15 WOODSIDE ST - BUILDING INSPECTION s ,
The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
� Massachusetts State Building Code, 780 CMR, 71h edition 'y ' Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
OOtte- or Two-Family Dwelling
I This Section For Official Use Only
Building Permit Num Date Applied: V
Signature: ( 16 C47
O Buildi tg Commissioner/Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
ISi+tnnrl�r4A ST
L l 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 ft) Frontage(II)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
'I�1PU CaCrVA QYJIA'� S:�p Sr
Name(Ynnn Address for Service:
J-7&- SciV o ra 2)
Signature Telephone
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 of Proposed Work': ^
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ r 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: $ / ,H
4. Mechanical (HVAC) $ List: i•>' /
5. Mechanical (Fire $
Su ression Total All Fees: $
` Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ b IS� — 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 4C,�Sc
N �., �S 1tAn CA.V, License Number Expiration Date
Name o CSL.-Helder ��1�►p List CSL Type(see below) (�
a lei I�111r�t. t.
/� T Description
dress (� U Unrestricted(u to 35,000 Cu. Ft.)
�J R Restricted 1&2 FamilyDwelling
Signat— ur��— -1 M Masonry Only
(.v11.—Pwi� RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2.nRegistered HomeAmprovement Contractor(HIC)
W l p t t '�t� Registration Number
HIC Co pa y Name or H C Regis ant Name
IF �) Ito ` ,_ v
A ss �S la c.7
Lt'1 ^4etl(�l(�s� Expiration Date
Signatu 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 '\1 16 -T 190 VAC,U O , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate, to the best of my knowledge and
behalf.
Print Na /O
Signature of ONner or Auth zed Agent Date
(Signed under the pains and enalties 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(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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.RS, 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"
CITY OF SALEM
PUBLIC PROPRERTY
T DEPARMENT
d A INS 1'it1.1 T 4 $AI I M, NIA IS It 1: 111 I✓
11:1 1, 1 .\X:978.174�- tN46
Construction Debi-is Disposal Afficlavit
(required l'ur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CN1R section 111.5
Debris, and the provisions ot*MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of a properly licensed waste disposal Facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
Uj60A
(name of facility)
��V AQle��J{ XAACj 0;�JtI4�
(address of lacilitvl
signs of pcffiiitja)plicalit
date
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
n l]t L' N!P.T JNI1CULL
�i.tn at 12C WASHING'ION S!'RELT • S.LLEM,M.\SSACI it .rl.I s 019700
71:1.:978-745-9595 0 1'nx: 978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
lMlicant Information Please Print Legibly
Nii-ne 113usincssiOr-,ani7ation/Indiv iduup: t IU) I (L t7f��- y%Ao�
Address: fi61on—,s,%de,k! 52
City State'Zip: CL-p�4;;C'1 (f4c( 0AI'J0 Phone ''':r,r1 ` $rCy'y 1 S J
Arc you an employer'.' Check the appropriate box: 'Type of project(required):
4. Iam a general contractor and 1 G. New construction
I.❑ I um a employer with S ❑
employees(full and/or part-time).` have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet. t 7. Remodeling
ship:unl have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
(No workers' comp. insurance 5. ❑ We are a corporation and its go.❑ Electrical repairs or additions
required.] officers have exercised their
3.0 1 ❑ni it homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself. (No workers' comp. c. 152, y 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13.0 Other
comp. insurance required.]
'Any:gyp plicant that decks box 01 must also till out the wetion hLiow showing their workers'compensation pul icy inGirnwtiun.
' Ilorno..mrs who submit this affidavit indicating they are doing all work and then him outside cwumetors must submit a new aMda,il indicating such.
�C'ommctun that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
/not can employer that is providing workers'c'ompenvation insurnucefur afy eutplayees. Below is thepulicy and job site
iujoronation. tg_ �,
Insurance Company Vame -�—:�t L. o ir'a_..
Policy 4 or Self-ins. Lic. P"(;S CC)x�--r69X.ct��-�_7�_V CT Expiration Date: 3
(q sot S� Cit iStatei'Li 1V 3 "/V
Job Site Address: _ y P��SA-F�--C—
Attuch it copy of the workers' compensation policy declaration pate (showing; the policy number and expiration date).
