14A RAYMOND RD - BUILDING INSPECTION e 4 J � 0� d�0 CK 3
The Commonwealthl f vlassachusetts RECE kSpECTIONA S�"fid
i Board of Building Regulations and Standards Lr
q � Massachusetts State Building Code, 780 CMR ')p�'�S5 ppFFrr Revised Alar 2011
Building Permit Application To Construe Repair, Renovate Or`t181MdifStt A 4 b
One-or Two-Family Dwelling
This Section For Official Use Only
O BuilJmg Permit Number. Date A l ed
Building Official(Print Name) Signature : Date
L SECTION 1,SITE INFOILVIATION
1 I. Pro er AJdressi 1.2 Assessors Map&Parcel Number
t11 S �� �>�7tP�1�t1d 12v
I.Is Is this an accepted street9 yes no Nino Mariber Parcel Number
1.8 Zoning Information: 1.4 Property Dimensions:
Zoning District c pn+powd Use Lot Area(sq ft) Frontage(ft)
1.3 Building Setbacks(R) .
Front Yard Side Yarib . .. . Rear Yord
Required Provided Required Provided Required thovideJ
1.6 Wafer Supply:(M.G.L c:Je,§51) 1.7 N7aod Zooe Information 1.8 Sewage Disposal SyslOt '
Zone: Outside Flood Zone? Muriel O On sitr dti Iem`D
PriblieO PriveteO C"if':;'sEt, o .
SECT10lYZ: PROPERaTOWNERSITYPw
21. roY7�!.�.V LI~M fM 9 D
No.xW Street Telephone Email Addrez;4
SECTION 3:DESCRIPTION OF PROPOSED WORKr(cheek olfthat apply)
New Construction O EBisting Building O Owner-Occupied O 1 Repairs(s) 13 1 Alterations) O Addition O
Demolition O Accessory Bldg.O Number ofUnfts Other O Sperry:
Brief Description of Proposed Work : Kc' ! �Obtn S ' " '.
K -. 1 e lrte.f
l�t (�(A-C 3 EK1-Ti6( pcocs-tu`fh Pree.4a:sc r'Sr t
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofticial Use Only
Labor and Materials
I. Building 13 cl L �rL (7 1• Building Permit Fee:f Indlcate how fee is determined:
17 Standard Cilyllown Application Fee
2.Electrical S
Total Project Cosh(Item 6)x multiplier x
3. Plumbing S 2P Qther Fees: S
a.Mechanical (HVAC) S List:
5.Mechanical (Fire $ Total All Fccs:S
Suppression) - '
Check No. Check Amount: Cash Amount:
6.Total Project Cost: -S 6'l!v ❑Paid in Full ❑Outstanding Balance Due:
SIJ p �_�7Z,WLvS'. Ql� e�tJR'
c .s
iS ;'x( `.+• SECTION 5: CONSTRUCTION SERVICES
((5.1 Gonslr(icf on'Sopervisor License(CSL) ES O 673 0D
`Qt0'r ` jMt-�`Pt "F 71ei _ License Number Expiration Date
Name'of CSL Hilder ListCSL'rype(seebelow)
2 54-
TYPe' Descliplion .
Nu.and Stree U i Unastdcted Duildui a to 35 uuu Cu.11.
y"'nri^�^i t144 M�O ���S R Restri�tedl&2Famil D+vellin
City/ru+vn,State,ZIP _ M Masonry
RC Reading Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7k/ 7 y 3 1s5-L, y 7c t n CB Ctsvvitp, WG rr I Insulation =
Tele hand Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
e i'u r c=6 � 11C Registranon Number Expiration Date
HIC Cumpany Name HIC Registrant Name / �I
L'v ,n.`CC. 1'l7-Ih Ti`✓�Cd �NC "j�GtNC a( OMC,�� ll/er
tea and syeet �y�n �y/,q o/i � Email address
)J— L _T
Ci /1'own State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURAdCE AFFIDAVITpwaL;c.14.4 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 Iduance of the building permit
Signed Affidavit Attached? Yes..........0 No...........O
SECTION Ui OWNER AUTHOli12ATlON TO BE COMPLETED W HEN: ;' t
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT`
1,as Owner of the subject property,hereby authorize Q COQ e— �C�tc
t9 act on my behalf,in all matte relative to work authorized this building permit applicatio
NL�� I � �Z 1°I )5
Print O+vaer's Name(Electronic Signature) Data
SECTION 7b:OWNEW ORAUTHORI2ED 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 Nume(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(HIC)Program):will fir(have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.G�terimpt rogram canbel
ortaninforms i—-f'on on the HIC-Poond at
w+vw.mass.eov.'oca Information on the Construction Supervisor License can be found at wwa.mass tuvhips .
