19 OLIVER ST - BUILDING INSPECTION (3) 'rhe Commonwealth of Massachusetts :;ySPEC'� ECEIV O TY
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Board of Building Regulations and Standards AL 1
Massachusetts State Building Code, 780 CMR Rug ReviseJ.Nm 1011
Building Permit Application To Construct, Repair, Renovate AR
One-or 71vo-Family Dwelling
This Section For Official Use On ' `
Building Permit Number Date.Appli s
Building 0lrichd(Print Name). _- Signature
SECTION t:sift INFORNIATION`
1.1 Property Address- 11 Assessorsblap&Parcel Numbers
� ) I1..1 a Is this an accepted street?yes no Map Number Parcel Number .
1.3 Zoning Information: IA Property Dlmensloto:
ZoningDistdct PruposedUse. - _ Lot-Area(sq ft) Frontage(4)
v LS Building Setbacks(R)
Front Yard, Side Yards`- Rear Yard`'
Required , Provided Required Provided ... Required., Provided_
1.6 Water Supply:(M.G.L c.40,§SJ) 1.7 Flood Zone Information: 1.8 Sewage DLsposal System:
Public O Private O
Zone: Outside'Flood Zone? Munici dis tern`O
_ Cheek,U' O. t�OOn Sita P�� ..
SECTION2: PROPB(lTVOWNE!!M
2.1 wner;of Recce: 6 /jy4/' S
N)me(Print) .. .- �+ t:rtyr State,ZIP
�SAIQ h7 �G S S', D77 7Dr
No.ami Strcet - Telephone - Email,Address
SECTION 3: DESCRIPT1ON OF PROPOSED WORW(cheek all that apply)
New Construction O %Eiisting Building O Owner•Occup)ed O Repairs(s) O Alteration(s) O Addition O
Demolition 17 Accessory Bldg.O Number of Unin . Other O Spccitr
Brief Description of Proposed Work-: QrY7 vG 147V-1.1 ' S '
a �
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SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: - Official Use Only, -
Labor and Materials
1. Building $ / 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical g O Standard Cityfrown Application Fee
O Total Project Costs(item 6)x multiplier x
3. Plumbing SaDC03
her Fees: S
4.Mechanical (FIVAC) S
S.Mechanical (Fire S TotalAll Fees:S
Su ression) -
No. CheckAmount: Cash Amount:
6.Total Project Cust: SJ3 in Full ❑Outstanding Balance Due:
('I,rz t o Tl) co tJT 1 1(0
%.i.S`r) �„;.;.,•, SECTION 5: CONS'FRUC ION SERVICES
5.1 ConsMr'ctim/i Supervisor License(CSL) b (f�.c� c-4—rhe
YGv/ h�C,Qr t License Number Expiration Date
Name a ]�L_fWIJC-. t.r ' J List CSL Type(see below) `
till/t f S i/G �t S f– Tye Description .
No.and Street
Unrestricted Buildin u”
to 35,000 cu.R.
Restricted 1&2 Farmly Dwelling
Citylrown,State,ZIP M Wasmay '
RC RooOn Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address FD Demolition
5.2 Registered Home Improvement Contractor(HIC) / 7 Z��� –�
)/4 v L' 6y� HIC Registration Number Expiration Date
ti1C Cump�ny Narr/9 or 1115 Registrant arae
No.mrd§tmetEmail address
5*&� 06- ZL- 715`=329
Ci /Town State ZIP Tel ora
SECTION 6:WORKERS'.COMPENSATION INSL!4"CE AFFIDAVIT(w. . ::.c.llli g 2$C(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 Isbuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION lot OWNER AUTHORIZAT[ONJO BE.COMPLETED,W HEN',
OWNER'SACENTORCONTRACIORAPPLIESFORBUILDIN .PERhIIT`
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
1G/grip, F0v�6,-t
Print Owner's Name(Electronic Signal ) Dam
SECTION 7b:OWNERt ORA UTHORIZED 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 Autho zed Agents N (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(NIC)Program);will Lag have access to the arbitration
program or guaranty fund under M.G.L.c. 142A. erimportani rnft—ormafon on the HICYrogram can 5e loon a
+vww.me4ss.eov.'ort Information on the Construction Supervisor License can be found at www.mass.aov;dns .
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. R.) *s .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of h:dObaths
'type of heating system Number of decks/porches
"rype of Cooling system Enclosed Open
J. "Total Project Square Footage"may be substituted t'or"Total Project Cost'
� R
ucm ed0Insured Estimate
"Tire fight hand for the Job"
�.� Date Estimate#
11/11/2015 466
Name/Address Project Address
Mane Fouhey 19 Oliver St
Salem,MA
Description Total
The following Estimate for the property located at above address.
The following paragraphs explain the work that Mendez Home Improvement will carry out.
SCOPE OF WORK:INSTALL CLAP BOARD SIDING
INSTALL CLAP BOARD SIDING(white cedar prime)IN FRONT OF THE HOUSE(OLIVER ST
SIDE),DRIVEWAY SIDE,LEFT SIDE OF THE HOUSE THE LONG SECTION.