Failure Lo sccurc coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a
Fine 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. 13e advised that a copy of this stutcment may be funkarded to the Office of
Incesligali.nu Lifthe DIA for insurance coverage verification. -
l do her cern uude the a as and penalties of perjury that the information provided above is true and correct.
Si nalure. Date ll ; OF
Ph c ": 611 - b E4`(4 1 $".-)
Ofliciul use only. no not tvrire in this area, to be completed by city or town oj)ic•ial.
City or'fown: .. Permit/License
Issuing Authurity (circle one):
I. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical lusli"tor. 5.'Plu.mbing Inspector
b. Other. _. . ._
Contact Person: Phone#: JI
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empluree 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 m 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."
h1GL 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 wbo has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, 'vlGL 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) narne(s), addresses)and phone numbers)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 permit/license number which will be used as a reference number. in addition, an applicant
that must submit multiple pennitflicense 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 ttiay 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 comnmercial,venture
(i.e. it dog license or permit to bur leaves etc.)said person is NOT required to complete this affidavit.
I he Otficc ut luvestigations would like to thank you in advance for 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
Offlee 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
4
<� Board of Building R eguiati(l. and Standards
HOME IMPROVEMENT CONTRACTOR
Registration: 151814
Expiration: 715I2010 Tr# 270620
Type: DBA
ANGELO J. ROMANO ROOFING CO
ANGELO ROMANO -
19 BLOOMINGDALE STREET -
CHELSEA, MA 02150 Administrator
*. B dofuil�n w Rem 4u oi and Standards
Construction Supervisor License
License: CS 96986
Birthdate: 41411973 TAi 96986
Expiration: 41412010
Restriction: 00
ANGELO ROMANO
10 EMERY STREET Commissi
PEABODY.MA 01960
DATE(MM/DO Yj
ACOR0. CERTIFICATE OF LIABILITY INSURANCE BasrODS
PRODtIR THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
E A Kelley ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
PO Box 14190 HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
450, East Providence
East Providence_RI 02914 __-_ INSURERS AFFORDING COVERAGE - _ NN_C M
IaET>nIns
Angelo Romano Roofing Company, r— Neuttlus ------- --- = ------
19 Bloomingdale Street •st'RER a Nautilus Ins. co
W aGRER C
Chelsea,Ma 02150 —�—
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WrrH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TOALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE_BEEN REDUCED BY PAID CLAIMS.
TSLT-__ ___. T POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LTS —_
A OErERAL LNSILMY NC746012 1232008 11123r2DD9 EACH OCc:RREN:a -T—�-- $1.000.000
MECIA- E.NERAL.LIABILI X COMRG 'v �' 'E-01FF . $50D DD0
—T PREMISES Ea xture�al f __
J CIP.,M:=Ma)E K f O(:CUR I I I V.ED E%P,Mvorn WORnI f $5•000
—'
�_______._______ . I v�as�ru•,_ax.v'.H,r,,Rv t $1,000,0DO i
{ S2.IXXJ.000
_.
