82 SUMMER ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
! t + Board of Building Regulations and Standards M
1 Massachusetts State Building Code,780 CMR SALE
+ Revised LE 2PJI
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
O T bisS,et4jim For t ctrl Use.
Building Persalt Number , Date Applies;
>1tuTding OtEeial(Print Name) Srgnahno e
SECTIC?N 1:&ITE IIVFOR1tffA'I'(OIV
/I 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers Qs
�..! Lla Is this an accepted street?yes noMap Number Parcel Number
13 Zoning Information: e 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:
Zone: Outside Flood Zone?
Public❑ Private❑ Chock if Yes❑ Municipal❑ On site disposal system ❑
SECTION 2; PROPERTYOWNERSMIO
2.1 Owner of Record:
YiCCr �iA 1�F,-1 t. k-lQmZC+q� bfaC.y h'�4- QLR
Name(Print) City,State,ZIP . .
No.and Street - Telephone Email Address "
SECTION 3:DESCRIPTION OF PROPOSED WORK'(ebeek all thaf apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.O Number of Units I Other ❑ Specify:
BriefDescription ofProposed Work: 15it2t.'t� •Fit ti, {�S > � C „ { C. C(r
9\�� —c
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Laborand Materials
1.Building $ L Building Pomr#Fen:$ Indicate how fee is determined
2.Electrical $ ❑Standard City/Town Application Fee
O Total Project Costs(item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ .:
4.Mechanical (HVAC) $ List
5.Mechanical (Fire $
Su ression Total Ali Fees:$
(;beck No. Check Amount., Cash Amount:
6.Total Project Cost: $ �g ❑Paid in Full ❑Outstanding Balance Pae:
11) 4 P 0 • � Ill faLU-- To G� .
SECTION 5: CONSTRUCnON SERVICES
5.1 Construction Supervisor License(CSL)
cS- 09,25!4o3
Sep" 412�CJQI� License Number Expiration Date
Name of CSL Holder ki
Lis[CSL Type(see below)_
9-CO S VT `51--
and I Description
Street Type -,
15E'c O��-ac0 x Unrestricted
I2(Buildings up
000 a.
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
I Solid Fuel Burning Appliances
I Insulation
Telephone Email address -Gam- D Demolition
5.2 Registered Home Improvement Contractor(RIC) LZ3e�3
u3C1�o HIC Registration Number Expiration Date
HIC Company Name o IYC Registrant Name _
• No.and Street r�.��,�,r��� Email address
C.AXMX—%` V-4-1— \�a� Rit7!lry7CJ�
Ci /Town State ZIP Telephone
r SECTION 6:WOiiIUM'COMPENSATION RMURANCE APFHIAVIT(NLGJ-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...........❑
SECTIOFi 7a:OVMR AUTHORIZATION TO$E COMPLETED WHEN
OWNER'S AGENT QR CONTRACTOR_APPI.IES.FOR ,iI ING PERMIT
1,as Owner of the subject property,hereby authorize � 4Ct C53k —
to act on my behalf,in all matters relative to work authorized by this building pern it application.
Print Owner's Name(Electronic Signature) Date
SECTION'7b:OWNER!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
wtivw.mM govloca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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"may be substituted for"Total Project Cost"
203 WASHINGTON ST.#256
PRESERVE SALEM, MA 01970
SERV 1 C E S carpcnvylpainting lrnn!'ingfguttcrx PHow:978.745.8745
rax:978.745.3476
SALES@PRESE RVESERVICES.COM
Victoria Dell Monica
Date Bid:7/21/2016
82 Summer St Estimator:Sean O'Connor
Salem, MA 01970 Mobile:(978)395-7737
(978) 744-4071 Email:sean@preservese"ices.com
EXTERIOR PAINTING ESTIMATE
COMMENTS
Replace the shingles from the chimney back on the left wall and paint the entire left wall.
CARPENTRY*
Pull a building permit. The cost of the permit is included.
Remove the shingles; dispose of the shingles; install tyvek; reflash above doors and windows; install
pre-primed red cedar shingles using stainless steel nail's.
PRIOR PREPARATION
GUTTERS /DOWNSPOUTS: Remove the downspouts and re-install.
SHUTTERS: Remove the shutters and then re-install.
MINOR MAINTENANCE
CAULKING: Caulk all gaps and cracks.
PREPARATION
PREPARATION: Scrape all loose and peeling paint.
AREAS TO BE PAINTED
SIDING: Apply I full coat of primer. Apply 1 full coat of finish.
TRIM: Apply 1 full coat of primer. Apply I full coat of finish.
WINDOWS: Paint the wooden portion of the window but exclude the vinyl. Apply 1 full coat of
primer. Apply 1 full coat of finish.
