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B-20-773 - 0093 BRIDGE STREET - Building Permit S . cr-ga �5-1 d 5� S The Commonwealth of Massachusetts p , Department of Public Safety VVV��yll�ll `� Massachusetts State Building Code(780 CMR) ^n Building Permit Application for any Building other than a One-,or Two-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ Alteration ❑ Addition ElDe olition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other pecify: Are building plans and/or construction documents being supplied as part of this permit app cation? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: � ^ SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP,(Check as applicable) A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ElIB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ VA D VB ❑ SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal: pp y Public D Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ : Private❑ or indentify Zone: or on site system required❑or trench or specify ❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review c PH n34 Not Applicable❑ Is Structure within airport approach area? Is their review complete or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ `� SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner kacen Name(Print) No.and Street City/Town Zip Property Owner Contact Information: Title Telephone No.(business) Telephone No. (cell) e-mail address If applicable,the property owner hereby authorizes \ Name Street Address CityllYwn State Zip to act on the property owner's behalf,in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1 10.1 Registered Professional 1Responsible for Construction Control ' o�e r� I o. iU to ')39 b y A Tn - o b Name(Registrant) Telephone No e-mail address Registration Number Soy `�n Qo y 0.k W e� Mft om N)— Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor `� OfT•n a L Com any Name �0 '(V I,. La �.r1� 15u 0 ebg Name of Person Responsible for Construction Li ense No. and Type if Applicable Street Address Ci /Town State Zip Telephone No.(business) Telephone No. cell ` e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6) A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the i uance of the building permit. Is a signed Affidavit submitted with this application? Yes No 13 SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ Q ea Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note;_Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ It oU (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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. Please pri t and sign name Title Telephone No. Date i 3b 0,5 off Sa S Q�cMOt CIA06 Street Address City/ own State Zip Municipal Inspector to fill out this section upon application approval: Name Date The C•ominon wealth of zAlssachusetts �I? .Deptat tattent of lradtcstricrl A cciclefrts j I Con o revs Street, Smite 100 �f.;• ,ol Boston,MA0?.11 4-?01;'1 ww w,na ass.s O v1dia Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansiPiun)bers. TO BE MED WITH THE PERNIITTI\G AUTHORITY. Applicant Information Please Print Le ibiv Name (Business,,Oraanizatior./Individu��aal/l}__: �j N Cj- .ddress:_3b �d S 7y Pt�57`" �DG City/State,/Zip: hl/wlt/ - c7/' 'phone : / O ( � 3 ar.�e You an employer:'Check the appropriate box: Type of project(required): t am a employer with nptuyees(full andior part-tune).' , 7. New construction i am a sole proprietor or partnership and have no employees working for me ut ; 3. El Remodeling 1. any caoactn.(No worker'comp.insurance required.i t I t 9. ❑Demolition I[]I am a hoincowncr doing all work myself[No workers'comp.insurance required.i' � S.❑!am a homeowner and will be hiring contractors to conduct all work on my properly. (wilt t0 O Building addition ensure that all contractor either have workers'compensation insurance or are sole 11.17 Electrical repairs or additions oroprictor.,with no employees. 12. Plumbing repairs or additions j.0 I am a general contractor and 1 have hired the sub-contractors listed on the attached sheet. :hose sub-contractors have employees and have workers'comp,insurance.. + i 3.❑,,Roo f repairs ` C)Q vie area corporation and its officers have exercised their right ofexempoun per.\K;L a. ; 14.[ [her %1'42C .'1(4),and the have no employees.iNo workers'comp.insurance required.l I .\ny applicant that checks box 91 must also Fill out the section beloty;showing their%vorkers'compensation policy infonnation. Itntteowners who submit this affidavit indicating they are doing ail 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,ub•contractor and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. 