16 GENEVA ST - BUILDING INSPECTION e, The Commonwealth of Massachusctts Town of
Board of Building Regulations and Standards
t1 ° Massachusetts State Building Code, 780 CMR, 7'"edition Almma Dn
J\ Building Permit Application Construct, Repair, Renovate Or Demolish a *kvomdwo
rre- or Tito- amift Dtrrlling
is Secti For Oficial Use Only
Building Permit Numbe Date Applied:
Signature: J t I y s G
Buildi Commit ioner/Idings Date
CTION 1: SITE INFORMATION
1.1 P pert Address: 1.2 Assessors Map At Parcel Numbers
—'�� Ma Number Parcel Number
I.la Is this an accepted street?yes_ no
P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(MAUL C.40,954) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
xNam mt) , Address for Service:
, O C
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bfdg. ❑ 1 Number of Units
Other ❑ Specify:
Brief Description of Proposed Work=:
x
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building $ 1. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical s ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) 5 List:
5. Mechanical (Fire S Total All Fees: s
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: s ��d • 6 d 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /t�//r2 '� p�
/J`!/ 7
EL�ceroc Number Espuauon ate
N:) ut CSL Held
L� List CSL Type(see below)
Add, T Description
U MasonUnrestry
Onted u to 35,000 Cu. Ff.)
R Restricted 1&2 FamilyDwelling
Signature p ��// M Mason Only
RC Residential Roofin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2�R_g�ster mem rov e�tContractor(HIC)
A67 Z
HIC /o Name or HIC Regrsirant N�r--.•a�rme Reegistrano Number
!� Add ss e '
7 `f 3 Ex ration Date
Signa Telephone
SECTION 6: ORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(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........... [3L.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, OOF52M21914ras Owner or Authorized Agent hereby declare
that the st en d information on the foregoing application are true and accurate, to the best of my knowledge and
behal .
Print Na
Signatu Owner or Authorized/gent O
ized gent Daft
(Signed under the pains and penoies of perjury)
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 110.R6 and I I0.115, 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'
AnointedRemodeling
Home ImprovementSpecialist
10/14/08
To: Mr. & Mrs. Richard Lessor 16 Geneva St.
From: Mr. Dana R. Neves Salem, Ma.
CONTRACT
1) To tarp off the sides of house that are to be worked on, to protect it from
falling debris.
2) To strip the entire roof of old roofing shingles.
3) To install ice & water barrier to all edges of the roof,valleys and sides of
the chimney.
4 To install all new 30 felt tarpaper a er to the entire roof.
5) To install all new (White) Iko 3 -Tab roofing shingles to the entire roof.
6)To install a new ridge vent to the entire length of roof for proper
ventilation.
7) To re- mortar the joints of the brick staircase on the driveway side of the
house.
8) To clean up all job debris from the customer's property.
9) The contractor will supply a dumpster for all of the debris.
10) Any additional work not mentioned in the above contract will be handled
with a new change order with new costs to be agreed upon by both parties
before any additional work is performed.
"We Turn AN Your Household Needs Into Blessings!" sT
516 North Street • Georgetown MA• 01833 Phone(978) 352-2351 Cell (781) 727-3226 MEMBER
f
- ) Remodeling
'AnointedHome Improvement Specialists/
Cont. pg.#2
TOTAL COST $ 8500.00
DEPOSIT TO SCHEDULE $ 5000.00
PAYMENT AFTER HALFWAY $ 3000.00
PAYMENT UPON COMPLETION $ 500.00
H.I.C. # 145670
C.S. #084197
INSURED BY : Safety Insurance Company
The contractor will have a valid permit from the Salem Building Department
to adhere to all State & Local Building Codes and Laws of Massachusetts.
Customers Signature Contr ctors Signature
X X .4 f /
"We Turn AU Your Household Needs Into Blessings!"
516 North Street• Georgetown MA f. 01833 Phone(978) 352-2351 Cell (781) 727-3226
Safety Insurance Cox ipany
20 Custom House Street
Boston,MA 02110 Businessowners Policy
14MO-951-2100 New Business Declaration
DirectBill- Insured Declarations Effective 10/28/OF
BP00011197 1 10/28/0 10/28/09 12 :01 AM STANDARD TIME 65831
ANOINTED REMODELING NC DUFFY INS . AGENCY, INC .
C/O DANA NEVES 317 BROADWAY
516 NORTH ST LYNN , MA 01904
GEORGTOWN , MA 01833
Phone : ( 781 ) 593- 1200
Form of Business: Corporation
Business Description: (0)Carpentry-it terior
In return for the payment A the premium,and subject to all of the terms of this policy,including forms
and endorsements madea part hereof,we agree with you to provide the insurance as stated in this policy.
