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B-20-772 - 0001 BERUBE ROAD - Building Permit The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only (� Building Permit Number: Date Applied: (� Building Official(Print Name) Signature Date �J SECTION 1: SITE INFORMATION N1.1 Property Address: N 1.2 Assessors Map&Parcel Numbers I I 9..P rvb4.. „(\ 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 OWNERSHIP' 2.1 Owner'of Record: ` \ t too a 0 i L1 7 0 Name(Print) City,State,ZIP 94e-rubc QLA. JJ .9b)- I q9 e-C-1v, tD C- t 51 .r,P4 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ['Specify: lnJ r�dI o w� Brief Description of Propose Work2: SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ oo 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ . 4.Mechanical (f VAC) $ List: 7 Pml:34 5.Mechanical (Fire $ L Suppression) Total All Fees: $ 0� Check No. ' Check Amount: Cash Amount: 6. Total Project Cost: $ ` , 5 5'8 , p paid in Full 0 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) eve L �Dateor License umber Expira Name of CSL Holder _ List CSL Type(see below) V r Wo O a Type Description o.and Street yp (��) M/�, U Unrestricted Buildings u to 35,000 cu.ft. a/OICtiV �ZI . 1 ' �` f�� � R Restricted 1&2 FamilyDwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding t� SF Solid Fuel Burning Appliances 916, , 11 U.�B . ��� QOIV\•l�c� (`A� Ce�Y�c 1 C G1��•+t� I Insulation Telephone �— Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) n ` 1 ppl q y )-� L'j g O.S 4 n mo /-r-I 4 A hA . N \4 HIC Registration Number Expiration Date HIC Company Name or HIC Regi tr t N SA No.anq Street Qi Email address wo cn okRo► City/Town,State,ZIP 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,as Owner of the subject property,hereby authorize j Al• ,r•\ A 6 L,, n r to act on my behalf,in all matters relative to work authorized by this building permit application. rt pw�aS 4�a e_rR -3-1-7-.3 p 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 www.mass. ov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss 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"maybe substituted for"Total Project Cost" %�he L"f3i.21P_{pFZTugQJy;g DfStitf�iS/2C� iSa_ 6uJ �w 3eVL7rf1nL-Yst of bldrast7'ial A widens -. I' 600 P'esAtngron Stt'eet Ostopz,t r_l 0?_111 14;--'1V P710S.ffov/dia Workers' COBJlPehSadon�o1SE&A'�IInt?. [la g; Builders/'Coiatractors/Electrieiama/Piumbes =� E)L"callt FnTorm.*; r5d C nn GS Please tJsiBt : 41 n Hnle(Businesiorganizdonlndividuat): o �' { l rtc t!J(51 ��ddress: / S !-D /CGt t'nT'hr/lGi S !'Gc��C City/State/zip:k66o—r''(� }��1c( Gl ;'�d --? _ C Phone rr: Are y u an employer? Check the appropriate bps: r t. tr r am a employer.vith SO 4. ❑ I am a general contractor and I Type of project(required); employees(filll and/or part time),= have hired the sub-contractor; o• ❑Ne�v consttuction 2.❑ I am a sole proprietor or partner_ listed on the attached sheet. 7. ❑Remodeling ship and have no employees These sub-contractors have i %vorldng for me in any capacity, employees and have workers' s' ❑Demolition ' NO workers'comp.insurance comp.1nmzance.+' 9. ❑Building addition 3.❑ required.] d. C] We are a corporation and its 10.O Electrical repairs or additions i if am a homeowner doing all tvork officers have exercised their I t trio1 myself No workers'coma, right of exemption per MGL ❑Plumbing repairs or additions insurance re t , g_(,),and we have no 12 Roof re airs gtired.j C.152 i �. ❑ P employees. [No workers, corm.insurance required.] Any applicant;fiat chm'a box r?must also fill out the section blow ahowing t}:ir workers'compensation policy inn"otmatien. HOmeovme s:vho submit this aTdavil indicating thr-y are doing all:vorl and ehen.hire outside contractors must submit a new arxidevit indicating such. 'Contractors that check this boa must artach.-d an addition at sheet showing the name the sub4ontrnetors.and state loyces. if the sub-cont whelhr.ornot those entities have 2r7rectors have emplovess,tfiey must provide their war..ers'COM P.pofiej number. l arn.at,employer that Ispr'ovidirrg workers'conepensatioa insurance information foray employees Below rs tJte policy andJob site Iasuaance Company Marne:�5 S ce r Policy R or SeLi ins.Lic_a `J U (�Cj nn Expiration Date.- Job Site Address: ' Fv K City/State/Zip: 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 IvfGL c. 152 can lead to the-impositioa of cririiinal penalties of a fine up to S 1,500.00 and/orone-year imprisonment;as yell 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 maybe forwarded to the Office of fnveSt ffatioos of the D' for insurance coverage verification ' !do hereb certi tt .L ---`--•— y f3' i nd pen of �ury that t d'—rfo— an provided above is true and correct. Sitmature: Phone4�4� �ffictml use only. Do not write in this area, to be completed by city or town oJficiaL City or Town: Permit/F.icense m issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/iown Clerk 4.Electrical Inspector 5.Plumbing inspector 6. Other Contact Person: Phone r: CITY OF SALEM) MA.SSACHUSETTS BUILDING DEPARTMENT 98 WASHINGTON STREET,2ND FLOOR TEL:.978-745-9595 KIMBERLEY DRISCOLI. MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING CON MUSSIONER 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 deposit facility as defined by MGL c 111,S150A. QU . The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature of applicant (today's date) Window World of.Boston MAHICRegistration Offices St.Showrooms Number: ' 015A Cummings Park- -❑295 Old Oak Street: Cl 1000 Boston Turnpike 166025 .Woburn,'MA 01801 Pembroke,:MA 02359 Shrewsbury,MA 01545 Federal ID# (781)932.4805 (781).826-6281 (50B)'845.6676 82-4898432 t wwva.W indoWWoridofBos.ton.coin Customer: 1 f KJ(�RS 1 faLp �� Phone(h) Install Address: � �'?�fV�i RCJ 1.>�r.\K6 � Phone(c�3 9© -/997 City: z!'�PiYN; M� State:MA ZIn -/9 70. Email WINDOW WORLD GLASS OPTIONS _1000 SeriesSingle-hung All-Weld $249 a _ $259 2 SolarZone.U-Factor27 or Lower S129 iay VV 2000 Series OH All•Weld. �-- 1L4000Serles OH AI!-Weld $269 df _Triple Pane _6000 Series DHAll-Weld $309•. — WINDOW OPTIONS _2 Lite Slider $429. r 'Olass Breakage Warranty(460016000) $151NCLUDED ' _3 Lite SNder p,an.Irn ut<.rie,r+l: $669 $9INCLUOFS. j ✓✓1/2 Screens _Picture,/Fixed file(0-83 UI) $419 Foam Insulation on Jambs and Head $I I INCLUDED _Awninei Fixed Lite-(84 130 Lill $539 Double Strength Glass(40oo)6000) $15`INCLUDED Awning $359 t✓ Double Locks(>26") $51 LUDE q Casement Plus$49(DH'Sash Rail)$379Z`z Full Screens $25. _2 Ute Casement $659. _Colonial Grids(Contoured/Flat) $65 _31.1teCasement pn:w.,m (aorta;) SfM Prairie Grids _Basement Hopper $469 Simulated'Divided Lite; $182 'Bay;Window,Soffit.Mount/'INS SeaL..$2859 71Z—Tempereil DH Sash(BSO)(TSO) $75 Bow Window-Soffit Mount:/INS Seat$2999 Obscure Glass(BSO)(TSO) S75 _Garden Window $2179 _Oriel Style(40/60 or 60/40) S75 _Bay,Bow,Garden.Oversfze (-109 UI);$979 _Foam Enhanced Frame S35 i. _Beige Almond $49 PRE`1978 BUILT HOMES(RRP SAFE RENOVATION Wood Grain Interior(Serles a00016o0oonry)l$100 MY HOME WAS'6UILT IN 7HE YEAR f 95-7 Initia (Ughl Oakl Dark Calk/Cherry!Fox Wood Rich Maple) MISCELLANEOUS _Designer Color Exterior. S179 !?:Custom Exterior Aluminum Cladding(Two-Bend) l _Speciality Window $ O Textured$99 8 SmoothS99 $ { Facing Color (A) e— t' ! Window Color Alle/ / tLlh4e, _Multi-Bend.Cladding $20 Inside outside;, _Install lnlerior/ExteriorStops, $59 S I NON CUSTOM DOORS install lnlerfor/Exterior Casing Starts At$95 Vinyl Rolling Patio.Door Sri.or 6N. S1219 _Repair Sill,Jamb or replace sill nosing $75 ! i i _Vinyl Roiling Pato Doov eh. S1329 _Full Sub-Sill(Single)replacemen(. $175 a _Add to base price lot Custom Rolfing.Patio Door$1259 Insulate Weight Boxes $25 {. f French Hall Sliding Patio Door Sit.or6N. .