•Remove old aluminum siding 925.00
•Install new Tyvek
•Install new flashing on top of windows and doors
•Install new ice water shield 4"wide around window and doors
•Install new clap board siding(white cedar prime). 11,000.00
•Install new vertical trims on the comer sides 575.00
•Install 1"x10"prime pine horizontal(Approx 130 lining ft) 725.00
Completion means satisfactory cleanup,removed of debris
Payment terms:
$5,000.00 down payment
$5,000.00 upon the job is in progress
$3,225.00 upon the job is completed
Mendez General contractor Home Owner
Walter Mendez-Sales Manager
www.mendezcontractoncom
NOTE: Any alteration will be approve by all parties before is done Total
these may result an extra charge. $13,225.00
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual); .t
Address: ` I Urs r /,-( vi e
City/State/Zip: Phone#: Q
Are y an employer?Chec the appropriate box:
Type of project(requir d):
1. I am a employer with-_employees(full and/or part-time).*
7. New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. Remodeling
any capacity.[No workers'comp.insurance required.]
3.F-1 I am a homeowner doingall work myself 9. ❑Demolition
y [No workers'comp.insurance required.]t
4.EJ I am a homeowner and will be hiring contractors to conduct all work on m property. 10❑Building addition
Y P eery. I will
ensure that all contractors either have workers'compensation insurance or are sole 1 I.Q Electrical repairs or additions
proprietors with no employees.
i�I am a general contractor and I have hired the subcontractors listed on the attached sheet. 12.QPlumbing repairs or additions
These sub-contractors have employees and have workers'camp.insurance.= 13.Q Roof repairs
6.❑we are a corporation and its officers have exercised their right of exemption per MGL e. 14.Q Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
Any applicant that checks box#1 must also fill out the section below showing their workers.'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
(Contractors that check this box must attached an additional sheet showing the time of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: S Q- �''� V-X S Q
Policy#or Self-ins.Lie.#:--b//� �"I V % /3f— Expuylon Date:
Job Site Address: City/State/Zip:
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 oft s statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage venficatio
I do hereby certify and penalties ofperjury that the information provided above i true and c 91rrect.
Si ature: Date:
Phone#:
r,
Official use onl D no write in this area,to be completed by city or town ojficiat.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#•
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 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 pemtit 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 permitilicense 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 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 bum 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
T— Da CK TO Message
LILIA-1 OP ID:KMC
WDDNYY
CERTIFICATE OF LIABILITY INSURANCE 1 °"1"10/26/20156/2015nols"
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: H the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. U SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder In lieu of such endorsement(s).
PRODUCER NAVE: John J.Doyle Insurance
John J Doyle Insurance Agency 97&TT/fi344 No,978.7T7A804
35 Constitution Lane Ste 2H
anvers,MA 01923 WD%w:kevinCWdo leinsurence.com
In C Lawrence
INSURER(s)AFFOROINa covEMOE NAIc B
INSURER A:SafetY Insurance 39454
INSURED I-Iliana Mendez
Mendez Home Improvement 1"s°REN e`
16 Walden Street INSURER C: -
Lynn,MA 01905 INSURER o:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REOUIREMENr, 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,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR TYPE OF INSURANCEPOLICY NUMBER fififfififoplyYYY) (M""YM users
GENERAL UASILITY EACH OCCURRENCE $ 1,000,00
A X COMMERCIAL GENERAL LMBILTIY BMA0019296 03MWS 0326/2016 PREMISES Ea aanance) $ 100,00
CLAIMS E O0001F1 MED EXP(Arrydne pmdon) $ 10,00
PERSONAL&ADV IWURY $
GENERAL AGGREGATE $ 1,000,00
GENIAGGREGATE UMIT APPLIES PE R: - PRODUCTS-COMP/OP AGG $
X POUGY PRO- LOC $
ECTAUTOMOBILE LMBIUtt $
ANY AUTO BODILY IWURY(Per Person) S
ALLOWNED SCHEDULED BODILY IWURY(Pmd1) $
AUTOS AUTO$
HIREDAUTOS AMOK OWNED A DE $
UNeREI LA UAB OCCUR EACH OCCURRENCE $
am-sum CLAIMS AMD a AGGREGATE $
DED I I RETENTION S
WORIWRSOOIMPIeR (TION
AND EMPLOYERS'UABIUTYORY UM& ER
ANY PROPRIEfORIPARn1ERlEXEC1/iNE YQ /A HUB-51391341-9-14 03/12/2015 03/12/2016 EL EACH ACCIOEW S
OFRCE EMBER EXCU.OM?
(Ntldenaryl.Nin EL DISEASE-EA EMPLOYE $
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DESCHIPTION OF OPERATIONS EeIwv EL DISEASE-MUCY UMR I S
DESMMMOFOPSMnONS/LO ROM/VEHICLES(AnxA ACORDtpt,ACUItlanM Ranmlm SCM1W4Hmom apace is Nqulyd�
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
Western Ave THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Lynn,MA ACCORDANCE WTIH THE POLICY PROVISIONS.
AUTHORIZED IIEFRESENrAME
Kevin C Lawrence
®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The ACORD name and logo are registered marks of ACORD
CITY OF SALEA AidSSACHL SEnN
BLuDiNG DEPAitnrNT
120 WAStmcwNS7mT,3IDFLooR
TSL(978)745.9595.
FAX(978)740.9846
KIIvJBERIBYDRISQ7LL
MAYOR Tkcarns ST.Pn=E
DIRECTORoPPuBucrRcFmY/Bu[Dnac commissiomit
Construction Debris Disposa/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 c40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit 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)
l
(address of facility)
Signature of applicant
Date