DOORS: Paint the exterior of the doors. Spot prime all bare areas. Apply 1 full coat of finish.
OTHER: Paint the deck on the left and on the front wall.
OTHER: Paint window sills on the windows on the rear.
PRICING
Painting $3,295
Carpentry $8,495
Basic $11,790
Sales Tax $0
Total Price $11,790 Including Labor and Materials
Payment Terms: 20% deposit(day of start); 30%progress; 50%end of job Mc/Visa/Amex
Sear 'Connor Customer Signature
ADDITIONAL TO ABOVE ESTIMATE:
BID 1: Replace the door and window facia, molding, and window sill noses on the left wall from the
chimney back excluding the windows covered in aluminum.
Price $3675 Including Labor and Material
Note: If we are powerwashing your home the windows may be streaky post washing. If you wash your
windows on a regular basis, you should wash them after we wash the outside of your home.
* If we are painting, the cost of paint is included in the above price except for the following: Benjamin Moore
Aura exterior paint will cost an additional $15 per gallon; other specialty products prices will be given on a per
product basis.
**The carpentry portion is valid for 60 days and the painting portion is valid for 365 days.
**** Warranty: Craftsmanship: Kyron Inc. DBA Preserve Services warrantees all exterior painting against
blistering and peeling for a period of 2 years. The only exclusions are: wooden gutters; walked on surfaces; and
structural problems such as but not limited to"mill glazing." Should peeling or blistering occur we will fix the
affected area including labor and materials. For the warranty to be valid the invoice that was presented at the
time of completion must have been paid in full.
Licenses:
Home Improvement Contractor Preserve(HIC): 123553
Construction Supervisor Sean O'Connor(CS): 93403
EPA Renovation,Repair and Painting(RRP) Nat-21650-0
Insurances:
Liability Insurance:
Our policy is under Kyron Inc. DBA Preserve Services and has limit of$4,000,000.
Protection: Covers your property in the event of accidental damage up to a dollar limit specified on the policy.
To check our policy we will provide a certificate from our insurance company.
Worker's Compensation
Our policy is under Kyron Inc. DBA Preserve Services.
Protection: Covers the injury of a worker employed by the contractor doing work at your home. To check our
policy or our competitions go to http://mass.gov/dia/ on this page go to "check worker's compensation
proof of coverage"our license is under Kyron zip code 01970.
�\ The Commonwealth of Massachusetts
Department oflndustrialAccidents
a I 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: P 2 > ttC
Address:_ l>.WPRVY>t^(aref1 ST P Zoo
City/State/Zip: OZP-� meq, Phone#: C'Vz� ; q 11
Are you an employer?Check the appropriate box: Business Type(required):
1.211 am a employer with (22 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 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*411.❑ Health Care
4.F1 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#1 must also till 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#1.
I am an employer that is providing workers'compensation insurance for my employees Below is the policy information.
Insurance Company Name: jy tS
Insurer's Address: fOfO tCQA14.o QP-r, <�J"'j8'
City/State/Zip: l—)Ar 7
Policy#or Self-ins.Lic. X52'? r r,-A>Qt,I t--k Expiration Date: 517A/{—j'—
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.
/do hereby certify, under pains and penalties ofperjury that the information provided have is true and correct.
Signature: /, Date: 6
Phone#: "T
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: PermitfLicense#
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.
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). 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
Fonn Revised 02-23-15
CITY tF SALEA MASS A SETT,
BUMMDUARBOU
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MAYOR 7 ASST.PIBttRF
Dn scrcitcr wjcrav wT/BUm
Construction Debris Disposol A„fidavit
(required forall demolition and,.renova#ion work)
in accordance% th the sbA edition of the State Building Code, Mtn Secttm+:1LS Mbri,
and the Mons of MGL c00,S 54; BuIldbW Permit B is issued with the
condfflon that the debris resuitlag from this work shag be disposed of in a properly licensed
waste depastt tuft as defined by MGL c 312,S 156A
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
ignature of applicant
Date
Massachusetts DePa utatians and $ta dards
R
Board of Building eg
License: CS-093403
Construction Supe
SEAN OCONNOR
26 CHESTNUT ST
SALEM MA 01970
_ ( Expiration'.
12131i2017
Commissioner
VIIC !(OA(Jl[OIF[lMp���Ofl�iflfllXlflf![JC�fJ
Office ofConsamer Affairs&Business Regulation
IOMEIMPROVEMENTCONTRACTOR
egistratlon: 123553 Type:
xpiration: 31612017 DBA
Preserve Painting
Sean O'Connor
203 WASHINGTON ST.#256 g . „�•�_
SALEM,MA 01970 Undersecretarywry
Undetcretary
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