COVERED LOCATION(S)
LOC:001,BLDG 001:516 NORTH ST, EORGETOWN,MA 01833
PROPERTY < ,
This H :contains a$506uctible unless otherwise s ecified see additonal cove es section
LOC BLDG COVERAGES LIMITS OF VALUATION AUTOMATIC
NO NO INSU CE CLAUSE INCREASE
001 001 Personal Property $3,000 Replacement Cost 04 %
LIABILITY- AND- MEDICAL .EXPENSES
Except for Fire Legal Liability,a tch paid claim for the coverages listed reduces the amount of insurance we provide
during the4plilicable annual Peri A. Please refer to Paragraph D.4.of the Businessowners Liahility.Covcragc Form.
DESCRIBED COVERAGES LIMITS OF INSURANCE
LIABILITY $300,000 PER OCCURRENCE
MEDICAL EXPENSES $10,000 PER PERSON
FIRE LEGAL LIABILITY $100,000 ANY ONE FIRE/EXPLOSION
ADDITIONAL COVERAGES / OPTIONAL COVERAGES PROPERTY
The followi additional/optional coverages are afforded under this policy._
Some cov :rages are subject to deductiblesspecified in the poticy forms.
LOC NO BLDG NO DESCRIBED COVERAGES I LIMITS OF INSURANCE
ADDITIONAL COVERAGES / OPTIONAL COVERAGES - LIABILITY.
The following additio tional coverages are afforded under this policy.
DESCRIBED COVERAGES LIMITS OF INSURANCE
PREMIUM
Annual Premium $838
y �
Insured Copy AUTHORIZED RrMESEWAnVE
PAGE 1 • 10/31108 (Print Date)
t„
y 5
CITY OF SALEM
slI PUBLIC PROPRERTY
DEPAR"f'MENT
.. :;I r " , I.: U •.. u•.,.., `.1;,;iir � �V iii. \I� .� .. i . ,_I• _
•i'8.1: '.i Je
Construction Debris Disposal Affidavit
(rcquired litr all demolition and ranuvat ion work)
In accordance %%ith the sixth edition of the State Building Code, 7S0 CNIR section If 1,5
Debris, and the provisions of'vlGL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting from
this work shall he disposed of in it pruperly licensed waste disposal I'acility as defined by MGL c
1 11. S 150A.
The debris will be transported Iby:
c1� 1
1 name of I der)
l he debris will be disposed of•in
,9
(l ame ul lac'ihty)
(address 0Ijciluyy
a�nalwC at pa nurf pphcanl
latr
y
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
•i\1M I I Int\( .X11
\I\` +t I1� WPI\Iu�t.l\1.�SCt Lkf • 5.111'II, Pt.NV Ia 111 M i n.�l'IT
Ir.I. vrb7liri'IS • I %s 979 74Z Iso.
Workers' Compensation Insurunce \ifitlosit: Hui lders/Contra(tors/Electricians/Plumbers
1 ili(am Inforinatioa Pleaxe Print Leaihlv
Villne Ilh(•Ilws,l)rpatn�V.ln�(Nlnlln�.luall
%duress: �+ r
(,Ily.St:l[C. If)
a3> Phone
.\re),to its employer?Check the appropriate box: I)pe of project(required):
i 4 ❑ 1 nn a general coin ractor and 1 (r. Ncw cunstrucuun
I.❑ 1 .un�cmpluyer with ❑
cm du ces lull +nd,ur art-unle).' hove hired the sub-cuntracturs
1 y ( P 7. ❑ Remodeling
s I .un a sole proprietor or partner- Thlisese
un the juiclintract d shave
e N ship and have no cinph,yecs work sub-contractors have tl. ❑ Demolition
working tort me in any capacity. workers' comp. Insurunce. 9. ❑ Oudding additwn
No workers' cum . tosurauee 5. ❑ We are a ensparation and its
p 10.❑ Electrical repairs or additions
I rcquireJ.J olticers have cxcrclscJ their
light of exam tion r MOI. 11.❑ Plumbing icilain or additions
5 E3 i :un hamcuwner cluing ill work c 152, ( ,a
myself. Igo wnrkcn' cunsp. 413) nd we have no 12.❑ Rauf mpain
u%surancc required.l t cinpluyces. (Ko workers' IJ.❑other
comp. in,urancc rcquircd.J
• ... ..pp4a+la 1hM1 atcclis box AI AIMS%Aso IIII Wl IhV W'"0I"low allow,ng Ihort wurkos cunlpunuaiwl pulley.,.hwtrutiun.
' I lum.:uwrwn who udmlil this afrijavil iAdiuunj Ihe)+Ie auina At..,it vW Ihcn Aiw wNldr etnumaln man.uhlnir+Aew'I(daril uldi""s."ll.
