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11 PRESCOTT ST - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR, 7h edition OF SALEM Revised January \ Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Numb Date Applied: Signature: a/l5f L/ Building Commissioner/Inspector of Buirdings Date SECTION 1: SITE INFORMATION 1.1 Property= 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 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? Check if yes[] Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHW 2.1 Ownert of Record: Name(Print) Address for Service: c� . y tzz- Signatureture Telephone SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s),52c, Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work 2. vz CA "vtic�,c��.. - Vis^ `� (r •Q,tiy. - opt tJe � SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials) Official Use Only 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: $ / ,/I 4.Mechanical (HVAC) $ List: / 2-6-6 5. Mechanical (Fire Suppression) $ Total All Fees:$ 6.Total Project Cost: $ OO Check No. Check Amount: Cash Amount: ❑Paid in Full ❑Outstanding Balance Due: S C-dT e . "n'le�,YeAC64 SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 1 of)t-I ` 2- (�C,-V\v,�g License Number E pir/a-tio Dale Name of CSL-Holder List CSL Type(see below) 4 LOS �P��c lti\ �� VV1�bcV — Address _ Type Description U Unrestricted(up to 35,000 Cu.Ft.) �� R Restricted 1&2 Family Dwelling Signature ^� M Mason Only 7Qr-CD'>j\` 1� `L RC Residential Roofing Coverin Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D I Residential Demolition S�Registered me Improvement Contractor(IIIc) ' J� 3�� HIC Company Name or HIC Registrant ]�ame Registratmn Number S Address �/- �i�� Z `� . Ziration Date Signature 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 ......... No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, C� _\J.tr\ �-�_S , as Owner of the subject property hereby authorize \ z\C to act on my behalf,in all matters relative to work authorized by this building permit application. J Signature of Owner Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION I, ` v�y\\\ ��.,75'l\ ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behal . Jr Print Name nn Signature of Owner or uth ri gent Date (Signed under the pains and penalties of 'u 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,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" CITY OF S.UEM. AxSSACHLSETTS • BUILDING DEPARTMENT • 130 WASHINGTON STREET,iso FLOOR 0j TEL- (978) 745-9595 FA-X(978) 740-9846 KIN[BERLF-Y DRISCOLL 1i1AYOR THoh1AS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNGCO% IISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A i licant Information I . Please Print Legibly Name(Busiixsx Organization/individual): P e 4, 0, ., �- Address: S City/State/Zip: `{t �, C�4� t Phone#: C Are you an employer?Cbeck the appropriate bort: Type o'project(required): IlAilTam a employer with 7 4• ❑ I 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. 7• ❑Remodeling ship and have no employees These subcontractors have 11. ❑ Demolition working for me in any capacity, workers'comp.insurance. 9, ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.El Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions myself[No workers'comp. c. 152,§1(4),and we have no 12,❑Roof repairs insurance required.]t employees.[No workers' 13.C]Other comp.insurance required.] •Any appliram that chucks box#1 must also fill out the section below showing thcu worker'compensation policy information. 'I hmwowrxn who submit this affidavit indicating Iln are doing all work and then hire outside contractor most submit a new amdavit indiesung such =Contractor that check this box mwt attached an aaditiorsl sheet showing the name of the subcromtracbr and their worker'wrttp.policy information. I am an employer that is providing workers'compensation hnsurance for my employees. Below is rhepolicy and Jab site irjarmurian Insurance Company Name: c�`VNWI . Ypp kk --�y-a��C �� t�M V\r p Policy#or Self-ins.Lie.#: L�- c�y N ��nt $ 3 Expiration Date: t 26 .��g_-pr r Job Site Address: ,k �1�5C e7 C S o -+S _() 7C) City/State2ip: c7! Artach 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 S 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 5250.00 a day against the violator. Se 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 lid the pains and penalties of perjury that the iufarmadoa provided above is true and correct. -� I/ YYY Phone U -%st-',� Oficial use only. Do not write in this urea to be completed by city or town official City or Town: Permit/License# Issuing Aulhurity(circle one): 1. Board of Ilealth 2.Building Department 3.Cilyrrown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other -____ ___ Contact Person: Phone#: [ CITY OF S.UEM, NL-ksSACHUsETTS ' BL:ILDLNG DEPARTMENT • 120 WASHNGTON STREET, 3'0 FLoop ` TEL (978) 745-9595 FAX(978) 740-9846 KI.,iBERL.EY DRISCOLL. MAYOR THoNw ST.PIHRRE DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG CO\QMSIONER 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 : c, 0 (name of fa Alit Y) �1/l y 1r 9�i1 \, G— (ad ess of facility) signattire of permit applicant date JcbrisalLdK: 1 PRE S TO C.4RPPNTRY • PAINTMC, ROOFiNr 8 Yorkshire Road HIC#153422 - CSSL #10045 Marblehead, Ma 01945 FID#20-5794889 (978)356-5419— (866)PRESTO-7 www.prestoroofing.co PROPOSAL SUBMITTED TO: WORK TO BE PERFORMED AT.