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0012 PYBURN AVENUE - BPA-16-982 q z c-K -z 3 The Commonwealth of Massachusetts OF Board of Building Regulations and Standards, SALEM Massachusetts State Building Code,780 CMR ylb`gU6-31 R4,s�l blar 2011 Building Permit Application To Construct,Repair,Renovate r Demolish a One-or Two-Family Dwelling !us S,ection For 01116W Llse 0m Building Perrah,Number: Date Ap 'ed: bo l Bvildiug Official Mint Name) Sigaatire e SECTION 1:SITE INf ORikIATICIN r---' 1.1 rorty Address: 1.2 Assessors Map&Parcel Numbers l.la Is thisan accepted street?yes_ no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq it) Frontage(II) 1.5 Building Setbacks(ft) Front Yard - Side Yards Rear Yard Required Provided RequiredProvided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal 13 On site disposal system 13Public❑ Private❑ Check if yesI3 SECI14DN2i PROPERTYOWNERS1I1e 2.1 err of Recor : L7 �•rueT6r tri 1'�/r Name(Print) City,State, ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: ._ Brief Description of ProposedWorkz: SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials 1.Building $ 1. Buihling Permit Fee,$ Indicate how fee is detemlined, ❑Standard City/Town Application Fee 2.Electrical $ 13 Total Project Cose(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List' 5.Mechanical (Fire $ Total Ali Fees:$ Su ression Check No. Cheek Amount: Cash Amount' . 6. to]Project Cost: $ E3P�;n Pill ❑Outstanding Balance Due: .. q1l rnrat To cn� SECTION 5: CON$TRVCPION SERVICES t5.'.1 onstruction Supervisor License(CSL) „ 'I - 6-1 ,�,au, Z n' R P✓1� LicenseLicense Naber E iration Date Name of CSL Holder " -14 List CSL Type(see below) Type No./aand Street [ f 1/(/��// may? � trOII I-IX OP-r-i i 11 /'/Gt 9/D J� U Unrestricted Family u to 35,000 w.R. R Restricted l&2 Famil Dwelling City/Ibwn,State,ZIP M I Masomy Roofin Coverin wmaow ana s; SF Solid Fuel Burning Appliqm I Insulation Te hone Email address D Demolition 5.2 e^giisstered Home Improvement Contractor(RIC)�P/w e A HIC Registration Number HI�C7om�v Nam0r.Ijl€Registrant Name No.and Street f[ H[/ Email address G/ ,PrA./-/0 ✓!1A 61 6 Ci /Ibwn State ZIP Tel hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(ALG.L.e:152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ..........11 No...........❑ SECTION Tai OWNERAUTH RIZATION TO BE COMPLETED WHEN OW1vEx's Ni'OR�9NTRACTgR F4R$ ':. ING 1,as Owner of the subject property,hereby authorize /--)k n CAP M C.17 s 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 76: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. flk... Cle Mew--5 4Z-3/- M 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 mnLmassgovloca Information on the Construction Supervisor License can be found at www.mass. ov/d s 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable room coma Number of fireplaces Number of bedrooms Number of bathrooms Number of halflbaths 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 CosP' The Commonwealth of Massachusetts Department oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114-2017 UW www.massgov/dia Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FIUD WITS THE PERM ITING AITI'HORITY. Anolicant Information n Please Print Leeibly Name (Business/Organintion/Individuat): (,.,/etst P_n C Sagt 'K Address: / CoiNrlterClC ! 5 �i1- yy City/State/Zip:L C1 Phone#: Are you an employer?Check the appropriate box: Type of project(required): L'3 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 g, Remodeling any capacity.[No workers"comp.insurance required.] ❑ g 3. I am a homeowner doing all work 9. ❑Demolition ❑ 8 myself[No workers'comp.insurance required.]t 4.❑I am a homeowner and will be hiring contractors to conduct all work on m perry. I will 10❑Building addition y pro ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet. These sub-contractors have employees and have workers'comp.insuream.t 13.