2A WOODSIDE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR S
Revised dMar Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D e Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel NuPtJie�70
-- >t U/t?O s7 V-e /((tee
I.la 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(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Regdved Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Be Private❑ Zone: _ Outside Flood Zoye? Munici
Check ifycl Pal eOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Pont) City,State,ZIP
0214 tyb0lo s i Ae
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : — -S O
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 00 v 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x \
3.Plumbing $ 0 r 2. Other Fees: $ f � J�
4.Mechanical (HVAC) $ List: Lill, (J
5. Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount Cash Amount: '
6.Total Project Cost: 1, 13 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�"1 CS—o�8379
V O ll 1^^ 7) B r i p4� License Number Expiration Date
Name of CSL Holder EI
U I ^n Ave ' List CSL Type(see below) U
No.and Street +. Type Description
�
d / U Unrestricted(Buildings u to 35,000 cu.ft.Vs �/r 40114 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7rt-s-7()-1�7a i�kcs 415-1 ® a.l ,CV� I Insulation
Tele hone Email address D Demolition
5.2 Regist ed Ho a Improvement Contractor(HIC)
A . � 11 �f Uf'^( HIC Registration Number Expiration Date
HIC Company Namgg o]]HIC Registrant Name
��� Cl,, JT'
No.and Street �^/^�1111,, J-.7 Email address .J
i- 14 OtJ' U�_ ! /(J�� / 1�
Ct /Town�Itate,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 ..........)K No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize_ /�\
to act on my behalf,in all matters\relative to work authorizad y this building permit application. ('
Print Owner's Name(Electr`tic Signature) )' Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,1 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 Authorized Agent's Name(Electronic Signature) Date
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(I-IIC)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. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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 O -k Number of bedrooms
Number of bathrooms c Number of half/baths
Type of heating system O 12 Number of decks/porches , 1 Oe I PoM.I•I
Type of cooling system Noa Enclosed Open L,--
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
,< CITY OF S.U.&NI, 1rLxSSACHUSETTS
• BU ELDNG DEP.ART.%w,%T
• 120 WASHIINGTON STREET,V FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI,NigERLEY DRISCOLI.
MAYOR DIRECTOR
ST.PIF1eRs
DIRECTOR OF PUBLIC PROPERTY/BU HMIING COtMUSSIONER
Construction Debris Disposal, Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
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 be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in :
LSOo b U/efr e -
(name of facility)
&3/oK &i. 4ri t ITT PIA . G a/ 4
(address of facility)
v
signature of permit applicant
date
e�nri�ir.dx
i CITY OF S.UX.11, AxSSACHLSETTS
• BuILDLNG DEPART%ffiNT
120 WASHINGTON STREET, 3'a FLOOR
TEL (978)745-9595
FAX(978)740-9846
Ki%tBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COSLNIISSiONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le¢ibly
Name(Busim�Organizatiotvindividual): "i tom^ l.El�S ��.yCi/ ✓ a y_
Address: 41V�4LI94f Z i� ioff 2j::�
City/State/zip: IV
Are yo an employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet. 7. [B Remodeling
ship and 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. l7 We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 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 12.0 Roof repairs
insurance required.)t employees.[No workers'
lha
comp.insurance required.] I3.❑O
•Any applirare that chocks box 91 must oleo fill uut the section below,slowing their workens'compensation policy isdormadon.
1 hxrrcownexs who submit this affidavit indicting they a r doing all work and then hire oauide conttagors must mboth a new alydavd indicating seek
:Contnkyors that chmk this box most attached an additional shoes showing the name of the mbtiontrdams atd thek workerx'comp.policy information.
I am an employer that Is providing workers'compensaton hiss rance for my employees. Below Is the policy and job site
information.
Insurance Company Name: /f�
Policy#ur Self-ins.Lic.#: e7�� / Expiration Date:4
lob Sire Address: [r/D nd d%O e tl LcM 1;�R• City/State/Zip:
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 of MGL a 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. 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 pains and penalties of perjury that the information provided above is true and correct
. '> aium Date:
o c#'
Ojjiciel use only. Do not write in this area,lobe completed by city or town offichd
City or Town, _ Permit/1.1ccnse# _
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cilytrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
From:CDcran HdVhn 1+781+235+1822 08/03/2012 09:18 #168 P.001/001
ACORD CERTIFICATE OF LIABILITY INSURANCE DATE(MMID0IYYYY)
O9/03/2012
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLYAND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER_THIS
CERTIFICATE DOES NOTAFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S),AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the ce"cate holder is an ADDITIONAL INSURED,the policyCles)must be endorsed. If SUBROGATION IS WAIVED,subject Is
the terms and condiDons of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NAYCT
Ep lane K. Loomis
Corcoran & Havlin Insurance N.E„1, 781.235.3100 u241 Na:781.235.7190
Insurance Agency, Inc. n 01AIL
287 Linden Street D NEJUpC 00022z81
Wellesley, NA 02482 INSURER(S)AFFORDING COVE RAGE NAM
INSURED INSURER A: Lloyds of London
I.R. & Sons Construction Inc. INSURERS: Safety Insurance 394S4
4 Hallberg-Park INSURERC:
North Reading, NA 01864 INSURER0:
NSURER E:
NSURER F:
COVERAGES CERTIFICATE NUMBER:12/13/Master2 - REVISION NUMBER:
THIS IS TO CERTIFY THAT 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 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 REDUCE_D BY PAID CLAIMS.