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) '+ (including garage,finished basementlattics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halFbatlis
rype of healing system Number of decks/porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage"may be substituted for"Total Project Cost"
AC a° CERTIFICATE CIPLIABILITY INSURANCE
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 INSURERIS), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the poilcylles)must be andorsed. If SUBROGATION 15 WAIVED,subject to
the terms and conditions of the policy,certain policies may Inquire an endon;amom. A statement on this cartificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER NA E• Stephen Duffy, Sr
Duffy Insurance Agency Pa (781)593-1200;pe11a93-T2W
317 Broadway psoas;stavooduffyins.com
NyOma Square DMIAMUS1 MPOMMC COVERAGE "moo
Lynn NA 01900-2602 MMERA:Safet _Insurance Company 39454
11SUREo enll3Eas:Safety Indemnity Can 33619
Service Painting Co Inc INNFUNICAsbociatotl Rsplayaxa Insurance _
93 Collins Street INSURER O:
INSURERS:
Lynn NA 01902-2247 In E •
COVERAGES CERTIFICATE NUMBER:C115121500160 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. NOTIMTHSTANDING 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LER 1YPEOF WBUAANCE Is POL UM F10/2312015
MPpIIDY QP LVIITS
% CONNHiCIALGEMERAl UA8ar1Y EACH OCCURIO:NCE a 1,000,000
A _]CLAU3SeAA0E ❑X OCCURAamRmcll a 100,000
TIODO10900 10/21/2016 IAEDEXP(ARr Ae:6 pawn) 8 10,000
a 1,000,000
GENERAL AGGREGATE E 2,000,000
PROMICIS-CONDI AGG E 1,000,000
J%NY�O BODILY INAIRY(Pwwmm) S 250,000
A10g EO X 3roDULED 6212196 2/6/2016 90OLLY WAIRY fPe otrlOaY) a 500,000
HBtEO AVMS
AUTOS araA^GE a 250,000
ppgT,t s 8,000
UMBRELLA UAB OCCUR EACH OCCURRENCE E
QCE88LNe OVIMBMI.DE AGGREGATE a
oE0 RETeMImI I a
WORItEPSCOMPEA'9AlgD1 5TATVJE _
AND EMPLOYEps'WBRRY
AHY PROLP4EMMPARTNERIEYECUTNE YIN E.EACH ACCIDENT E 100,000
OFFICEROlEMWR Q0.110Eoi NIA
C (MmievwYq NN) VSC5006018012015 10/3/2015 10/3/2016 EL D6Ea5E-EA EHAlO a 100,000
O IPiMNOmF OPEMTroNB Jreba EL°iSFASE-POLICY LuvT a 500 000
CS9CMPTION OF OPERATIONS IlAWT10N81VEHICL£8 tAC0A0 qLA dG MRo-naM1f SCI,MWa::a9W+wl V mora s *JS"w*w)
Painting contractor
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ATTN: Building Department ACCORDANCE WITH THE POLICY PROVISIONS.
City Hall
Salam, MA 01970 AUNUMMR)REPRF.SEMTATRIE
S Duffy, Sr/STEVE J�?G/I.'z'� ��'6til•i�`�t'.
01988.2014 ACORD CORPORATION. All lights reserved.
ACORD2512014101) The ACDRD name and logo are registered Craft of ACORD
INS026(miclN
CITY OF SALE1V,Zy MASSAcHmnS
BLn Dn rG DErAjm&rrr
120 1WAgmgGTONS7nET,32DRo R
7kL(978)7459595.
