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B-19-766 - 0004 BARTON PLACE - Building Permit t The Commonwealth of Massachusetts , Board of Building Regulations and St, FOR 0 gpgw . MUNICIPALITY Massachusetts State Building Code, 780 CMR USE Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 One-or Two-Family Dwelling This.Section For Official Use Only Building Prmit Number. Date Applied: 1 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers L la Is this ain accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1A Property Dimensions: Zoning Distrii:t Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required :::F Provided Required Provided r I1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Info mation: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIPt 2.1 Owner'of Record: Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) O Addition ❑ Demolition ❑ Accessory Bldg.❑ I Number of Units Other ❑ Specify: Brief Description of Proposed Work2: 1 L ("<42 lorc, S a40-cy s < 6 R SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only or and Materials Y 1.Building $ ,®�v 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ 3 ©B ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ , d a 2. Other Fees: $ ; 4.Mechanical (HVAC) $ List: , 5.Mechanical '(Fire $ S ression Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ,2 ago ❑paid in Full ❑Outstanding Balance Due: y ' SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor Lic ense(CSL) c D O�' ,?-a?D2 �1� 1� License Number Expiration Date Name of CSL Holder /E f�,jC f List CSL Type(see below)ly/ , ® G Type Description No.and Street ��n ��/y-$�t ^� ®/��y U Unrestricted(Buildingsto 35.000 cu.ft. ,l R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry F RC Roofing Covering WS Window and Sidin SF Solid Fuel Burning Appliances Insulation el hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) J 9 5`l-,/(v' 05-0/-aU (4✓I S Registration Number Expiration Date B' / Gb /e ,X � HIC R� HIC Compan Name or HIC Registrant Nam No.and Strget -� Email address 12�1146/0.?/!/ y e/ 95F363185,3 City/Town,City/Town,State,ZIP Tel hone 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,as Owner of the subject property,hereby authorize 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 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my time 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 www.masL og v/oca Information on the Construction Supervisor License can be found at www mass.Pov/dns 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 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" ,l Commonwealth of Massachusetts Division of Professional Licensure Board of Building Regulations and Standards Constr—#&$'A%{ jrisor CS-113464 Eoires:08/06/2022 CARLOS H*RTI 10 CHELMSFORDi:ST METHUEN MA�01844 / Z Commissioner ` 0 a % CITY OF &U.&M INLksSACHLSETTS • BUILDII IG DEPARTMENT 120 WASHINGTON STREET,r FLOOR TEL (978)745-9595 FAX(978)740-9846 KI,\BERIEY DIUSCOLI. MAYOR THOMAB ST.PIERu DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CMMSSIONER Wot•kers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anplicatnt Information Please Print Name(I3usim-ssiOrganization/lndividual): C ,,I CO f Address: /o r,�!�n�/ �rn 9 Aa r City/Staite/Zip: hone €,4:_ �'S 2 34;3 Are you wn employer?Check the appropriate box: Type of project(required): LEI❑ I am,a employer with 4. i am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: ?• ED Remodeling ship and have no employees These sub-contractors have S. ❑Demolition workin for me in an capacity. workers'comp.insurance. g Y9. ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.[1 Electrical repairs or additions requ,red.] officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL l l.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp. insurance required.] Any applicant that chm*s bolt#I must also fill uut the section below,showing their workers'compensation policy information. t I lorneuwnep who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. -Contractors flat check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information. I um an enn player that is providing workers'compensation insurance for my employees. Below Is the policy and Job site informadoj''r. Insurance Company Name:_ Policy#or Self-ins.Lic. Expiration Date:i0l2-2 /20 1 Job Site Address: Ll &---10 1 F)a CcR Sq k"n City/State/Zip:- Sat ko-� 0/?70 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to*.