' 0.N'L AGGREGATE LIM?APPi IFS FER ipRpD_:CTS iGMWiOF'AGG { Slow,000
! POI Irry PRO-
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-I COMBINEDSINGLE L.WR f
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ALL OWNEDAL+r OS —
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.. HREDA'ires I + 'BODILY IN,URY
iI INON-0O N_D ALTOS IPer ecgMnq —_ f
PROFERTV OPMAuF
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GARAGE LABILITY Al1T::`ONL/-EAACCIDENT f_
H YAUTO
OTHERiHAN EA AUJ f
FliTO ONLT _ —
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_ _
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WOPo(ERS COMPENSATION AND �. -DRY5p�;il FFI
EMPLOYER!'LIABILITYYE L EAC A CIDENI
AN'FROPRIETGR/ AR'NEP'EfEiI TIVE
FnrpRINEMFCR EXCIU*D9 E_ DKEASE EAEMPLOYEE f
OTHERLP OV S 1�SONS DB nry EL 015E 'C-P LCY U41r if
OTHER
DESCRIPTION OF OPERATIONS I LCGTON81 VENUES 1 EXCLUSIONS ADDED BY ENDORSEMEM/BPECYL PROVMpNS
Roofing&ODntractor
CERTIFICATE HOLDER CANCELLATION
SHOULO ANY OF THE ASO VE DESCPoSEO POIICIF9 SE CANCELLED EIBFORS THE EXPIRATION
Chad Gambone DATE TEREOF.THEISSUING IMaIArSR WILL ENDEAVOR TO MAIL 10 OAYS WRITTEN
15 Woodside St NOTICE TO THE CERTFICATE HOLDER NAMED TO THE LEFT BUT FAILURE TO DO101 L
IMPOSE NO OSUGATON OR LIABILITY OF ANY KIND WON THE INIPJAER,ITS AGE WS OR
Salem,MA 01970 REPRFSFNTA11VF3
AUTIOPoiED REPRESENTATIVE
Katherine M. Kelley, AAI, CIC
ACORD 25(2001100) ®ACORD CORPORATION 1999
)ACORD. CERTIFICATE OF INSURANCE OATE(MWDDIYV) 8/26/2008
PRODUCER THIS CERTIFICATE 151SSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERT,PiCATE
AI'7.FR}}'f):L•1.XY (N�'A(X'-i HOL DER T418 CERTIFICATE DOES No,AMINO,EXTEND OR
d S.LSHI�v:YJ`- >T'p,EF_7 ALTER THE COVERAGE AFFORDED BY THE POLIC:E5 BEL".
COMPANIES AXPORD940 COVERAGE
COMPANY
A H.NRTFORI)GRoI p
iNSURED COMPANY
9
011\0'0 1%-%('FW f.DBA
.kN(4-it. ) R.OXIANUACN)FINL,CY). COMPANY
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D
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HI{:E'O CFRTIFY'Htl 1HE PO' {OFMIBLRANG UVet AELOW HnYi MEN-LPUEU bTMi INAJ{iD M1AMiC AAOYf FOR I l P0U4,YPERI00INCMATl0,MCTMT.6tMV4
M`AB]U'RlRIpVl.1'XRMCAC 0!Y<Y CCM^RAC1'vII OTHER UOLUN{NT Wfry R@iP{C'h^HIHICa THH CERTOICATl IIAVg4{CW ORAMY/iRYAMt TMGNI•JRAMq
A"r CL., YV THE W.,C'599f9 FEC MEPflNnl tlyyECT TD A.:THl Tf NY{ %ACLU{IOMtl AMC COA99CN{Or SUCH PHLiCk@. LIIR"A PMOWM NAY HAVE BE{N AEO.A'fO Fv
am[.euiNJ.
CA) POLICY EFF POLICY F.XP i
LIR Iv YE OF WISURAN(:E POLICY NIMEJER UATFIMMDD'TY7 DATE;MM.DDMY' LIMITS
CENF RAL LIABILITY CIENERAL AGGPEGATF 5
'.OLPAERCIAL GENERA_LWELLITY llpocuctS cljkPop AGE: b
CLA:EFi VA:E OCCUR REPSONAL AA uCV.:41I.PY t
O;VNER'S AA CONTP.YCTCP'V PRO" EPVI OC:CLPRENCE
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vARAOE U ABEfTY
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OTHER THAI AL"O ON,,
EACH ACC!CLW i
AGRE.,4TE Y
EXCFBS UABILrly
LaRELI.A FORM EACH:000RPENCE X
•VHFP THMl UWAIlLIA F0:ZM AGGRF.CAIE y
'NCRAER'V COMPENSA'IR'jN AND
A EMPOI.YEM'S UABRITY 51-:'.00 D"r i'-;lf% STATUTORY'�MITJ
fHE Pw7pGle I'OR EA:MAG:ICkul $ PlirG.90C
-ARTWRb,EXEGUTNE @,ICL CSEASE POLICYLIMIT ISC'0.1;0.