1 am an employer that is providing workers'compensation insurance for sry employees Below is the policy and job site information. • r� a �/ , Insurance Company Name: qj dt'/Arl /V 4,j Policy#or Self-ins. Lie.T: '6 t� r0 0 U L21 �� ��5 / �l piration Date: Job Site Address: T `—�C-��cA t S� City/State/Zip: Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). J Failure to secure coverage as required under MGL c. [52,§§'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 Investiaations of the DIA for insurance coverage verification. do hereby certi under the and penalties of perjury that the information provided above is true and correct Signature: Date: el�.o Phone 4P 3 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Perrnit/License# Issuing.Authority(circle one): L Board of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone#: a' CITY OF SALEM) MASSACHUSETTS BUILDING DEPARTMENT 98 WASHINGTON STREET,2ND FLOOR TEL: 978-745-9595 KIMBERLEY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER Construction Debris Disposal Affidavit ' idavit (requiredfor 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. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility ddress of facility) Signature of applicant (today's date) HOME IMPROVEMENT CONTRACT Sold,Furnished and Installed by: Date: 06/03/2020 LaBelle Roofing,Inc. 304 Boston Post Road,Wayland,MA 01778 Job#: 5069 pry Phone:508-358-7663•Fax:508-358-7662 l Federal ID#20-8350649 MA Home Improvement Contractor Reg.#154084 Installation Address: 93 Bridge Street,Salem,MA 01970 City State Zip Purchaser(s) Work Phone: Home Phone: Karen Crosbie ((805)6*-8330 ((805)631-8330 Project Information:I/We/You("Purchaser"),the owners of the property located at the above installation address,offer to contract with LaBelle Roofing,Inc.to furnish,deliver and arrange for the installation of all materials as described on estimate#: 5069 LaBelle Roofing,Inc.reserves the right to cancel this contract if,upon re-inspection of the job,'LaBelle Roofing,Inc.. determines that it cannot perform its obligations due to a structural problem with the home or because work required to complete the job was not included in the contract. Contract Amount $ 4 833.00 • Deposit: Less Deposit $ 1,611.00 Please mail check or call with credit card for deposit payment. • Final Payment: Balance Due on Completion $_3,222.00 Due upon job completion,payable by check. Purchaser agrees that,immediately upon satisfactory completion of the work,Purchaser will pay any balance due.Purchaser also agrees to be jointly and severally obligated and liable hereunder. Entire Agreement:This agreement and its attachments,including any financing agreement,contain the complete agreement between the parties and cannot be amended or modified unless in writing in a separate agreement signed by both parties. NOTICE TO PURCHASER Do not sign this contract before you read it.You are entitled to a completely filled-in copy of the contract at the time you sign.Keep it to protect your rights.Do not sign any completion Certificate or agreement stating that you are satisfied with the entire project before this project is complete.Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to the actual completion of the work to be performed under the contract. BY MY/OUR SIGNATURE BELOW,1/WE AGREE TO BE BOUND BY THE TERMS OF THIS CONTRACT. 1/WE ACKNOWLEDGE RECEIPT OF A COPY OF THIS CONTRACT AND TWO COMPLETED COPIES OF THE NOTICE OF CANCELLATION. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES. SUBMITTED BY: _ t Date 06/03/2020 Sa es Consultant ACCEPTED BY: P.-SldneCl by Karen Grasbie Date 06/03/2020 �. Homeowner NOTICE:ADDITIONAL TERMS,CONDITIONS AND WARRANTIES ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT. HOME IMPROVEMENT CONTRACT The Purchaser understands that: L Purchaser is required to have any security/alarm systems disconnected prior to the commencement of work. Neither LaBelle Roofing,Inc.nor its independent contractor will disarm,arm,remove,install or reinstall a security or alarm system. 2. Purchaser is responsible for removing all breakable items form walls and shelves inside the home prior to installation. 3. Miscellaneous labor for work not included in the estimate will be billed at$75.00 per man-hour plus materials.Rotted or damaged fascia or rake board can be replaced at$9.00 per linear foot for primed pine and$18.00 per foot for PVC Board. 4. Any surplus materials remaining after completion of this job shall remain the property of LaBelle Roofing Inc.and no credit is due to Purchaser with respect to such excess materials. 