-cure 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 S250.00 a day against the violator. Be advi.wd that 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 and penalties of perjury that the information provided above is true and correct r Sienatttre: �ov7 6Z2 Date' O -;z Phone#: 2 S 3 a 3 ! 3 . Official use only. Do not write in this area,to be completed by city or town oJfciaL City or';ruwn: Permit/License# Issuing Authority(circle one): 1. Board of Health 2.Building;Department 3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other- Contact�Person: Phone#• • P' r (1TY OF SALEK MASSACHLJSE ( 1'IS BURDMG DEPARnOENT - 120 WASHINGTONSTREET,3'O FLOOR TEL(978)745-9595 1KAMERLEYDRISCLL FAX(978)740-9846 MAYOR THOMM STYIERRE DIREECTOR OF PUBIIC PROPERTY/BUILDING 00AWSSIONER Construction Debris Disposal Affidavit (required for all demolition & 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,S54;Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licenses waste on facility as defined by MGL c 111,5150A. The debris will be transported by: 2 29 (name of hauler) The debris will be disposed of in: (riame of facility) (a.ddress of facility) Signature of applicant (today's date) " ti 4 Barton Place Salem MA 01970 Scope of Work and Work Contract Vasey Family Trust LLC and CHM Carpentry Carlos Henrique Martins Contract Terms and Conditions NOTE: all permits must be signed off by the Building dept./punch list items must be corrected prior to final payment. Insurance Contractor Agrees to carry necessary liability, property and workers compensation insurance. Contractor requires sub-contractors to carry necessary liability and workers compensation insurance. Insurance must be coverage in the amount of$1,000,000 liability insurance and $500,000 workers compensation insurance. Hold Harmless The independent contractor hereby covenants and agrees to defend, indemnify and hold harmless the owner, its agents, officers, directors and employees of and from all liability, claims, actions, causes of action, lawsuits and demands including attorneys fees and costs,fines and/or penalties for personal injury, bodily injury, death (including personal injury, bodily injury or death of the independent contractor's own employees)and/or property damage arising out of or in any way related to the independent contractor's work or operations for or on behalf of the owner on, about or away from the owner's premises or associated with the breach of the construction agreement or the construction specifications. Contractor to accept all deliveries, i.e. cabinets, appliances, etc. Contractor must be available to correct any necessary defects originated by city/town inspector, Vasey Family Trust LLC inspector or Buyers Inspector Scope of Work Install 12/14 new replacement windows Install new kitchen/same location Re-niodel 1 st floor bath/same location Paint houses Will install half inch sheet rock and insulation in areas that were disturbed by electrical or plumbing install ACCEPTANCE By vigning below, CHM Carpentry Carlos Henrique Martins and Vasey Family Trust LLC agree that the above work will be completed for the agreed upon price noted below and in the agreed upon time frame noted below.Vasey Family Trust LLC will allow a 5 day grace period above and beyond the agreed upon date below to complete the work.Vasey Family Trust LLC agrees to pay for the work in 3 payments. 1/3 of the work is to be paid on the project start date. 1/3 at halfway point and 1/3 upon completion of approved work. Project Start Date: July 17, 2019 Price: $21,000 Payment Schedule: $7,000 Due upon full execution of the contract $7,00O Due upon 50%completion of the project $7,00()Due upon 100%completion of the project Amount Of Days To Complete Project: 30 Days Additional days of work due to approved overages: Contractor Name: CHM Carpentry Carlos Henrique Martins Print Sign Date Vasey Family Trust LLL��/� Print Sign Date 1144 .. ... 24'�. .1 z„12 . ' 30" 15" 1116 'a, 2016„ 3 ' „ HAMPTON BAY STOCK CABINETRY SHAKER STYLE THERMOFOIL, GREY --.52z„ 61 7.2 _28?