$1539 _Mull to Form Muill Unit $30. .. i .l _French Rail SNtling Patio Door ell-. S1539 :$50 1 _Mullion Removal ` FrenchRailSllding.PatioDoor9le Si749 Metal,Window.Removal $75 _Custom Exterior.Cladding. $300 SolarZone 5309 —New Construction Platinum Installation $749 _Grids Patio Door $270 ,New Const.Exf Relro FiVRembval $325 a Woodgrain Interiors $399 _Roof for Bay/Bow Windows $500 _Exterior Designer Colors $599 - _Removal of Existing Bay/Bow $250 _Interior Casing 2rR 3+9 5279 Bay/bow Conversion'Ext.Retro Fit $450 Handlesat Options $ —r p ,New Siding Will Not Match) _I Atelier Blinds!(six loot only) 3659 If:Customer cancels after three(3)business days;Window S World shail be entitled to a cancelation fee:equalto 33%percent i Door Color /', of the contract puce as relmburseinent for'thy.expenses i. rns:de Outside associated with a'custom made order.initlal_—.fl�J�.t•_ Customer declines exterior wrap and understands painting and/or repair may br3're ulred Initial ; Customer decline grids on^�_windows/doors initial !: fl DISCLAIMER:Customer Is responsib!e forte fodovdnp In connection vAli rids conbacl:.Painting,Staining,Alarm System'disconneWrecontimt Bul ding lfirimlfeas in- f excess of$25.90,Homeowner and orCmldo Association Approval;Historic District Approval.Cily:afBeaionpaddng&stdewaicPermit fees It.connectlonwnh instaga!ion;: NO EXTRA;WORK;IF,NOT IN-WRITING1 Customer agrees to the terms'of payment as follows; { Extra labor$Materials $ .: Site Set Up,Permit,Disposal.&Delivery Fees$ $399.00 .� `Total Amount$ Custom Order Deposit 33% $1 i"JISI Ck# C:'e Project Start Payment 33% $ ) 173.61 Balance Due Day of Installation$ 1,21(0 Amount Financed If yq Window World oflBoslon anticipates starling this work on r IO AJLgand being substantially completed in f-2 days Secudry nterast Yes. No Any deposit raqufred.in advance of the start of Lha work SHALL NOT exceed 331/U ai Uieiotal conkactprfce or the actual cost a1 anymalerial or equllimanrol a special erderorcustom made nalume which must be ordered in advance of the start of the work to assure that the oro!ecl will proceed on schedule:No final payment shall be demanded unlg the contract Is completed to the sadsladlon of coat parties. - All home Improvement contractors and subcontractors shall tie registered and that any inqukas about a conhacl or subcontractor refatinglo a registration should be tllrected to:Office of ConsumerAUairs and Business Begillation,Tan Park Plate,Sulfa 5170 Boston,1AA 02116;Phone:'(617)973.8700 f i. No work shall begin odor to the signing of the contract and liansmlttat to the owner of a copy of such contract. f Window World of Boston wrier praNs!on of Ohapler 142A of the general laws is required to apply for and obtain all canstruclion-related permits.Window World ul. Better!slid not be deemed responsible for delays in Nalvodi tlascnbed fn Utis agraemenleaUsed by regulatory,permit granting agencies,auihnddes or individuals.. tt Notice:If the PURCHASER(S)obtains his own construction related permits for the work described'undor this agreement or deals Willi unregistered conlraclats, i The PURCHASERS)is hereby,advised that lathe event of a dispule judgemont and nonpaymeoi,the PURCHASERS)will gal bo ehfllled lo.msko a elafm of colledlon from tbe.gearanty fund established by chapler'142A;M G L You the buyer may cancel this transaction at any time prior to midnight of the third usiness day Otter the dale of this transaction: Notice of cancellation mutt be in writing'postmarked no later than midnight of the fallowing[bird business day., k IS A CUSTOM ORDER OT O RESALE! t This Wo dow Ykdd8 Franchise is leda endeng owned and operated by L 8 P.Boston O eratiri Inc.anderf sense from VAndowth'oddr- i Ovrnar.oo not sign if More aro:ahyblank spades. Da o 7jg i :ConsuftanI;:Voj(0WgTl1rlhera are any blank spaces.