0022 ANDREW STREET - BUILDING INSPECTION U loy-SIJ C� >o P 1 n-cap't.,
t� Jr0
c
` The Commonwealth of Massachusetts '1 "+"
Board of Building Regulations and Standards CIO
Massachusetts State Building Code,Igo CMR 1016 SEP 2 ,A
r 2011
Q Building Permit Application To Construct,Repair,Renovate Or Demolish a
O One-or Two-Family Dwelling
T Section Pur.f}ffi :Llsa O
Budding Permh.Nttmber Date Applied.
llaz�ngot&eisl(Pri�I�lame) �'
f SECTION 1.8 M. 13V13'(1RK ATIDN
F- - 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoaatg 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:
Zone: _ Outside Flood Zone? Municipal❑ On site sal 13Public❑ Private❑ Check if es❑ P disposal system
SECTiON2: PROPERTVOWNERS)JVt
2.1 Owner'of Record:
Name(Print City,State,ZIP
ZZ <K- 8-as 333►o
No.and Street Telephone Email Address
SECTION 3t DESCRIPTION OF PROPOSED WORKS(check ali that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed World: Qr=- QC=s
SECTION 4:ESTO"TEDCO NSTRUCTION COSTS
Item Estimated Costs: Offreial Use Only
(Labor and Materials
1.Building $ 1, Bttng Permit Fee: _ Indicate how fee is deteiminedi
O Standard City/Town Application Fee
2.Electrical $ C7 Total Project Cost'(hero 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Toil All Fees:$
Suppression
Check No. Cheek Amount: Cash Amount:
6.Total Project Cost: $ a21e►I!5� Cl Paid in Fall ❑Outs lending Balance Due:
'E iVa r L-- -r-to i-1 . 0 .
k1.. mrattk'p I vl 3
SECTION 5- CONSTRUCTION SERYICSS
5.1 Construction Supervisor License(CSL) GS C�g3�lC3 �
� �..., License Number Expiration Date
Name of CSL Holder S
List CSL Type(see below)
,26 CXl�c -KtJ-� 'C--` TYFe Desr�tion
et
No.and Stre
U I Unrestricted(BuBdings up to 35,00U cu.R
SfTc� kt pt 01��—� R I Restricted l&2 Family Dwelling
Cityrrown,State,ZIP M
RC I Rmfing Covering
Window and Siding
K Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) l'
PSzC �L (2�g53
zn+
HIC Registration Number Expiration Date
HIC Company Name or PC Registrant Name
No.and Streets Email address
Ci /Town State ZIP Tel hone
SECTION f:�URKERS°G�S:AnON R003RANC'�E AF'FMAWT OLG.L e.152.4 25Q0)
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...........❑
7a OAVt&RAUTH694 OIY'7O B$COMPLETED WOEN
WXER'S AG9NT ORC.O CTOR APPIAP.FO _ MPERMU
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-
print Owner's Name(Electronic Signature) Date
SECTION 741.OWNEW OR AUTBORMII AGENT DECLARATIOIVV
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 Authorized Agent's Name(Electronic Signature) Date
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
a�vw.ntass.gov.!oca Information on the Construction Supervisor License can be found at wwnv.nuus.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 Number of bedrooms
Number of bathrooms Number of haWbaths
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'
Massachusetts Department of Public 5atety
1N� Board of Building Regulations and Standards
License: CS-093403
Construction Supervisor
SEAN OCONNOR
26 CHESTNUT ST
SALEM MA 01970
(,-jZ7, b'— Expiration:
Commissioner 12/3112017
L i
1NPoce0
lnsumerAffairs �r'r'rrrr
XrOME IMPR ie`BsenessRegeladanOVNTCONTRACTORe9istratlon: 123553xpiration: 3/6/2017 Type:
Preserve P DBA
Painting
Sean O'Connor
203 WASHINGTON ST.#256
SALEM,MA 01970
Undersecretary
- £ a
203�%-ASn ING[ON ST.n2S6
PRESERVE SALE M, PIA 01910
SERVICES 975.745.8745
rti *375.7•iS.3476
SALESPPRESERVESERVICES.COW
Dan Pierce
22 Andrews St Date aid-9/7/2016
Estimator:Victor Calumby
Salem,MA 01970 Mobile:(978)594-3590
(978) 853-3310 Email:victor@preserveservices.com
danpierce22 crgmail.com
ROOFING ESTIMATE
COMMENTS
The estimate below is to replace the roof over the rear addition only; Timberline HD Weathered wood i/
color, starter strip shingles,and matching ridge cap shingles
PRIOR PREPARATION
PERMITTING: All permits will be obtained in accordance with the law as required.
DISPOSAL: A dumpster will be placed in an area designated by the homeowner.
ROOFING PREPARATION
COVERING: Tarp the exterior of the house so as not to damage the siding.
SHINGLE REMOVAL: Remove all layer(s)of old shingles.
NAILING: Re-nail roof decking as necessary.
CARPENTRY*
Remove and re-install copper gutter using same. Price for any parts replaced will be additional
UNDERLAYMENT
ICE AND WATER SHIELD: Install ice and water shield on the entire roof.