FAX(978)740-9846
RIMRFRi FYDRISQ�LL
MAYOR Turas STAEM
DmEcrcRcFnwcrxom=/Bl mDncoamm sloNEn
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 8 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:
ZfJiU'�V�'iul�i\'4�U�'ne
(name of hauler)
The debris will be disposed of in:
`r'fAn5 ( W<ftr&, S res(
(name of facility)
► �o ConaMLr�z�+L
(address of facility)
Sigr4ture of applicant
Date
,. V`e y:01/1nroHC0^[fly/P t��/��UJlOc�ltJe��J•
Ofree 0f Consumer Affairs&Business Regulation
Massachusetts-Department of Public Safety TOME IMPROVEMENT CONTRACTOR Type:
Board of Building Regulations and Standards egistrati 111402 t
Construe oa Sunezisoi Expiration: 12/17/2016 Pmate Corporal'
License: CS-067300 SERVICE PAINTING CO INC
GEORGE W MCI** GEORGE McKIE
48 GREGORY SSC J1 L t ST
MAIMUMAD INA r0 ' 93 COLLINSS ST Q�..l�--,®.�
i
� of LYNN,MA 01902 Undersecretary
Expiration
Commissioner 0712112017
� - Commonwealth of Massachusetts
OSHA 002209864 K.y Department of Labor Standards
[ Heather Rowe.Director
Deleader Supervisor
�i S pe�artn.¢et of tabor'
Occnt,at;m,at safety�d
HWIP GEORGE W. MCKIE
Georgie McKie Jr. Eff.Date 01102/16 f ,
Exp.Date 0103116
has sUcces5Yully<onpicteo a 102rour Occupr+r"�Sakry tieaf•hDS
e..
7rarmN " m16 1
t. 'v"oerof GO N.ES.T-
Cons"dion Safety&Health 's
_ 305R BOS-RENEW ^D
—Wendy R John'V011 212512009 t I I1}
ITaza ) (Oa[eI
l
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for thea 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 writtep."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or say 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 then 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 badness 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 ofpublic work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please 511 out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply subcontractors)name(s),address(es)and phone number(s)along with thea certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other then the
members or partners,are no 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 sore to sign and date the atkldavit 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 DepaMmemt 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 aura that the affidavit is complete and printed legibly. The Departament 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 511 in the pemmit/ticeuse number which will be used as a reference number. In addition,am applicant
that mast submit multiple pemvttlicense 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 proofthat 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 dQg license or permit to bon 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. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
n;
CommonlveaJth ofMttssachuseds
Depailsnent oflndustri6lAatgdenty
I CongressSbw4 Suite 100
Boston,M..4 02114-1017
www mas.gov/dia
Workers'Compensation Insurance Affidavit Bonders/Contractors/Elecbidans/Plum6era.
TO BE FILZD WITH TEE PERNDITING AMHORIT Y.
sPlemeridat
Name(Bttsiaess/OrgmizsticmRndivdupl): 2C J 1 C L� '�l �� :� C
Addtess: g 3 COW vtS S`-
City1Stata(7jp: 0 /90Z- Phone#: ;7k/513. /5-6-2-
An
k/513 /5- 2 -
L6.0%w
an empbye r ChKk m`e app,eprWe bor: Type Of project(rcqufred): .
m a e7. Q New constru�on
masokpeo}aiaworyarmerehip sop leave no�?X9f4 wo7)pog fmmem 8: :0JtemOdplinupee3iY (Lltiwokre' ftmahaerequL+d) 9: QI)amolitienm a homeoaverdomg all vrodr myuu.(No wo>kesa•camp.iasmaocertquved.a hoIwtBi0 13in7dmg'edthYiwl.
e nut all comr�ma ehbahave wmkers•eompensamm maaancearae5016 11.07lectrical repairs or additions
afataa general eoIDoiawmd 7 hmlifted Poe mb�adm lilted rat Poe sued"atme"ta sobeenrpeoa have employee and bare wo*='C-W mw•-:ara a wryoiationand ila offiieishaveeaeacisedPoeanigatofeemptionpcMGLa
)a.06tb§l(47,endwbaieroemployeea:lNowwkw't=W-moue wquuiaj- .