• Christine Weis 11 Prescott street 11 Prescott Street Salem salem, Ma DATE OF PROPOSAL: (978)594-0615 2/15/11 Having visited and examined the site of the proposed project and being familiar with the conditions relating to the construction, including the availability of the materials and labor, Presto Painting Company hereby proposes to furnish all materials, labor, equipment and supervision required and to complete the work in accordance with this contract document. CARPENTRY: Kitchen 1. Replace two windows, <one bay windows and one double hung> 2. Rough opening to remain the same 3. Finish the interior&exterior trimmings with stock. COST: $5,700.00 OTHER COMMENTS: Care will be taken while working on project. All work to be finished in a timely manner INSURANCES: FULL PROPERTY AND LIABILITY INSURANCE IS THE RESPONSIBILITY OF PRESTO PAINTING&CONSTRUCTION INSURED UNDER NATIONAL GRANGE MUTUAL INSURANCE FULL WORKERS COMPENSATION COVERAGE INSURED UNDER GRANITE STATE INSURANCE COMPANY PAYMENT SCHEDULE: Payments are to be made as follows: One third upon beginning of work, one third at mid-completion of work and balance including any extras in full when work is complete. I ACCEPTANCE OF PROPOSAL: The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Payments will be made as outlined above. P �r Authorized Signature PrSo04tingL&Construction Signature ) � Christine Weis 11 1,f_' f4-Street, Salem Date of Acceptance "HIGHEST QUALITY AND CLEANLINESS-- YOUR PRODUCT OUR BUSINESS" f "� CERTIFICATE OF LIABILITY INSURANCE DATE(MMIDDIYYYY) 1131 3 2011 PRODUCER Phone: 508-651-7700 Pax: 508-653-0089 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Eastern Insurance Group LLC - Main ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE 233 West Central Street HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR Natick MA 01760 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Main Street America Assurance 9939 Presto Painting & Construction INSURERB:Safet Insurance Co an 8 Yorkshire Road 9454 Marblehead MA 01945-1028 INSURER G:National Grange Mutual 4788 INSURER D:Granite State Insurance CO INSURER E: COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO TEE 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, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD - L POUCY EFFECTIVE POLICY EXPIRATION LTR ° S POLICY NUMBER D MMID DATE IMMIDD)YYYYjLIMITS A GENERAL LIABILITY MP089800 11/15/2010 11/15/2011 EACH OCCURRENCE $1,000,000 X COMMERCIAL GENERAL LIABILITY DA ETO NT. D PREMISES Ea occurrence $ 5001000 CLAIMSMADE OCCUR MED EXP one pemon) $10,000 PERSONAL B ADV INJURY $1,000,000 GENERALAGGREGATE $2 000, 000 GENT AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2 000 000 POLICY X PRO- LOC B AUTOMOBILE LIABILITY 6203010 4/5/2010 4/5/2011 ANY AUTO COMBINED SINGLE LIMIT (Eaaccident) $ 1,000,000 ALL OWNED AUTOS X SCHEDULED AUTOS Br peneor) (Peer BODILY INJURY $ X HIRED AUTOS X NON-OWNED AUTOS (Per accDILY dent)RV $ PROPERTY DAMAGE $ (Per accident) GARAGE LIABIL11TY AUTOONLV- EA ACCIDENT $ ANY AUTO EA ACC $ OTHER THAN AUTO ONLY: AGG $ C EXCESS I UMBRELLA LIABILITY . CU089800 11/15/2010 11/15/2011 EACH OCCURRENCE $2, 000,000 X OCCUR I CLAIMS MADE AGGREGATE $2,000,000 5 DEDUCTIBLE X RETENTION $5,000 WORKERS COMPENSATION $ D AND EMPLOYERS'LIABILITYYIN WC004476183 12/12/2010 12/12/2011orH- MYPROPRIETORIPARTNERIEXECUTIVE r 8500 000 OFFICERIMEMBER EXCLUDED? E.L.EACH ACCIDENT (Mandatory In NH) E.L.DISEASE- Ifyes,descdbeunder EA EMPLOYE $500 000 SPECIAL below OTHER E.L.DISEASE-POLICY LIMIT $500 000 OTNER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVIon"b he Workers' Compensation certificate will be issued from the carrier. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, ITS AGENTS OR REPRESENTATIVES. AUTHORIZED REPRESENTATVE ACORD 25(2009101) ©1988.2009 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD *= �lassachutictt� - Dcpartmrnt of public S:+fct� �� Board of Building Regul.ttion. and -Standards Construction Supervisor Specialty License License: CS SL 100452 Restricted to: RF,WS IOANNIS MAKRIS 8 YORKSHIRE ROAD MARBLEHEAD, MA 01945 Expiration: 1/27/2012 ( nnurti�tiiuner Tr#: 100452 office AbnfWWMW dWf-e1&W;�ft& HOME IMPROVEMENT CONTRACTOR Registration: 153422 Type: Expiration: 11/30/2012 Private Corporatio P 1f0 PAINTING'AND CONSTRUCTION COMPANY LOANNIS MAKRIS> # a F- t 8 YORKSHIRE ROADi --- MARBLEHEAD, MA 01945Undersecretary