❑Roof repairs 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑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 worker:'compensation policy information. f Homeowners who submit this affidavit indicating they we 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 name 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. lam an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Licic..#: Expiration Date: Job Site Address: 42 /A 6a nn Sf City/State/Zip: 54le/_( Attach a copy of the worker ' ompensation 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 certify under the pains andpena/ties of'perjury that the information provided above/is true and correct. Suture: ZGLI Phone#: Official use only. Do not write in this area,to be completed by city or town ofciaL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health Z.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 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 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 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 pertruts 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-NIASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia CrTYOFSALEA MASSAQ-REE BULUMDatrACMWrr IM WA9MCMS"tWr,3jDRcoart 7� 7*5-9595. Frac 710.9M BD�BRih]'DI, MA]7L1R 7t�ST.PueatF DumcwacrpuujcmwrmylBumnmcamwmcmm Construction Debris Disposa/Afldavit (required for all demolition and.renovition work) In accordance with the sixth edition of the State WNW Code, 780 CMR, Section 11LS Debit, and the provisions of MGL M,S 54; Building Permit#1Ls issued with the conditionthat the debris resulting from this work shall be disposed• of in aP►ope►IY licensed waste deposit facility as definedby MGL c 111 S 150A150A The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) WC 4 (add ss of facility) Signature of applicant Date ..EMENS&SONS GONSMUCT10N&R001V4G►Nc CUSTOMER INFORMATION CONTRACTOR INFORMATION Name Newhall Brothers Real Estate CLEMENS AND SONS CONSTRUCTION AND Investments Inc. Company ROOFING INC. Address 2 Pyburn St website clemensroofing.com _ City, State Salem, Ma Address 180 COMMERCIAL ST. Unit 11-12 City, LYNN, Phone 781-974-7379 State ZIP MA 01905 CELL (781) 244 9582 OFFICE (781) 584 4475 Email Phone FAX (781) 584 4372 Email clemensandsons(a)yahoo.com SCOPE OF WORK Strip entire roof to boards. Install ice and water shield to lead edge of roof and in valleys. Install felt paper to the remainder of the roof. Install 8 inch white drip edge to entire perimeter of the roof. Install new GAF lifetime architectural shingles to entire roof. Install cobra ridge vent to all ridges. Clean and remove all debris. All work to be completed for $6,000 Down Payment $3,000 Completion $3,000 Massachusetts -Department of Public Safety Board of Building Regulations and Standards Construction Supervisor Specialti License: CSSL-101231 F, -DANIEL F CLEMOS _ 679th Avenue. = - Haverhill MA 01$30 %I �..G.•� � .,ne" s Expiration Commissioner 11/0612015 ;�Cl�e�arlt> atlu.��lti.- N Office of Consumer Affairs&Bu mess Regulation . - OME IMPROVEMENT CONTRACTOR Registration '169611 . ..Type: e Expiration 71872;17, `. Individual. u' DANIEL CLEMEN�f i i DANIEL CLEMENS - ' 67 9TH AVE. - _l1 -- HAVERHILL,MA 01830��"' �� Under— The Official VVelosite of the ExeCLItlVe OfflCe of Pjubli�Safety and Security(EOPSS) Public Safety � r kjj nsee Details Demographic Information Full Name: DANIEL F CLEMENS Gender: jOwner Nam Address information Address: Address 2: City: Haverhill State: MA ipcode: 01830 o n U fates . icense n'tedorma ion License No: CSSL-101231 License Type: Construction Supervisor Specialty Profession: Building Licenses Date of Last Renewal: 10/29/2015 Issue Date: Expiration Date: 11/6/2017 License Status: Active Today's Date: 11/23/2015 Secondary License: Doing Business As: tus Chance: Prerequisite information Licensee: CLEMENS, DANIEL F Relationship: Attribute Of License No: CSSL-101231 Licensee: CLEMENS, DANIEL F Relationship: Attribute Of se N CSSL-101231 Discipline No Discipline Information ocumen um Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us]Verification/Detailt.aspx?agency_id=1&license id=290160& 11/23/15, 6:52 AM Page 1 of 1 Public �.x- R .'