5. Performance of this agreement on the part of LaBelle Roofing,Inc.,its successors and assigns,and any and all subcontractors engaged by it or on its behalf and hereby authorized to perform work listed herein,shall be subject to delay due to acts of God and other causes beyond the control of LaBelle Roofing,Inc.,including without limitations,strikes and other labor disturbances,fires,wars and civil insurrection,inability to obtain materials or labor, and orders by any governmental agency,and LaBelle Roofing,Inc.,shall not be liable.Purchaser represents that no other representation or promise has been made to be relied upon by purchaser regarding any of the aforementioned matters. 6. Purchaser indemnifies and holds harmless LaBelle Roofing,Inc.and its employees,authorized contractors and their subcontractors from any claims as to the identification,detection,abatement,encapsulation or removal of asbestos,lead based products,mold or other hazardous substances inside or outside of the structure being improved. LaBelle Roofing,Inc.is NOT responsible for: 1. Pre-existing violations of building,electric,plumbing,or other governmental codes with respect to the premises. Corrections of violations are the responsibility of Purchaser and Purchaser represents and warrants that no such violations exist. Purchaser understands that LaBelle Roofing,Inc.will rely on such representation and warranty. 2. Rotted or damaged wood that is hidden or not visible,unless otherwise noted on the Specification Sheet. If,after work commences,LaBelle Roofing,Inc. finds any rotted or damaged wood,LaBelle Roofing,Inc.will provide Purchaser with a price for replacing the rotted wood,which will be in addition to the contract amount. Mediation: In the event that you and LaBelle Roofing,Inc.are unable to resolve any dispute which arises out of this Agreement or the Installation,you agree that before filing a lawsuit you will participate in mediation in an effort to fully resolve the dispute. That mediation will be at least one-half(1/2)day in length, utilizing an experienced mediation service acceptable to you and LaBelle Roofing,Inc. Start and Completion: Subject to obtaining credit approval in the case of financed purchases,the work described in this contract is estimated to begin within approximately eight weeks of the date of this contract and to be substantially completed within twelve weeks of the date of this contract. Note: These estimates are subject to the following DELAYS IN INSTALLATION conditions: LaBelle Roofing,Inc.shall not be liable for delays due to reasons beyond its control,including without limitation fire,Acts of God,labor or material shortages,war,government regulations,delays caused by Purchaser or Purchaser's other contractors. Home Improvement Installation Contract For Massachusetts Residents Only Contractor Arbitration:The Home Improvement Contractor Law provides homeowners with the right to initiate an arbitration action(as an alternative to court action)if they have a dispute with a contractor.However,the same right is not afforded to a contractor.The contractor would have to resolve any dispute he/she has with a homeowner in court unless both parties agree to the optional clause provided below.This clause would give the contractor the same right to arbitration as is afforded to the homeowner by the Home Improvement Contractor Law. r Homeowners Rights:A homeowners rights under the Home Improvement Contractor Law(MGL chapter 142A)and other consumer protection laws(i.e. MGL chapter 93 A)may not be waived in any way,even by agreement.However,homeowners may be excluded from certain rights if the contractor they chose is not properly registered as prescribed by law.Homeowners who secure their own building permits are automatically excluded from any Guaranty Fund provisions of the Home Improvement Contractor Law.The contractor is responsible for completing the work as described in a timely and workmanlike manner.Homeowners may be entitled to other specific legal rights if the contractor guarantees or provides an express warranty for workmanship or materials. In addition to guarantees or warranties provided by the contractor,all goods sold in Massachusetts carry so implied warranty of merchantability and fitness for a particular purpose.An enumeration of these matters on which the homeowner and contractor lawfully agree may be added to the terms of the contract as long as they do not restrict a homeowners basic consumer rights. If you have questions about your consumer/homeowners rights,contact the Consumer Information Hotline(listed below). Execution of Contract: The contract must be executed in duplicate and should not be signed until a copy of all exhibits and referenced documents have been attached.Parties are also advised not to sign the document until