�;_- _�.;?."_ 30".._ 15"__,:;..._....24��. . 7.4 STAND. CONST. CEIL.HT:9 _ .. ::. ALIGN:84., M KAFKW123! KW3012 KWKAF` �_ _ ' I CROWN:SHAKER _ �� . KACt RANGE1.30 i KB15.....J wo NIA TOEKICK: MATCHING I N • � w OD - W.____ CUSTOMER: N ch m r cry w �! N a, SCOTTO DELL ! N 7 18 0 4462 W O W 00 - - co M �' w DELIVERY ADDRESS: rn o o � , . 4 -.4 s M M w Y s o ti! rn 4 BARTON PLACE SALEM, MA. 01970 i N o ° INSTALLER: o N coy Cn � N HEATH m M 00978-876-7946 n rn _ _ -- - #99687 o , _21"_....._._ .--12" 21 12 .; 33" All dimensions_size designations This is an original design and must Designed: 7/12/2019 _ given are subject to verification on not be released or copied unless Printed: 7/16/2019 job site and adjustment to fit job applicable fee has been paid or job conditions. r order placed. I i 71209fe7 All Drawing#: l No Scale. I \ t { I ! I , i I I J i \ i dim t Note: This drawing is an artistic ' Designed: 7/12/2019 1! �!, interpretation of the general Printed: 7/16/2019 appearance of the design. it is w not meant to be an exact rendition. 71209fe7 All Drawing#: 1 ACORD Client#: DATE r TM CERTIFICATE OF LIABILITY INSURANCE 7/19/2019 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHT 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:If the certificate holder is an ADDITIONAL INSURED,the policy(ies)must be endorsed.If SUBROGATION IS WAIVED,subject to the terms and conditions o1'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 endorsements. PRODUCER CONTACT NAME: GUILHERME CAMOSSATO PHONE (978)645 6996 1-INSURANCE GROUP INC (A/C,No,EXt): 799 GORHAM ST-UNIT'A EMAIL vborba@Finsurancegroup.net ADDRESS: LOWELL,MA 01852 INSURER(S)AFFORDING COVERAGE NAIC INSURED INSURER A:THE BURLINGTON INSURANCE COMPANY INSURER B: CHM CARPENTRY INSURER C: 10 CHELMSFORD ST INSURER D:TRAVELERS INDEMNITY INS CO METHUEN,MA 01844 INSURER E: INSURER F: COVERAGES REVISION NUMBER: 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 TALL THE:TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSRL ADDLI SUBR POLICY EFF POLICY EXP , TR TYPE OF INSURANCE NSR VIVO POLICY NUMBER MM/DD/YY MM/DD LIMITS A GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000.00 DAMAGE TO XPREMISES Ea ocurrrreence) $ 100,000.00 COMMERCIAL GENERAL LIABILITY CLAIMS-MADE IX I OCCUR MED EXP(Any one person) $ 5,000.00 Y 3188003229 2/21/2019 2/21/2020 PERSONAL 8 ADV INJURY $ 1,000,000.00 GENERAL AGGREGATE $ 2,000,000.00 GEN'LAGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 2,000,000.00 X POLICY 4PROJECT RLOC B COMBINED SINGLE LIMIT ' AUTOMOBILE UABIDTY (Ea accident) ANY AUTO BODILY INJURY(Per person) ALL OWNED SCHEDULED AUTOS X AUTOS BODILY INJURY(Per accident) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS (Per accident) C UMBRELLA LIAB OCCUR EACH OCCURRENCE EXCESS LIAB I JCLAIMS-MADE AGGREGATE DED I I RETENTIONS D WORKERS COMPENSATION WC STATUTORY OTH AND EMPLOYERS'LIABILITY YIN LIMITS ER ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.EACH ACCIDENT $ 1,000,000.00 EN(Mandatory In NH) NIA 6HUB-1 K85903-8-19 2/22/2019 2/22/2020 E.L.DISEASE-EA EMPLOYEE $ 1,000,000.00 It yes,describe under E.L.DISEASE-POLICY LIMIT DESCRIPTION OF OPERATIONS below E.L. 1,000,000.00 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(Attach ACORD 101,Additional Remarks Schedule,if more space is required) { GENERAL LIABILITY:for regular and usual jobs.Workers'Compensation: benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 B,no authorization is given to pay claims for benefits to employees in states other than Massachusetts if the insured hires,or has hired those employees outside of Massachusetts.This , certificate of insurance shows the policy in force on the date that this certificate was issued(unless the expiration date on the above policy precedes the issue date of this certificate Of insurance).The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Venfication Search tool at www.mass.govAwd4vorkers- compensationAnvestigations.TEDCO INC is listed as additional insured on CGL POLICY. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE IT IS THE CUSTOMER'S RESPONSABILITY TO INFORME ANY CITY OF SALEM CHANGES OR CANCELATIONS. GUILHERME CAMOSSATO 1 If 1 ©1988-2010 ACORD CORPORATION.All rights reserved. ` . i I