-Date Oymor:Do not sign it ihore'are any blank spaces. Dato 1, i While Coov=011alrial Yellow Copv Fle: :Phudopy-Customer rcrxs an;,n�oasosera r,e Full \iafma: 3:ja Cwner Narn.a:- Lkenie,Address:hiigrmation I citif gan-ver3 S ate: MA Zo-coda..- 04,92" 'LCOun,tnr: United.States Liceriae Imformation CS 072772' Licansa:T pa:. Construction Super-iisor ProT sidn E*&,of, ast R-anevivai: 3/10/2,01-3 Ah- Dat-- 4/7 2-02.0 .6/;31' 4, oi X 0 , j 1A ' Chan 0,5 177j: -4, S. M - hq_. zjq yr, Zk"SH WO-A, .................. .. ..................... . Office of Consumer Affai(s&Su'siries's Regulation HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only TYPE:Suonlement Card Registration Expiration before the expiration date. If found return to, Office of Consumer Affairs and Business Regulatid 01/0212022 1000 Washington Street - Suite 710 L&P BOST ON,QPERATINQ:INC Boston,MA 021 IS STEELE I 5A CUMMINGS PARK..-: 0108URN. MA 01,301- Undersecretary valid without Signature j 1A e- ,-A 2 '1"-, r CERTIFICATE OF LIABILITY INSURANCE GATE(MM/DDIYYYY) THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.3 0 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 have ADDITIONAL INSURED provisions Or be endorsed. If SUBROGATION IS WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in liewof such endorsement(s). PRODUCER NAME: M.P.Roberts Insurance Agency Inc. PHONE 1060 Osgood Street A/C No Ext: 978.683-8073 AIc..No: 978-683=3147 North Andover,MA 01845 E-MAIL ADDRESS; mike@mprobertsinsurance.com INSURERIS)AFFORDING:COVERAGE NAIC q INSURED wsURERA: WESTERN WORLD INS COMPANY INSURER a: MERCHANTS INS COMPANY L&P BOSTON OPERATING,INC INSURER c: ASSOCIATED EMPLOYERS DBA WINDOW WORLD OF BOSTON 15A CUMMINGS PARK INSURERD: NAUTILUS WOBURN,MA 01801 INSURER E: COVERAGES INSURER F: CERTIFICATE NUMBER: 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. NOPMTHSTANDING 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. INSR LTR TYPE OF INSURANCE INSD WVD POLICY NUMBER POLICY EFF POLIC EXP x COMMERCIAL GENERAL LIABILITY MMIDD/YYYY. MM/DD/YYYY LIMITS EACH OCCURRENCE S 1,000,000 CLAIMS-MADE OCCUR PREMISES iEa occurrence S 100,000 A MED EXP(An- one erson) S 5,000 GEPPL AGGREGATE LIMIT APPLIES PER: :A Y NPP8525379 04/05120 04/05/21 PERSONAL3DVINJURY S 1,000,000 PRO- GENERAL 5 X 2,ODO;000 .POLICY JECT LOC OTHER.: PRODUCTS-COMP/OPAGG a 1,000,000 AUTOMOBILE LIABILITY S COMBINED SINGLE LIMIT 5 ANY AUTO tEa accident 1,000,000 B BODILY INJURY.(Per person) S AUTOS ONLY AUTOS UL�D MCA1002569 HIRED NON-OWNED 04l0$!20 04/65/21 BODILY INJURY(Per accident) S AUTOS ONLY -x AUTOS ONLY PROPERTY DAMAGE S mer accidentY UMBRELLA LIAB S x OCCUR D EXCESS LIAB CLAIMS-MADE AN065362 EACH OCCURRENCE 5 1,000;000 04/05/20 04/06/21 AGGREGATE 5 1,000,000 ED RETENTION S WORKERS COMPENSATION S AND EMPLOYERS'LIABILITY 5TATUT'E .OETTH ANY PROPRIETOR./PARTNER/EXECUTIVE Y/N C OFFICER/MEMBER EXCLUDED? a N/A 5018609 04105/20: 04/05121 E:L,EACH ACCIDENT 5 1,000,000 (Mandatary in NH) Ityes.describeunder E.L.DISEASE-EA EMPLOYEES 1,000,000 DESCRIPTION OF OPERATIONS below E.t_DISEASE-POLICY LIMIT 5 1,000,000 A BUSINESS PERSONAL PROPERTY NPP8365971 04/05l19 04l05l20 340;000 DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (ACORD 101,:Additional Remarks Schedule,may be attached-it more space is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN EVIDENCE OF INSURANCE ACCORDANCE WITH.THE POLICY PROVISIONS. AUTHORIZED REP EgEOTATIVE `� ©1988-2015 ACORD CORPORATION. All rights reserved. ACORD 25(2016103) The ACORD name and logo are registered marks of ACORD