11 LINCOLN RD - BUILDING INSPECTION 3a s
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF z
Massachusetts State Building Code,780 CMR SALEMd
Revised Mar sW I m
Building Permit Application To Construct,Repair,Renovate Or Demolish a rn y
One-or Two-Family Dwelling C-") �5 m
c
This Section For Official Use Only D m
Building Permit Number: Date Applied: �r�t
\v czl
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Building Official(Print Name) Signature 00 Date n
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1 SECTION 1:SITE INFORMATION
(� 1.1 Pryy rty Address: 1.2 Assessors Map&Parcel Numbers
r 1.1 a Is this an accepted street?yes no Map Number Parcel Number
�
QQ 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 Rem Yard
Required Provided Required Provided Requtred 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 ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1�O1wner'of Record:
Dame(Print) City,State,ZIP
No.and Street Telephone - Emaltt-Addmss
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building)0C. Owner-Occupied ❑ Repmrs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work2: 6-�2
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1 Building $ 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: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �/�� ❑Paid in Full ❑Outstanding Balance Due:
IhAlt_00-1D C)1S-=ormtor-
Yr Y� t ll- 12-1 L�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Y .���/ License Number Expiration Date
Name of CSL
.H�of p
,oz lcn,6Lf�s / List CSL Type(see below)
No.and Street Type Description
U UnrestrictedB arm s u el fing cu.ft.
z ZiC� d`Y�7 R Restricted 1.Q2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
_ SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(RIC) _ ��xpi
H C egis�r Eration Date
FIj>y�o any Name or C Registrant Name
No.14 Street Email address /
Ci /Town,State,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 ..........�8, No...........0
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 authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'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 Authorize ear'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(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
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.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"maybe substituted for"Total Project Cost"
CITY OF SAI.&N1, 2UNSSACHUSETTS
• BU7LDLNG DEPAR'i'JE+rT
130 WASHLIIGTON STREET,P FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
(O-,{BERr RY DRISCOLL
MAYOR Tliobus ST.PtERRti
DIRECTOR OF PUBLIC PROPERTY/BU:UMING CONI-NQSSIONER
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 :
(name of facility)
b,ZZIV 7W
(address of facility)
signature of permit a cant
date
JcbriutT.Jcn
_ Office of Consumer Affairs&Business Regulation
- ME IMPROVEMENT CONTRACTOR
gistratlon: 174889 ' TYPw-
phation: ;.327/2017 Corporation ,
E)(TERIOR REMODELING INC.
EVGENIY KUNTSEVSKIY
882 A WASHINGTON AT
ATTLEBORO,MA 02703
Undersecretary
License or registration valid for individul use only
before the expiration date. If found return to: -
Office of Consumer Affairs and Business Regulation
10 Park Plaza-Suite 5170
Boston,MA 02116
Not valid witho rgnature
IN& Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen-icor Specialta-
License: CSSL-105954 -
EUGENIY KUNTSEVSKM
12 IONGSLEY ROAD
North Attleboro NIA 02760 ,r
Expiration
Commissioner 03/06/2016
CITY OF Smym. N'LASSACHUSETTS
• BuMDIIING DEPARnwmr
' 120 WASHINGTON STREET,3'FLOOR
TEL (978) 745-9595
FAx 978 740-9846
KIMBERL.EY DRISCOLL
MAYOR TttoMAs ST-PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUUML11IG COXMIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(BusinesiOrganintioNlndividual):
Address: ��� G1f/// -S b�1L�OL r S 70� '
City/State/Zip: /�Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1:�(] I am a employer with 1z 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
workingfor me in an capacity. workers'comp.insurance.
Y P tY� 9. ❑Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised thew 10.0Electrical repairs or additions
3.❑ I 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' 13.0 Other
comp. insurance required.)
-Any applipm that checks box A must also fill out the section below showing their workers'compensation policy inturmadon.
>t Inmeownaa who submit this affidavit indicating they are doing all wok and thio hire outside contractors must mbmh a new affidavit indicating such.
=Contmetors that check this box most anached an additional short showing the n me of the sub.cantnwtors and their workers'camp,policy information.
1 am an employer(hat is providing workers'compensaden lnsurancefor my employees. Below is the pollay and Job site
information, o t/� 1
Insurance Company Name: Z—e
�l i tlz Lf� L e
Policy#ser Self-ins. Lia#: WCoe"ZIS 4�2 ,47 7 I—r Expiration Date:
Job Site Address: �� ®!/� �/� City/State/Zip: Z/�/_,9 u /
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 S1,500.00 and/or one-year imprisonmen%as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify aider t Ins artd penalties ojperjury that the hiformadan provided above Is true and correct.
Sian t u
Date:
P o N.
Oficial use only. Da not write in this area,to be completed by city or town oBwiat
City or Town: Permit/I.icense#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
E11112102 Exterior Remodeling Ina
882 Washington St
Attleboro,MA 02703
(508)3425373
extedorremudeling@gmail.cem
httpllextedorremodeling.net
O Q
ADDRESS
Daniel McCue
11 Lincoln b
Salem,MA
SITE LOCATION ADDRESS LICIREG#
Same Roof&back porch 105954/174889
fmwpo / Z
Roofing 14 5,040.00
GAF Timberline Architectural roofing system with lifetime warranty.
Strip up to two((2)layersof roofingg on 5"&7'pitched roof.Indudmg entire roofing system and removal.
-Inspect wood kr water or any Wr damage,repait if necessary. This job inducting 1 full ptywood replacement or 32 f of board
re famment. Apply 6f.of Ice&Water barter to Eaves,18 inches on the rakes by code. Apply synthetic rooting undedaymenl.
White(Bin ch)dnp edge for entire perimeter on top of Ice&water shield. Six(6)nails per shingle to code. Starter strip to all
perimeter. All new pipes Flashing. Install cobm ridge vent.Replace roof on over the entry door porch. _
Roofing
Strip willed roofing from rear roof section and install new wiled roofing over,color to match as close as possible to main roof 2 960.00
shingles color.
Chimney
All new chimney lead,flashingf cut in 314 inch).Seal with concrete sealer. 1 600.00
Building permit 1 200.00
Any wood replacement greater than one(1)full plywood or 32 f of board will be additional charge of (60$)per sheet for plywood
or 4$per linear feat for board.
10 year Exterior Remodeling Inc.labor warranty included+Manufacture LiteTime,transferable materials warranty(you will
receive your waman"mail within 10 days after project completion).---
You,the customer,may cancel this transaction at any time prior midnight of the third business day after the date of this
transaction,without any penalty or obligation.
We am registered home improvement contractor in state of Massachusetts,any inquiries about a contractor registration should
be directed to:Office of Consumer Affairs and Business Regulation,Ten Park Plaza,Suite 5170,Boston,MA 02116.Phone
:617-973-8700
Final contract amount should be paid within 10 days after project completion.
E-signed contract valid as original. ___
I VA/I Ca( ME&c P— as Owner of the subject property
SUBTOTAL 6,800.00
hereby aulhor(ze Exterior Remodeling Inc.to act on my behalf,in all matters relative
to work authorized by this building permit application.Signature: DISCOUNT -599.00
Accepted y Accepted Date
tot V415-
Contractor signature: Date: