1&2 Famil Dwellin
Cityrown, tate,ZIP o
fm Coverinff
dow and S']dlm
/� d Fuel Burning Appliances
�AFFmN*i
Telephone Email addre •D ' Demolition
5.Z Registered Home Improveryent Conn r`acttoor(HIC) /77�l.7Q �a
[�'7I �(/�///!J/\ HIC Registration Num Cxp' 'on Date
HIC Company NaAie!ogHIC Rejistrapt Name
aft �Et
Po.andStreetf'StrR/�1 . 0if R7!_ /1rs— 7S/b c Email dress
City/Town, Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(ALG.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 7w OWNER AUTHORIZATION TO DIE COMPLETED WHEN
OWNER'S AGENT 4R C()NTRAC 0R APPLIES]FOR$UILDING PERMIT
I, 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. `
Print Owner's Name(Electronic Signature) Date
SECTION 7630WNERr 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.
Print Owner's or Autho zed Agen s Name(Electra c Sigoature) '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
wlvw.mass.aov/oca Information on the Construction Supervisor License can be found at www.ntass.eov/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"
a
Office of Cansume'Affatra
"> :iHOME IMPROVEMENT C&Business Regulation
6 Registretion: 1770 ONTRACTOR
:.-Expira[ion: 1/12/2618�. Type'
may, DBA
AFFINITY CONSTRUCTION
PETER SHEPPARD JR
25 OSGOOD ST -- -
SALEM, MA 01970 �•s-= _
- _ Undersecretary
`t r �1l9ssnCiluSgt`s - _
Buf'ol^C ubli1 S-7Te"i
'<@ft'ii2t7UFt5 =Rr3 $t�4cFd.�S
C}�pasuCtinti Sttperrt•:„�- -
'c�nsa CS-064786
PETER A SHEPPARD v TM
25 OSGOOD ST
SALEM MA 01970
. 10/01/20.16.�
Marcia Kirkpatrick
From: Craig Bujold <clbujold@gmail.com>
Sent: Monday, May 16, 2016 8:43 AM
To: Marcia Kirkpatrick
Subject: Affinity Construction - 183 R Federal St
To whom it concerns:
I, Craig Bujold, made the condo association at 183 R Federal St. Salem, MA 01970 aware of the construction
being performed by Affinity Construction. The member of the associate were informed of our intention to
remove and replace cabinetry, flooring, plumbing, electrical, etc..
Craig Bujold
clbujoldAgmail.com
617-756-4661
183 R Federal St
Salem, MA 01970
i
OTY OF SALEIV4 MASSACFREE M
BuuxmDEFAx>mmT
120 WAsr VWNSUWO3=ROM
T1,078 745-9595.
FAx�97$ 740 9846
$A�ERIEYDRiSQ7IL
MAYS 7 STMMM
DmEcrcmtcrFuRuCPFj3wWY/Buuw Gazn=cm R
Construction Debris D1sposa/Aff1dav1t
(required forall demolition and,.renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 0ebris,
and the provisions of MGL coo,S 54; Building Permit g 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 MAGI.c 111,S 1WA.
The debris will be transported by:
r I
(name of hauler)
The debris will be disposed of in:
(name Hof facility)
(address of facility)
Signat re f a plicant
Date
'\ The Commonwealth of Massachusetts
_. Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITnNG AUTHORITY.
Applicant Information Please Print Lealbly
Name (Busiums/Organization/bA[vidualy v
Address: x-f-- C)�'-, ( .
City/State/Zip-SC-' kt,1r YM - 0/cf'?d Phone f 6 76
Are you an employer?Check the appropriate box:
Type of project(required):
1�am a employer with employees(full and/orpart-time).• 7. ❑New construction
2.0 I am a sole proprietor or�Tnerd ip and have no employees working forme m
any capacity.[No workers'comp.irrsursnce required] 8.&!FRMC dehilg
3. 7 am a homeowner doing all work 9. ❑Demolition
❑ 8 myself.(No workers'comp.insurance required.]t
4.❑1 urn a homeowner and will be hiring contractors to conduct all work on m o 10❑Building addition
y property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contract"and I have hired the subcontractors listed on the attached sheet.
These sub-contracmrs have employees and have workers'comp.manni amt 13.E]Roof repairs
6.0 We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other
15Z§1(4),and we have no employees.[No w"kers'comp.insurance required.]
-Any applicant that checks box#1 must also fill our the section below showing their workers'compensation policy brformation.
1 Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors must submit a new affidavit indicating such.
;Contractors that check this box must attached an additional sheet showing the name of the subcontractors and slate whether or not those entities have
employees. If the sub=conftwors have employees,they most provide their workers'comp,policy number.
1 am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
Inr y � ✓ ��
Insusuranceance Company an Name: t �.
Policy#or Self-ins.Lic.#:= -�/�_,�(r�7� a�,(�� Expiration Date:
Job Site Address:.�� GSty/State/Zip:.(-.rZ/RNN, /✓lid •Ui/��
Attach a copy of the workers'compensadodon policy declaration page(showing the policy number and piration 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
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.A copy o 's statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
7:7
eby certify and th aims and enalties a erjury that the information provided above ' true d correct
e
.� / ate:
Phone Gyr O
Official use only. Do not write in this area,to be completed by city or town ojjtctal
City or Town: Permit/License#
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 M
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, §25C(7)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 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 afdavit. 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 be 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 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 permit 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 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 02-23-15 www.mass.gov/dia
Affinity Construction,Inc. Estimate
25 Osgood St
MA 01970 Date Estimate#
2/2/2016 44
Name/Address
Q n craig and Kristen Bujold
O 3JA5 Federal St.Rpm
v Salem,Ma.1970
Project
Description Qty Rate Total
Interior Walls-remove existing wall approximately 5',and patch in 750.00 750.00
ceiling and wall
Plumbing-move gas line to accommodate new stove placement 2,375.00 2,375.60
move heat to allow for cabinetry
Electrical&Lighting-install 4 recessed lights,and 2 pendants 1,250.00 1,250.00
Cabinets&Vanities-remove existing cabinetry 4,100.00 4,100.00
install new cabinetry per plans dated 1/21/16
install crown molding
construct cabinet over the fridge
Painting-paint existing walls affected by cabinetry,and ceiling 350.00 350.00
Cleanup&Restoration-removal of trash and debris 575.00 575.00
DOES NOT INCLUDE ANY FLOORING
-T
J
Total $9,400.00