15 LYNDE ST - BUILDING INSPECTION t ,t
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The Commonwealth of Massachusetts
W Department of Public Safety
Massachusetts State,Budding Code(780 CMR)
ungermppcaonor any Building other than a One-or Two-Family Dwelling
(}O (This Section For Official Use Only) .
Building Permit Number: Date Applied: Building Official:
p SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
�I No.and Street City/Town S6,f-e Zip Code(,7) ) S -7G Name of Building(if applicable)
N 1 SECTION 2:PROPOSED WORK.
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
I Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out mrd submit Appendix 1)
Charge of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ N2)q—
Is an Independent Structural EngineeringPeer Review required? t Yes ❑ No
Brief Description of Proposed Work: ..L eUS 1.� 1 f u,ne( 11 D.NN
CIA Mr£ Y n h � �'i ( � A0Z
ALAr S0 F # 2a� ,
X--4-v! �t tf : tic P<ef by cr f ct�E�Slv�v�
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY - -
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1 C) H-2❑ H-3 11H-4❑ H-5❑
1: Institutional 1-1❑ 1-2❑ I-3[1 Fl❑ M: Mercantile❑ R: Residential R-111 R-2❑ R-3❑ R-tW
S: Storage S-1 Cl S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ 111 13 IIA 13 11B ❑ IIIA ❑ IIIB ❑ IV 13 1 VA E3 VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:i
Permit:Water Supply: Flood Zone Information: Sewage Disposal: TrenchLicensed Dis osal Site❑
Public❑ Check if outside Flood Zone❑
Indicate municip rl❑ A trench will not P
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \Ir\I Int I u. iw„n ko" " Pmcf
Not Applicable❑ Is Structure within airport approach area? is their review completed?
or Consent to Build enclosed❑ 1 Yes❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Ed ikon of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
�hc. i LIZ e-(7/6
V 1
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Ccs ar4, .1 Lcr,t� t CaM�I . IQ 0/ PZr
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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Title' Telephone No.(business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
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None Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please-fill out Appendix 2)
If build in S is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
4!✓�-_- Itn/IN,jT.RP1F/3:59(tt
®509 -77
tme Registrant) T�Iep�,e No. e-mail addressG/aA•/-'Ca Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name j
�20C Z (74- 1
None of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No, cell e-mail addressi
SECTION 11:W0RKEIS'COAIPFNSAI'ION INSUKANCH AFF'IUAWr M.G.L.c.152.S 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industria Accidents 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.
Is a signed Affidavit submitted with this application? Yes O No ❑
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(tabor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4.Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other S Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 3:SIGNATURE OF BUILDING PERMTr APPLICANT
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.
Please pruit and sign name Title Telephone No. Date
Zd �/i(f) W( ✓ S ( Sr3C4rr A� Cli i 2 G
Street Address City/Town �,S�tate Zip
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Municipal Inspector to fill out this section upon application approval: -"vim 7 17
Name Date
� 1
The Commonwealth ofMassaehusefts
Department oflndusirialAccidents
1 Congress Street,Suite 100
Boston,AM 02114-2017
www massgov/dia
WWorken'Compeasatioji Insurance Affidavit:Builders/Contractors/Electridans/Piumbers.
TO BE FILED WITH TBE PERMIITBVG AUTHORITY.
Applicant Information Please Print Lee16
Iy
Name(BusinesstOrgamzationlladividual): /Y(/J• iV Ptic�� e
Address:_
city/state/zip: M Lf-1 v en. M- '9 Phone#: �j 7� C17S�fJ=CJ b
Are you an empmyerr Check the appropriate box:
l aemplOyer with !ft-4 � EOdier
project(required):
empbyees(full aod/orpart-time).•
ew constriction
2. i am a sole proprietor or permaship end have no
my cerin rty WO wmkm'comp.msmance required]�le yees working forme in emodeling
3.❑I am a homeowner doing all work myself[No workers'comp.immu not required-)t emolition
4.❑]ort a homeowner and will be hiring cmaactors m conduct au work on my property. I will uilding addition
®sore that aU cmmactors either have workers'co peosstm msunuoe mare sole ectrical
proprietors with uo employees. repairs or additions
5. Ismer 12.E] or additions
❑7hese sub-conmacmrs have 'kava hired the aub.conmactore listedmthe attachedshea
®ploy=mad have workers'comp.asnamemt ofrepairs
6-El We son a corporation end its offiws have exercised thetrright ofeaerrption per MGL c er
152,§1(41,end We have no employees[No workers'coop.mstnaoce required,]
'Any sppliwnc ox that checks b #1 most also as am the section below showing their worker'compensaym policy mfmmstim.
Homeowners who subndt this at6dmt indicating they are doing as work and then hire outside concretions anon submit a new affidavit indicating such
'Contractors that check this box must attacked an additional shed showing the name offfie subcontractors and state whether or not those metes have
employees. ifthe mbcmmadors hive employees,they mint provide their workers'comp,policynamber.
low an employer that is providing workers'compensation insurance for my employees Below is tbe
tpoliey and job site
ajormatian
Insurance Company Name: C v,R 40
Policy#or Self-ins.Lic.#:Af C 6 6 cT 6 S:2 J G3 / 6
Expiration Date:
Job Site Address:_ /S C �4,y l�F yr city/stare/zip:S,�y L/,(�- -,7( /�/Y
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby ere derlhe pater pen of is that the information provided above it tree and correct
Si
67;7 3 tF�s �t 6 ate:
Phone
acral ase oitJJt Do not write fn Chir area to be rn lcted b
rep y city ortown ojlfcial
City or Town: Perldt/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#•
i
a'
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 ofhire,
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 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."
t
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 sub-contractor(s)name(s),address(es)and phone number(s)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 amopriate 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 511 out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permitthoense number which will be used as a reference number. In addition,an applicant
that rust submit multiple permit/license 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 may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit most 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 bun 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, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
07YOFSALEA4 MASSAQYGBETP.
BULDMDRPaMrr
12o Wasfm�x,7�S7RBef,3mJhoat
skr.(978)745-mss.
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Construction Debris D1sposa/Aff1dav1t
(required for all demolition andrenovation work)
In accordanoe with the sath edition of the State Building Code, 780 CMR,Setdon 111.5 Axis,
and the provisions of MGL c40, S 54; Building Permit N is issued with the
condition that the debris resulting from this work shall be disposed of in a properly l kersed "
waste deposit facility as defined by MGL c 111,S 15M.
The debris will be transported by: /
/9t--1Soh/ //Z//rCa� �G/,i✓. �G5/ r J
(name of hauler)
The debris will be disposed of in:
OU IL s ��
(name of facility)
(address of facility)
Signature of applicant
7 l&
Date
"Y
Aulson Roofing, Inc.
49 Danton Trove
Methuen,Massachusetts 01844
Tel:(978)975-4500-Fax:(978)685-0753 I
Proposal BY EMAH,ONLY
kenOrichardHoufandcomoanv com
roposal submined to: phone pate
Richard J Louf&Company (508)962-8337 May 31,2016
Street Job Name Comact Penon
PO Box 2012 Ken Louf
City,State and Zip Cade Job Location
Salem,MA 01970 15 Lynde Street,Salem
We are pleased to quote you on thefollawfng:
' This estimate covers the following areas: porch ceilings and edge metal
* Remove existing edge metal at rear sides and rear of building. '
* Install new edge metal and flash properly.
* Install new solid vinyl soffit panels over entire ceiling of all porches at top floor.
* Provide standard Aulson Roofing,Inc.TWO year workmanship guarantee.
* Remove all outside job related debris.
* Carry all necessary insurance,workman's compensation and liability.
We propose hereby ro furnish marerlals andlabor,complete in accordance with above spechcanon,far thesum of. $72,285.0
Twelve Thousand Two Hundred Eighty Five Dollars and no cents. iUjOuc ca
Terms and Conditions.
1. Payment-Payment terms areas follows:
*Deposit of 1/3, 1/3 when half done;balance upon substantial completion
2. All monies due and payable shall accrue interest from the date such payment may be due
at a rate equal to 1 1/2%per month.
3. Permits,Fees,and Notices-Aulson will secure building permits and other permits.The
customer is responsible for the cost of said building permits and other permits,as well
as governmental fees,licenses and inspections.
4. Preparation-The customer shall be responsible for preparation and cleaning of interior -
of the building,specifically the attic as small particles may fall into the attic from the roof.
5. Delay-If there is a delay at any time in progress of the work by an act or neglect of the
customer or contractor,change order,casualties,fire,weather or by other unavoidable
delays,the completion time shall be extended for a period equal to the time lost by
reason of such delay.
6. Changes-Changes in the work may be accomplished after execution of the contract,
and without invalidating the contract.Any alteration or deviation from the above
specifications involving extra costs will be executed only upon written orders,and
will become an extra charge over and above estimate.
7. Insurance-Customer to carry fife,tomado,and other liability/homeownees insurance.
S. Disputes-Should any dispute arise between the parties arising out of this contract the
dispute shall be submitted by one party to the other in writing and parties shall make a
good faith attempt to settle such dispute.If such dispute cannot be settled the venue to
resolve any disputes shall be in Lawrence,Essex County,Massachusetts.This
agreement shall be interpreted and enforced according to the laws of the Commonwealth
of Massachusetts.In the event Aulson is a party to any legal proceeding on account
of any acts or conduct of the Customer,Customer agrees to pay Aulson all reasonable
expenses including attorney's fees incurred in connection with the legal proceeding.
9. Claims and Back charges-Customer shall notify Aulson within seven(7)days,in writing,
of any circumstances arising from the performance of the work herein described,which
reasonably may be anticipated to result in a claim or back charge to Aulson.Aulson
shall not be liable for any claim or back charge where Aulson has not been notified in
the manner as set forth above.
10. Waiver of Claims-the making of final payment shall constitute a waiver of claims
(except as to the workmanship guarantee)by the customer.
11. Indemnification-Customer indemnifies Aulson from any damage or delay that is not
caused by Aulson or their negligence.
12. All contractors and subcontractors must be registered by the administrator.The name,
social security number,address and registration number of the contractor is:
Aulson Roofing,Inc.
Tax ID#04-2549953
49 Danton Drive,Methuen,MA 01844
Registration# 111969
13. Customer represents that he/she is the true owner of the job location.
14. Customer has a three(3)day cancellation right as stated under M.G.L.Chapter 142A,
Section 2,Subsection(9)as may be applicable.
15. In case one or more provisions of this proposal or any application thereof shall be
invalid,unenforceable,or illegal,the validity,enforceability and legality of the
remaining provisions and any other application thereof shall not be in any way be
impaired.
Estimated by:Bruce Tinkham
Aulson Roofing,Inc.authorized signature
Above specifications and terms and conditions are satisfactory and hereby accepted.
Payments will be made as outlined above:
W'ae
contract if ere any blank spaces.
- �
r D o acceptance
Note:This proposal may be withdrawn if not accepted within thirty(30)days.
2