OTHER: *GRACE ORIGINAL(RED LABEL)ICE AND WATER SHIELD* �iPIiGZtz� r
FLASHING
DRIP EDGE: Install 8 inch drip edge on all perimeters.
WALL JUNCTION: Install or rework flashing where the roof meets the wall. lw_/
OTHER: **BRONZE ALUMINUM DRIP EDGE** -- **existing copper flasing will be be reworked
along with skylight flaring**
ROOFING MATERIALS
O�j/7JrG
ASPHALT SHINGLES:Architectural Limited Lifetime shingles either: GAF Timberline HD of—
Weathered\jfood color �Jl��rl�j�ls � G� iCE v7:
PRICING �/�1�� `� 5 E✓f>�
Basic $2,995
Sales Tax
Total Price $2,995 Including Labor and Materials*
Payment Terms: 201/6 deposit(day of start); 30%progress; 50%end of job McNisa/Amex
Victor Calumby ustomer S' nature
ADDITIONAL TO ABOVE ESTIMATE:
BID • RIP EDGE: Install 8 inch copper drip edge on all perimeters. /Ye'7` �LGIr
e$300 Including Labor and Material
BID 2: Timber PRO upgrade: 10 lbs havier than HD; 15 years algae resistance warranty over 10
years on HD i✓ LZ E�
Price$225 Inclu ' Labor and Material
Important Installation Note:If you have an older home that has dimensional lumber for roof decking you will
need to cover your attic because shingle debris may fall into the attic and create a mess.
**Above additional prices includes all discounts and coupons discussed prior to estimate. The above quote is
valid for 60 days
***Warranty: Craftsmanship:Kyron Inc.DBA Preserve Services warrantees all work performed for a period of
2 years. If any problems occur we will cover the cost of labor and materials. For the warranty to be valid the
invoice that was presented at the time of completion must have been paid in full. Materials:The duration of the
manufacture's warranty is specified in the materials section above. Acts of god are excluded in the warranty
such as but not limited to ice dams,tornados,and hurricanes.
Licenses:
Home Improvement Contractor Preserve(HIC): 123553
Construction Supervisor Sean O'Connor(CS): 93403
EPA Renovation,Repair and Painting(RRP) Nat-21650-0
Insurances:
43
r
Worker's Compensation:
hu policy is under Kyron Inc.DBA Preserve Services
rotection: Covers the injury of a worker employed by the contractor doing work at your home.
To check our policy or our competitions go to http://mass.gov/dia/ on this page go to"check worker's
compensation proof of coverage"our license is under Kyron zip code 01970.
Liability Insurance
)ur policy is under Kyron Inc.DBA Preserve Services and has limit of$4,000,000.
rotection: Covers your property in the event of accidental damage up to a dollar limit specified
n the policy. To check our policy we will provide a certificate from our insurance company.
r
r
H203 WASHINGTON ST.#256
PRESERVE SALEM,MA 01970
SERVICES carpentryl painting)roofing)gutters PHONE:978.745.8745
rAx:978.745.3476
SALES@PRESERVESERVICES.COM
To Whom It May Concern,
I Sean O'Connor give permission to Victor Calumby to use my building licenses to pull building permits.
Sincerely Yours,
Sean O'Connor
u fHJD �cc75C,�E?E1� 7-0 ,e67 1"6-
us
s
6US $
Erplres
2077
\ The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
' www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name:
Address:
City/State/Zip:g — Phone#: Q 1 e�221 4!5
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with D employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate, auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] $• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required]* 11.[]Health Care
4.r_1 We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.0 Other Cr>G
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I an an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: yszzl
Insurer's Address:�,?oC'J�lA1F� 1.'at `—Q(V �8� 42c�
City/State/Zip: KIN
,� ^C
Policy#or Self-ins.Lic.# KIN Expiration Date:
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 c. 152 can lead to the imposition of criminal penalties of 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. 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, un thepains and penalties ofperjury that the informationprovided abo is true and correct.
Si nature: /I•• Date: "1 2 t b
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2. Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 ajoint 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 your insurance company's name,address and phone number along with a certificate 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 permit/license applications in any given year, need only submit one affidavit indicating current
policy information(if necessary). 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
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Fonn Revised 02-23-15
OTYOFSALEII4 AA'SWASE77
Bcu»DBPAJMMxr
MW.wmUNaSU07,PPLO a
KrimBRiSYDdt6�Or)LL Fex 7149816
MAYQIt 7 �ST.P>BSRE
Dmscmatm+FEwuc /swswaGoomkuwm
Construction Debris Disposa/Affidavit
(required forall demolition and.renovation work)
In accordsm with the sbM edition of the State Buihiing Code, M Chit, &vdw 111.5 Dellis,
and the provisions of MGL c40,S 54; Building Permit B is issued with the
condition that the debris resul ft from this work shall be disposed of In a Properly licensed
waste deposit fadlity as defined by MGL c 111,S 156A.
The debris will be transported by.-
(name
y:(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature 9f applicant
Date