TYPE OF INSURANCE POLICY LIMNS
INS INSR MI) PODCY NUMBER 1MIDDIYYYY MMIO
GENERAL LIABILITY _ XS21615 03/23/2012 03/23/2013 EACHOCCURRENCE S. 1,000,000
X COMMERCIALGENERALLMMUTY PREMISES Eaomannoe 3 50,
aw—
CLAIMS-MADE FRI OCCUR MM F)(P(Nry one Person) 3 5,000
A PERSONAL&ADVINJURY i 1,000,00(
GENERAL AGGREGATE 3 z,000.0
GENL AGGREGATE UNITAPPLIES PER: PRODUCTS-COMPIOP AGG 3 - includec
POLICY JEC LOC 3
AUTOMOBILE UABIUW SOS8519QM01 05/28/2012 05/28/2013 CWBINED SINGLE LIMIT 3
fEa as wj 1,000,0
ANYAUTO BODILY INJURY(Per Parson) 3
ALLONMEDAUTOS BODILY INJURY(Per aoddeM) S
IS X SCHEDULEDAUTOS PROPERTY DAMAGE
X HIREDAVTOS (Par madent) 3
X NON OWNEDAIfTO$
i
s
UMBRELLA UAS OCCUR EACH OCCURRENCE S
EXCESS UAB CLAIMSf E AGGREGATE i
DEDUCTIBLE $
RETENTION 3 S
WORKERS COMPENSATION $TATU- OTH-
AND EMPLOYERS LIABIDTY YIN TORV LIMITS ER
ANY PROPRIETORIPARTNEIUEXECUTNEO NIA E.L EACH ACCIDENT S
OFFICERMEMBER EXCLUDED?
(Mandatory in NH) E.L DISEASE-EA EMPLOYE 3
lf
Dyyeess se-TON esker
DESEflIPi10N OF OPERATIONS Eebw E.L.DISEASE-POLICY LMIT S
DESCRIPTION OF OPERATIONS I LOCATIONS VEHICLES (Atwun ACORD 101,Addltlanal Ramarlo,SchoduW.If man si is n unit)
e workers Come certificate will be issued directly from the carrier.
CERTIFICATE HOLDER CANCELLATION
FAX: 978.664.07S4
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE VIM THE POLICY PROVISIONS.
City of Salem AUTHORIZED REPRESENTATIVE /J r/,T
120 Washington Street /y y �"'7
Salem, NA 01970 George Doherty III JKL
*kj, 01988-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009/09) The ACORD name and(ago are registered marks of ACORD
Unrestricted -Buildings of any use group which.,
contain less than 35,000 cubic feet(991m)of
enclosed space.
. Nassacrlusett 4� partnlent of Public Safety
�Lnard of Building Regulations and Standards
Construction Supa•l•s'isur Failure to possess a current edition of the Massachusetts
E ease CS-078374 State Building Code is cause for revocation of this license.
1 t rA o
!� For DPS licensing information visit: www.Mass.Gov/DPS
JOHN D BRIGa
66 CLIFTON:AVE
Saugus MA 9.1906 - II IIIII111111111111111111111
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MA
WWW.masos ass.Aovlrmv
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MASSACHUSETTS: DRIVER' NONE
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�\ Office of Consumer Affairs&Business Regulation }•
HOME IMPROVEMENT CONTRACTOR
.t Registration 169111 DBA Type:
Expiration:, 5/1.7/2013
y
A. .HILL CONTRACTINGr."- -
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JASON HILL
5 BIRCH ST.
BURLINGTON,MA 01803,,,. .H Undersecretary If
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PR Iv, RI
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3§70622810 s na,
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0308�201308OS/198Y _ I
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`BURLIN LINGTON
Y
01803-3.. 2561
i
GL
ctilz,
A and Sons Conn Inca
s 6 �* ,
' . Excavation-Demolition-Trucking
Property Maintenance
4 Hallberg Park, N.Reading MA 01864
Phone:(978) 664-0753 Fax: (978) 664-0754
To: Amy and Andrew Lypps Date:August 9,2012
Job:2A Woodside
Job location:Salem,MA
Work to be done:
• Gut and remove all old fixtures and file walls
• Redo second floor bathroom and redo plumbing as needed.
• Redo electrical fixtures as designed by Marty
• Re-insulate,blue board and plaster with skim coat
• Reinstall new fixtures and paint
Please help us in our efforts to go green. All metals and wood will be separated and recycled by J.R_and Sons
Construction. Our price is based upon our recycling efforts and if this is not agreed upon,a price increase
could occur.
We proposed hereby to furnish material and labor,completed in accordance with the above specifications,for
the sum of: $16,400.00(Sixteen Thousand,Four Hundred Dollars).
All work is to be completed in a professional manner according to standard practices. Any deviation from
above specifications involving extra cost will be executed only upon written orders and will become an extra
charge over and above the estimate. This proposal may be withdrawn by us if not accepted within 30 days
and payment must be submitted 15 days after bill is received.
Authorized Signature: Date:
Acceptance
Signature: Date: