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64 MOFFATT RD - BUILDING INSPECTION g1 The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code,780 CMR ;. Revised Mar 2071 Building Permit Application To Construct,Repair,Renovate Or Demolish a („n One-or Two-.Family Dwelling This Secy For ODio U.ss Only, Budding Pormh Nnntber_ Date Appliatl ' `4 ` BuilckugOtftCial(Prihttame) Signature Date n SECTION I:sITe PWORMT10N (Y� 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers G y InDFirA7T Rq IJ a Is this an accepted street?yes no Map Number Parcel Number 13 Zonine Information: 1.4 Property Dimensions: Zoning District Proposed Use Loi Area(sq ft) Frontage(fl) 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: Public❑ Private❑ Zone: Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes13 SECTION 2. PROPERTY OTVf+tERSHiP' 2.1 Owner'of Record: TiomAs A. CAMPSZu- 0i9 ?0 Name(Print) City,State,ZIP A20"L4'ATT)?D Q7-,�, 5(,-9739 No.and Street Telephone Email Address - SECTION&DESCRIPTION OF PROPOSED WOR10(ebeck anthill apply) New Construction Cl Existing Building❑ Owner-gccupied Repairs(s) Alterafion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify: BriefDescription of Proposed Worle: *t9_ 1A) A-rVIZ A A A4A - t t.,A L L- -$. V 5'rAi_L_ #Vr=tu 2Aic) ' 14 OAJ6, klguj f Aa =AfSTALL, E3 G SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: 0111eial Use Only (Labor and Materials 1.Building $ 1. Building Permit Fes:$ Indicate how fee is determined: 2.Electrics! $ ❑Standard City/Town Application Foe D Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2: Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Tonal All Foos:$ Check No. Cheek Amount: Crib Amount: 6.7 Project Cost: $ "�, (fid©, Oe 0 Paid in Fall O Outstandin Balance Due: m17\"ttt 0lj2So SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) --,g 61 3 OI-O/-l7 us /Vy SG a License Number Expiration Date Name of CSL Holder !�M List CSL Type(see below) tl ENN, J61 5 Gr 62 Type Descviptiat No.and Street a d00 � O`�/© U Unrestricted Family u el 35,000 �% (o R Restricted 1&2F Dwelling City/I'own,State M I Masonry RC Roofine Covering WS window and Siding SF Solid Fuel Burning Appliances I I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(RIC) 1D,o, �i53 S-a$' I� JW FL D'9 e47/.15 t 2U6 7f'011,1 LL HIC Registration Number Expiration Date Inc Companye or HIC Registrant Name, -R44 C/ENAIit/6s G1/2 .4JSi1r✓DMfLo�t� A4Sn/. GOHJ N d Street Email address s�oon� 9;'r-,-5- y�l Ci /Town Stfite,ZIP Telephone SECTION&WORIMR3°'COMPENS TT<)V MSURANCE AFFIDAVIT(NLGJ-c.152.§25C(8)) 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...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT QR CONTRACTOR APPIJES.EOR II ING 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:OWNEW 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 Authorized Agent's Name(Electronic Signature) Date NOTES: 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 wmvw.mass.eov.'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 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"' ' 07Y 4F SALEKMASSACHMM, BEILUMI)WAAMM M WA9R XKSnW,,30RM 1kLMAM. H111�BRL8YL5tLS�IZ F,AX7�49Bt6 WYCR Construction Debris Disposa/Af f"daW (required forail demolition and,.renovation work] in accordanm with the sbA edition of the State Building Code, 780 CA4% Section 111.5 Debris; and the provisions of MGL c40,S 54, Building Permit A! is issued with the condition that the debris resulting from this work shag be disposed of in a properly iioensed waste depos#facility as defined by A46L c 111,S 150A. The debris will be transported by. zac_ < (name of hauler) The debris will be disposed of in: (dame of faciiity) (address of facility) Signature of applicant Date �\ The Commonwealth of Massachusetts Department of Industrial Accidents 1 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: X-:rZOrS (MUST P(lGfij`f)/(/ LLG Address:3y (�/✓/1//�/rt^S �+� City/State/Zip: 143 © Phone Are you an employer?Check th appropriate box: Business Type(required): 1.[ErI am a employer with employees(full and/ 5. ❑Retail or part-time).* 6. ❑Restaurant/Bar/EatingEstablishment 2.❑ I 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] 8. ❑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 ]0.❑ Manufacturing no employees. [No workers' comp. insurance required]* 11.F] Health Care 4.❑ We are a non-profit organization,staffed by volunteers, with no employees. [No workers' comp.insurance req.] 12.0 Other *Any applicant that checks box NI 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 NI. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information. Insurance Company Name: TLS U f, rJG G Insurer's Address: ay— i o—b5 rE e fir( City/State/Zip: ;kx 5 not/ AyA o/9 60 Policy#or Self-ins.Lic.# -:t H U K-ISs I i4al q to;S ) -2— 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 certi under the pains mrd penalties of perjury that the information provided above is true and correct. Signature Date Phone#: c .-)8 — 5.31 — d e I ) 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 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." 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. i 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 f Il 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 Fenn Revised 02-23-15 i Me10' s Construction LLC 34 Jennings Circle Peabody, MA 01960 BBB Telephone: 978-531-0811 - E-mail: FaustinoMelo@msn.com _T Faustino Melo, General Manager Unrestricted Mass Builders License No. 80393 Contractors Registration No. 108953 The volae of smart easiness' MEMBER www.MelosConstruction.com Pro osal Submitted To: Job Description: a as A, ars be 1 71Z' l/Ja¢er caM c :r, Address: Date of Proposal: A rH ,�. MA At, rz"ifi Phone Number: E-Mail 417- tom- 973 We Hereby Submit Specifications and Estimates for: 1 -'Llq Wfjer i1mckge -`' t 1f 5 G r0% 411P ren winr�.ntwr5 have be?r rr�r d. o,,J !e4 erg. �+m roif/e t,/I / re /p A-D)ecru n;,k lA�ill .rP y +o be ave dli rinck Ile 6r% /or YAP ruryier /baf� in Sfa/gfiIo�,n� . _ r4�-o- rr inaul�rl,'on. 4nd O R bber ro"oF W:// lx in5fca/,Ed. 1 r KPr- r/oOM 1 � -11'M u i W�!tl loe replaced Luff /1PWcL_e t-,e5 l r14e or- 4 P 7Pr i W �l -W.p le e47. A�er i er W'Y he v mpe/roc/C, acr) Aran ro ofro eSf- Mf weill ct kd. Good o#4 Ar;new 4nd e6nk coaf �%li3�t Aa.n /v1e/O.J O.tSfr.ic/ro/1 � :5 /a'S Si. Q {pr Arrn:+s needed fo cam We the -kcht unciper dehree rerctnvct uri;)S (Sckni-� W i} be !tins+e7_1W . _ Extra work in which an additional cost will be added to the above price. Replace Rotted Rootboards Gutter Repairs Remove Aluminum Siding _ Relead Chimney(s) Install Skylight(s) Remove Old/Rotted Wood - Replace Facia Boards Repaint chimney Install Garage Roof Install Ridgevent Install Azek Board Install Insulation Install Roof Louvers Install Window Trim Install Tyvek Paper Install Aluminum Gutters Install Shutters Cover Aluminum Windows Install Aluminum Downspouts Remove Vinyl Siding Repair Vinyl Siding _ Install chimney cap Porch Repairs Rebuild Chimney , Total Amount for Additional Work We propose herby to furnish material and labor-Complete in accordance with the above specifications for the sum of b4_hf Aawsonc/ c6/ //Qe--T ($ Authorized Signature: Date: A. O 1 Fi Installation of Payments: Payments to be made in thirds.First payment will be made prior to the start of the job.The second payment will be made during the middle of the job timeline.The last payment will be made once the job is complete. Any alteration or deviation from above specification involving extra costs will be executed only upon written order, and will become and extra charge over and above the estimate. All agreementsare contingent upon accidents or delays beyond our control. PQyt l.} 01thone 401ASOt(Nd i//WO AUrld'YC/ Acceptance of the Proposal: k,;,5 10Ceo /r)Ar)e. 41- ia CJ�IpOSc The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified,payment will be made as outlined above. Payments are to made as per requisition and or invoice. The proposal may be withdrawn within 20 days. Date of Acceptance: S ` 12 " 1 G Signature: ^ FUC No:G 399GOi052 a} r FJ/r��nrurrrrroea/N c/.'r'i1�rs::ac/rree/!.' Office of Consumer Affairs&Business Regulation 1.,icevse or 3e8iSta nt'son vapid for i odividul M only is HOME IMPROVEMENT CONTRACTOR before the expiration dote. lfffoued return-to: v— W Registration 108953 Type: Office of Consumer Affairs and Barsiness$6gaintion 2 ' r'-Expiration 826/2018 Ltd Liability Corpor '<D 1i'ark Rlaae s;U1W 5170 g Basten,WWA 02116 'S CONSTRUCTION raustino Melo f — i 34 JENNINGS CIR. Peabody,MA 019607777- Y UaCersecretary _ Not Valid Witt hel signature ....: . ... . :. Massachusetts-Departmento'Public Safe._; -.-.Unreadc£ed-Buildings of any use group which Board of B iding &eguiafions and Standards3 . cot>oafn fess than 35,®f1Q cfalsic feet{491st)of , enclosed space. -- License.- 3 93 B�W�TY844®1V 1.Y�8Yaf�8i�RM� - •� `a f.�• I" 819U ,. faifuni to poste a current e0tion afthe Masachusetts � + illI{+ � State Building Code Is cause for revoeg ion afthis lieense. E. piratior, � ordmissioner. _. .® 18112017._ For DPS Licensing informationsrBFb wWWMass16v/DPS . ._.. -'. -ACOR®®® CERTIFICATE-OF LIABILITY INSURANCE 0(,TEc�910.0YYYY) 12 .10 15 THIS CERJIIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY-AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS ,".5IFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES I d.,THIS•'CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER($), AUTHORIZED kSENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER. IMPORTANT. ff the certificate holder is an ADDITIONAL INSURED,the policy(Es) must be endorsed. if SUBROGATION IS WAIVED,subject to I611erms and conditions of the policy,certain policies Bray require an endorsement. A statement onthis certificate does not confer rights to the !.•certificate holder in lieu of such emlorsemen s) PRODUCER NAME;ACT C3r109 Pinto North Shore Insurance, Inc. NAME; Carl 531-2755 Fax N (978) 531-2229.. . . . 111 Foster Street - - - - -- Ao n : Peabody, MA 01960 INSUR S AFFORDING COVERAGE HAIC9 INSURER A:Northland Insurance Co. - - - nsusm - _ ". INSURER B:Pro ressive -Casual 'Ins. - Melon. Construction Lle tNsuRERc:Travelers IndemnitV of America 34 Jennings Circle INsuRFRo: - - - Peabody, MA 01960 INSURER E: INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:- - - THIS IS TO CERTIFY THAT THE POUCES OF INSURANCE USTED 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,- EXcLUSians AND CONCITIONS OF SUCH POLJCIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. LNS'rRR TYPE OFINSURANGE ODL SUER POULY NUMBER - MIDDYYNAJDd IXY LIMITS oBNERALLiAe1LnY Y Y MP826983 12/4/15 12/4/16 EACH OCCURRENCE S 11000 000 X. COMMERCIAL GErvEMLLVi9EiTY _ - . DAMAGES TO RENTEDPREMIS S 100,000 CUAMStMADE.a OCCUR MEDENP(A,yamparsas). $.' S 000 PERSO NAL&ADV INJURY S 1,000.000 GENERAL AGGREGATE s .2 00,000 -GEN'LAGGRE 7.,LIN9TAPPLIES PER PRODUCTS'-6OW10P AGG 5' _.2,000,000 POLICY. PEr RO- LOC A. _. - ... .. . - _.. _ S AUTOMOBILE LIABIUTY C E CLE L 1 .. .. . . Y Y 02383499-0 9/21/15 9/21/16 �aau;me S 1 000 ,000 + X ANYAUTO BODILY INJURY(Per paron) SALLOVONED " AUTOS SAUTCHEDULED BODILY INJURY(P.,aeltlen0 S -- HIR EOAUTOS _NON-OVMAUTO ED PReOPPEE PAIAGE S' ..1,000"000 S UMBRELALIAB OCCUR - FACM OCCURRENCE. 5 IXCESSLIAB"' CLAIMS-MADE_- - AGGREGATE S J 2 :" DEO <,:RETENTIONS._. _. . ._ :. :?•. . _. S-.. ..'., NORKERS' PETSATION -Y- IHUB7814M46512 - 12/4/15 12/4/16 WC' ATU- OTH. - 'ANf)EMPLOYEItB'LfA01L17Y YINCRYRR ANY PROPRIETORIPARTNER(E)TCUTNE EL.EACH ACCIDENT 5 ,1 OOO QOO OFFICERMiEMBER EXCLUDED? dssume NIA _ (Mantlwalt,NH)antler - EL.DISEASE-EAEMPLOY S 1' 000,000 ' rcya8,- DESCRIPTION OF OPERATIONS below s EL.DISEASE-POLICYLA7R .S 1,000,000 _ DESCRIPnONOFOPERRTIONS!LOCATIONSIVEBCLES (Attach ACORD10I,AdTNanai Romft SchedWe,irmomop?cetmgWrstl) - - CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLEO BEFORE - -- _ -- - - THE. EXPiRATION' DATE THEREOF, NOTICE WILL BE DELIVERED IN -- - - - ACCORDANCE WITH THE POLICY PROVIS NS. AUTHORIZED REPRESENTATIVE _. - Carlos Pinto{_. ' 01966-2010 RD CORPORATION. All rights reserved. ` ACORD 25(2010105) The•ACORD'nahne and logo are registered marks-of ACO�D - Phone: - Fax: E-Mail' .'