all blank sections have been filled in or marked as void,deleted or not applicable.One original signed copy of the contract with attachments is to be given to the owner and the other kept by the contractor.Any modification to the original contract must be in writing and agreed to by both parties.Contracted work may not begin until both parties have received a fully executed copy of the contract. Accelerated Payments: A contractor may not demand payments in advance of the dates specified on the payment schedule in cases where the homeowner deems him/herself to be financially insecure.However,in instances where a contractor deems him/herself financially insecure,the contractor may require the balance of funds not yet due be placed in a joint escrow accounts as a prerequisite to continuing the contracted work.Withdrawal of funds from said account would require the signatures of both parties. Additional Information: If you have general question or need additional information about the Home Improvement Contractor Law or other consumer rights, or if you wish to obtain a free copy of "A consumers Guide to Home Improvement Contractor Law"contact the Consumer Information Hotline at: Executive Office of Consumer Affairs•One Ashburn Place,Room 1411•Boston MA 02108.617-727-7780 If you want to verify the registration of a contractor or if you have additional questions or need additional information specifically about the contractor registration component of the Home Improvement Contractor Law,contact the director of Home Improvement Registration at: Director,Home Improvement Contractor Registration•One Ashburton Place,Room 1301•Boston,MA 02108.617-727-8598 For assistance with informal mediation of disputes or to register formal complaints against a business,call: Consumer Complaint Division•Office of the Attorney General•617-727-8400 P , a OWNER AUTHORIZATION 5069 TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR A BUILDING PERMIT I Karen Crosbie , as owner of the subject property 93 Bridge Street,Salem,MA 01970 hereby authorize LaBelle Roofing to act on my behalf in all matters relative to work relating to this building permit application, and all permitted work. 06/03/2020 e-S+Qr�ec y KaFeR Gre6"i Si rib re of Customer Date " Hsu e z V-1 Or o ... � TIr ZV - .. KPL IN"K_ ? x _70 TRACTOR corlborq LA ya r �j STGN { � t AYL A Of 778..E .. ndersecree ;ac R CERTIFICATE OF LIABILITY INSURANCE °ATEYYY' os/08/20208/2020 THI 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 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 of 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 endorsement(s). PRODUCER CONTACT NAME: Peggy Sawyer D FRANCIS MURPHY INSURANCE AGENCY INC PHONE E (508)787-5101 Fa No: ADDRESS: psawyer@dfmurphy.com 50 MAIN ST INSURERS AFFORDING COVERAGE NA►C# HUDSON MA 01749 INSURER A: HARTFORD UNDERWRITERS INS CO 30104 INSURED INSURER B LABELLE ROOFING INC INSURERC: DBA WAYLAND SKYLIGHTS INSURERD: 304 BOSTON POST ROAD INSURER E: WAYLAND MA 01778 INSURER F: COVERAGES CERTIFICATE NUMBER: 541517 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. 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 ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR I ADDL SUBR POLICY EFF POLICY EXP LTR TYPE OF INSURANCEINSD POLICY NUMBER MMIDD MMIDD LIMITS COMMERCIAL GENERAL LIABILITY EACH OCCURRENCE $ 1-1 DAMAGETO RENTED CLAIMS MADE OCCUR PREMISES Ea occurrence $ MED EXP(Any one person) $ NIA PERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ POLICY❑JECTPRO- ❑ LOC PRODUCTS-COMPlOP AGG $ OTHER: $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ Ea accident ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED N/A BODILY INJURY Per accident $ AUTOS AUTOS ( ) NON-OWNED PROPERTY DAMAGE HIRED AUTOS AUTOS Per accident $ $ UMBRELL.ALIAB OCCUR EACH OCCURRENCE $ EXCESS LJAB CLAIMS-MADE N/A AGGREGATE $ DED I I RETENTION$ $ WORKERS COMPENSATION /� STATUTE ERH AND EMPLOYERS'LIABILITY Y/N A OFF CER/MEM ERREXCLUDED?ECUTIVE wA N/A N/A 6S60UB7H93534920 03/22/2020 03/22/2021 E.L EACH ACCIDENT $ 500,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 500,000 If yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT It 500,000 N/A DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES(ACORD 101,Additional Remarks Schedule,may be attached If more space Is required) 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 Verification Search tool at www.mass.gov/lwd/workers-compensation/investigations/. CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE 1 Daniel M.Crqyey,CPCU,Vice President—Residual Market—WCRIBMA ©1988-2014 ACORD CORPORATION. All rights reserved. ACORD 25(2014101) The ACORD name and logo are registered marks of ACORD