. •A�appliwttihe cheeks Eos dl mat am 1111 omPoeaeaim hekwsLiiawgfhebwarlcae potty '-` -
tHomeowmaautosubmit"affidavitiudinbogPoel'ste dohrg a0 work thui tihd oiraidemn�acte moat sobIDhanewaffidavithMlk%ek8such=
scontracim dowing do�e,oraksab-eat and swewhewi w na Posse mwie5 have
employees..7fthe,sub�counaeaa,#nTe.mW.0Yg4tbgywustETo tdidr:wmins',e�p.polkymmbn :..' -
Iamanepployerthatirprovfding allorkers'Con+Penaa!►anlnryrasjormyem 8e%aviafhepcllcyaadN+b+J!e
hrjora,oatoa.
InsuranceCompany Name: tA22oC`( Pn&210' vs.
Policy 8 or Self-ins.Lie.MW
J CC, JJrOO O t \�YJ 1 ?-Of 5- Expiration Date: !y�3 Z,-
/Q
Job Site Address: I / - 11 �V1/fE5 (z 1! City/StetaMp:
Attach a copy of the workers'compensation policy declaration page(showft Me policy number an expiation date).
Fa>7pre to secure coverage as required under MGL c. 152,§25A is a mina]violation punishable by Cline up to$1,500.00
and/or one-year impnsonmrAt,as wap as civil penalties in the from of a STOP WORK ORDER and a Sae of lip to$150.00 a
day against the yloluitor,A copy ofttiie sgtemtat may be forwarded to$e Office oflnvestigatiena of the DIA for innumce
coverage verification.
Ido hereby underlie ' and penahim ofperjury that the informalioe provided above is true and carred
Phone#
F
only. Do ao write in this area,to be coaaplded by arY or town o,OkkLn: Permit/ldcense M
orlty(circle one):
Bean 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
son: Phone d:
Contract
SERVICE PAINTING CO./NC.
93 COLLINS ST.
LYNN,MA 01902
781-593-1552
LIC. NO. DC000017
LIC.NO. H.I.0 111402
LIC.NO. CS067300 Date: 12/19/2015
Contract Number. 14araymond2
Alvaro Ibanez
20 112 Barnes rd
Salem.MA
Job Description: lead paint removal 14 A Raymond rd.
QUANTITY DESCRIPTION PRICE TOTAL
6 window trim remove supply and install new material match existing casing 225.00 -1,350.00
5 windows remove supply and install new vinyl replacements 345.00 1,725.00
3 doors hall 1 and rm 6 replace add door to basement from kitchen match existing doors 120.00 360.00
10 door casings remove supply and install new material 85.00 850.-0
0 0.00 0.00
0 0.00 0.00
1 window board up nn2/SHEET ROCK INT.WOOD PORCH SIDE 320.00 320.00
1 basement door replace with custom size pre hung door steel flat panel 36x80 right swing 650.00 650.00
1 front entry door replace with pre hung steel fan lite 36x80 left swing 850.00 850.00
1 porch remove slider, install siding ext.drywall int.wall, install pre hung door 36x80 steel fan lell 1,250.00 1,250.00
0 0.00 0.00
8 exterior areas cover with aluminum 70.00 560.00
1 boiler add wall and door wood door 825.00 825.00
1 water heater add wall and wood door 725.00 725.00
9,465.00
DESCRIPTION PRICE TOTAL
0 360.00 0.00
0 2,850.00 0.00
0 14.00 0.00
0.00
0.00
0.00
0.00
0.00
0.00
RESPECTFULLY SUBMITT D, ERVICE P 1 I ,�G�C71-T-
BY------------------ 3,224.00
DATE OF ACCEPTANCE1211d 16 BY-1------ .==- --- - Total CO/lfrdC>F 9,465.00