(..,mu.n that ahvck this box mtW nlxhad..n aedlliun+l.Jw.%1 Jll,wiuy nw IUIMa of tho sub:olnrxrars and Ihnr wuhun'comprwio,y mfurmanun
/am an cmpluyer Thur it prurid/nr%varkers'curnpenrarion hisarunce for illy enrp/uyees. Be/nry is rhe pu/ity and job.ire
b1fdristaliam I'd=
Imurwuc Cbnlpany Name: ��-r J--------
Policv a ur Scif-inn. Lic. n: __. . . .. ._ Ewpiratwn Date:
Job >ne Address: ---. Cny:Slntu"Llp:
.IIItaeh it copy of 11te workers' cumpensatlun polity declaration page(showing the policy number and expiration date).
I•adurc to.ccurc cuscrage as required under Sectiun 25A ul'>IOL c. 152 can lead to the imposition of criminal penalties o(3
rine up u%11.500.00 and/or une-year imprisonment, at well as cull rxnaltics in the form of a STOP WORK ORDER and a fine
.If up to)250 00.i J,ly .Igamst 111e lie adv s.cd that a copy of thu slutcinenl may be lum arded to the 011ice ill
I.n:.n•,a mnu ill :hc UI.\ :or 1 .w u:cc a.hc I:I Ili(at:on.
/Ju h.•r.Ay a:ni/`v mr./cr rhe p 1%,110 /renolria•v of per%a that the inlunnrNon pro Viideedubrowe i IF urd correrf.
I'I•, 1
I)fit iu/lr It urt/y. /)d ins a rite nr!hoc urru, /u ht I unrp/reed by airy up farm u//ia ioz
't iry or I�nlen: _.
Pur miul.ic,nse y
Luing \ulllurnv (circle Anel:
1. IL.+rJ of IIc.JIh !. Iluddmy Dglartulcul L Cih.-I uou Clcrk 4. L•'IaRrioJ fu.pc.roe S. ('lumbing Iulpactar
4 011ier _
l'..uuct I'anml; .. .. Phonc is:
t
Information and Instructions
s l.u,.c.hu.eua Gcncral Laws chapter 152 icquncs all cinplo)crs to pros ide workers' compensation t�)r their cnipluyces.
I`unu.mt
to r:us .iatuic, an emplulee Is Jetincd 34 - e.err prion in arc servLLe ul anurher under .city cumract of hire,
;,preys it unplicd, oral or ssnnen."
%n ,,npluyer is defined as"in individual, partnership, assoetatiou, corporanun or other legal cntiry, or any two or more
..r the cnvaycJ it a joint cnicrpnse. and ucluding the !cgil representatives of a deceased cmplu.�cr, or rhe
resoscr or uusrce of .m mcliviJuai, pwuerahcp,assocuttion or other legal rnmty. employing :niplo)ccs. However the
owner ota dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling Iwu,c of another who employs persons to Jo mauttcnam'e, cunstruaiun or repau work on such dwelling house
of on the--rounds i)r.hutlJing.appurtenint thereto shall not because of such employment be deemed to be in cmplu)er "
.NIGL chapter 152, ;75C(6)also hates that "every state or local licensing_agejpcy %half withhold the issuance or
renewal ora license at permit to operate a business or to construct buildings'in the cum' monweulth for ally
:nppliwnh
l "tic has n
'as ot
.1 'd'—
aced accipfable evidence of cumpliance;witb,theinsurancecoverage required."
Wdiuunilly, %IGL chapter 152, 42507)stades "Neither the cm
omonwealth dui any of iu'politicel subdivisions ,hall
enter into any :untraci for the perfom)ance ui puhlic work until acceptable es idence utcumpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Plaase rill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors)nanets), address(es)and phone numbers)along with their certiftcatc(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 docs have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance covarage. Also be sure to sign and dale the affidavit. The affidavit should
he retuned to the city or town that the applicauon for the permit or license is being requested, not the uepartment of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain is 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
f leasc he sure that the affidavit is complete:mJ printed legibly. The Departrnent has provided a space at the bottom
of the affidavit for you to fill out in the event the ORice`of Investigations has to contact you regarding the applicant.
I'I:asu be sure to till in the pcnnivlicense nuniWr which will be used as a reference nun)bcr. In addition, in applicant
iliac must submit multiple pennitllicense applications in any given year,need only submit one affidavit indicating current
policy intmi'mition(if necessary)and under"cob Site Address'the applicant should write "all lucatiuns in (city or
town)." A copy of the affidavit that his been officially stamped or marked by cite city or town may be provided to the
applicant as proof that a valid affidavit is on file f'or future permits or licenses. A new it7idavit must be filled out each
near. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
t i.e. a .lug license or permit to burn leaves cte.)said person is NOT required to complete thri affidavit.
I h: I )dice ,,t Inve,tf--itiuns swuld It" to dank you in adsancc tur your Cooperation and should you hasc.my questions,
please do not hcsitale to give us a call.
ncc Dcpartincnt's address, telephone and fax number
3 The Commonwealth of Massachusetts
Department of Industrial Accidents
OI}Ice of IlavesUratlons
600 Washington Street
Boston, MA 02111
Tel. N 617-7274900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mass.gov/dia