..' awm*W nsee Details Demographic Information Full Name: DANIEL F CLEMENS Gender: Owner Name: cense ACICIreSs information Address: Address 2: City: Haverhill State: MA ipcode: 01830 o nt U 'ted fates icense n orma ion License No: CSSL-101231 License Type: CSSL-WS-Windows and Siding Profession: Building Licenses Date of Last Renewal: 10/29/2015 Issue Date: Expiration Date: 11/6/2017 License Status: Active Today's Date: 11/23/2015 Secondary License: Doing Business As: Status Chan e: Prerequisite information Licensee: CLEMENS, DANIEL F Relationship: Attribute Of se N CSSL-101231 Discipline No Discipline Information ocumen um Close Wintlow ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=1&iicense_id=343361& 11/23/15, 6:54 AM Page 1 of 1 Commonwealth of Massachusetts l ' City of Salem 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 / Return card to Building Division for Certificate of Occupancy Permit No.$6 8-16-983 PERMIT TO BUILD FEE PAID: $63.00 DATE ISSUED: 9/13/2016 This certifies that YVONNE Y. MARTIN RLTY TR THE MARTIN YVONNE Y TR has permission to erect, alter, or demolish a building-31_PICKMAN_ROAD Map/Lot: 220015-0 as follows: Insulation BLOWN IN CELLULOSE INSULATION (ATTIC & EXTERIOR WALLS) I \ 10/06/2016 rec'd email from Mr. Anthony Grieco that client(The Martins) had cancelled this job. Filed w/permit ap & in street file. -- - - - - - Contractor Name: ANTHONY GRIECO I DBA: BUILDING EFFICIENCIES, LLC ' � f / Contractor License No: CS-104159 1" I i 9/13/2016 i Building Official Date This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official may grant one or more extensions not to exceed six months each upon written request. I All work authorized by this permit shall conform to the approved application and the approved construction documents for which this.permit has been granted. 1 i ` All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes. � � r This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the work until the completion of the same. ' The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. HIC#: 167942 "Persons contracting with unregistered contractors do not have access to the guarantyfund"(as set forth in MGL c.142A). Restrictions Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. PAO/-- -ro Do nix, 4. is'l--commonw}ea" N 44 wwrs Ith�of,Ma§sc!6h'us'otts,,1,'U', 'j em M Womhtnlk"$1,NO NO$OW".MA i if � o amid to"wing 011vislo"mr ctiiliroli�of�7a0upmn6y .; Permit Noe,-. W11-21 v_�T PEE PAID; $43,004 PERo U [LMIT .1B ua DATE ISSV& Via= 'this ceetifi,es that, YVONNE Y.'MARTIN RLTY TR THE,%%MM,,,TIN,YVONNE *,,tR,�-, has-permission to erect, I alter,or derPOII$h a building -31 PICKMAN ROAD, M a /Lot 220075'0 t as tollovys Insulation, lSLOVM IN CELLULOSE INSULATION(ATTIC &EXTERIOR WALLS) 60ntr$16NOr am9:'AN*kONY'W?J6 co,:g 7 N DBA: ­811.1114DING EFFICIENCIES, LLC `co St r ntrictorlice No:I CS-1641 N." wr�V % p 13/20.16 NJ J,Wi;., W Building dbl q fila pervnt sitau-be d"abandoned and ji4aMunless Od by may grant oneor more wdaim"not to 9 Oslox -�d by ibis W: -to it Wn ,Pqrn*MB,beefigfa 1, aut�oft penrift shall con he aWovad construction documants wr 06 7, tried, I Charg aa,afrL4 AD construction iftotaidna A," tw anc in compliance with diOml ze ofanylbuldingandstructures'Malbe, ring by-Wfil;j' as I 2, ;Open joecdom a ationt: rly visft arm ahill 6 6G61natt i 4 be C_ for il�� This 5 displayed fit loci W'd Wpm strost or`read ii(xii g1gq until fm of the .7' 4i 'i, jiul. of ci;(�Upart&y WE 6e j. Until SWOPPOCI)WO Sign UiliftiFid Fie 6#669-are pwow on this pant:-j, 1A, id :�W I `H10 M 18794 9. ;5 .»,°y MF''c ,.. 'Par4on4 acang wide urvoplatarod wnoactoro do.na hose acuss tame gw it� n {d 1114 W 9 'Q Ristirlictions: A IDII� "M _�kt gj are 03 biaA11able owsltdi 7-K tV