CFF!C:PSARE: EXCL DISEASE EACH EMPLOYEE .i ILO-0CC
"W R
Of 6l.PIPTXIN OF OF E RATIONB40CATIO hWVEHIC LES,RES IRIC'TK)NS,S►.CAAL ITEMS
fKG REPL e:LS aM"KL*CEII'IIF'v.:ATE I SS lBO-n'A0-C Ek7I11l AT P/LC[DLit AYFU rNU v,'L RXESS C 0%1?CO'✓2RAOf.
"lf_-i'f,;YEf. ' 'M11REN"71Ok Pl.'U_Y L'OFS Y07 FRU V[C F CltVERhC F x.:ik ROMAII 0 n%:,at'l
CERTFICArfi HOLDER CANCELLATION
sh..X.I.IAO x %•e M1a'A& DasA'PIRL-e F:'L:uvb -css[ELLFU REE,n> ult
TYI'41dAM1Y Off 41CRI'•X" PA'&h':YM14 Ord.•PA-.Y Av.i fVUF eyrEllO;'h
Uarti M:alhu bpM1V[iq'IHy TF'11::^nIL M,T,UCP Nan.-EO Mi 4d.F1, u',n
Chad Gambone feV„3l 1GNAI1 VA Mvgf{E rH l YH.'SF rQ:B IG Ii rJ IIA31Ri re A!•
TI+f,,m;r..•I n r.u.,:,e..,n'..,..M1r..:r.;a-rrr a'..r4m,F•.
1 .5 Woodside St A.UTHCN:ZEO PFPRESrNTATIVE
SIIfei9eQ3�6>01 970 Rama)li Aver
I
PRODUCT 118
Proposal Page No. of Pages
ANGELO J. ROMANO ROOFING CO.
Residential • Commercial a Industrial
19 BLOOMINGDALE STREET
CHELSEA, MASSACHUSETTS 02150
(617) 88"753
PROPOSAL SUBMITTED TO PHONE.,. DATE
Chad Gambone 978-594-0128 9-9-0
STREET JOB NAME
5 Woodside St same
CITY.STATE and ZIP CODE JOB LOCATION
Salem,MA 01970 same
ARCHITECT �e DATE OF PLANS JOB PHONE
Ma Re # 451814
We hereby submit specifications and estimates for
1.)__Stri.p...entire... roof.._down to_ boarding, .__
2.). Inspect decking and replace up_to 10.0 1n ft_of boarding if needed.
3). Install Certainteed winter, guard to .first 3f t of roof.
4_)_. Paper.., in existing... roof area with # 1 5__felt ..paper.__
5)._ Install-aluminium_drmpe.dge to_perimeter, of roof.
6.).. Shingle over underlayments with. Certainteed, 30yr Wood Scapes. _ _ _
8.)_ Contractor.to remove al,l,, de.br s, fr.om__site.
8). Contractor.to pull , all .permits needed.
9) All workmanship to, be warranteed for five ( 5) yrs._
10) Roof.. warr.anteed,..for thirty (30) yrs__by Certainteed.
............. Roof
Note-._additional.. 275-350 may be added for...ghimney pointing. _ ..._
*350
booski
4-
WP PtOPOSE hereby to furnish material and labor— complete in accordance with above specifications, for the sum of:
Five thousand eight hundred --------------00/100 dollars($5 800. 00 �.
Payment to be made a$follows:
2, 900 deposit upon start 2, 900 upon completion of 'ob.
Ail material is guaranteed to be as specified. All work to be completed in a workmanlike Authorized
manner according to standard practices.Any alteration or deviation from above specifications Signature
involving extra costs will be executed only upon written orders, and will become an extra
charge over and above the estimate. All agreements contingent upon strikes, accidents Note:This proposal may
or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. withdrawn by us if not accepted within 3 0 days.
O��nffn!lt!!
ks are fully covered by Workman's Compensation Insurance.
` nre of Proposal —The above prices, specifications are satisfactory and are hereby accepted. You are authorized Signature / ' ✓`
to do the work as specified. Pay nt will be made as outlined above.
Signature
Date of Acceptance:� � ' ' �/ � 9