B-19-1226 - 0037 UNION STREET - Building Permit The Commonwealth of Massachusetts C �y', :�, ,4, ,,��,rr
® Board of Building Regulations and Standards
Massachusetts State Building Code'780 CMR SALEM,
.7319 , 'V1RcvlsedAIar 20
Building Permit Application To Construct,Repair,Renovate Or Demolish a f
One-or Two-Family Dwelling
This Section For Offi ciaLJse Only a
Building Permit Number , ' Date Applied
"_l Building Official(Print Name) Signature Date
SECTION.1 SITE,INFORMATION
1.1 Pro a Ad ress:, 1.2 Assessors Map&Parcel Numbers
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? Municipal❑ On site disposal system ❑
Check if yes❑
,` • . ;SECTION 2: PROPERTY OWNERSHIP'" � � k,;,, ,
`Owner of ecord:
N /Pin)
o.and Street Telephone Email Address
SECTION 3 pESCRIPTIONOF PROPOSED WORKZ(check all that apply) �
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify: D,.
Brief D,escription of roposed Workz: f
9L GV
.�^
SECTION STIlVIATED`CONSTRUCTTON CbSTS
Estimated Costs
Item Official Use Only
Labor and Materials
1.Building $ t) 1 But}dmg Permit Fee $ Indicate how fee is determined
❑Standard City/Town Application
2.Electrical $ ❑Total Pro e'ct Costa Item 6 x multi 'her x,a
J ( ), p
3.Plumbing $ 2 Other Fees'
4.Mechanical (HVAC) $ Ltst
S.Mechanical (Fire $ Total All Fees;$
Suppression)
s
Check No Check Amount � Cash Amount
6.Total Project Cost: $ �v �❑Paid}m Full ; ; ❑*Outstanding Balance Due ,,,, .x
004
PHq
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor Lie se(CSL) /O O
R��'ot/ Z
(� License Number Efcpiration ate
ame f CSL Holder
List CSL Type(see below)
-e- y
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.)
R Restricted 1&2 Family Dwelling
Ci /Town te, IP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
(f� I Insulation
Telephone Email address D Demolition
5.2 Resistered Home Improvement Contr,#ctor(HIC)
V Q HIC Regis tra'on Number (�Ex iration Date
C o y N, e or HIC e trant N
0. S et �/J`.� fao ��� � y� Email a s
Ci own,S te,ZIP � Telephone
,,j
SECTION 6:WORKERS'COMPENSATION INSCTRANCE 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 BUILQIYG PERMIT
I,as Owner of the subject property,hereby authorize S�"-,-J
tq,ffe9Dn my be If,in all matters relative to work authorized by this building peAbit application.
o �a
P ' t wner' ame ctro Signature) Difie
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 t is application is t nd accurate to the best of my knowledge and understanding.
Print Owner's or Authorized gent's Name(Electronic Signature) Dafe
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/dps
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 dec " orches
Type of cooling system Enclosed Open
Lff
3. "Total Project Square Footage"may be substituted for"Total Project Cos (�
i CITY OF SM� E.M,'N A SSACHUSETTS
• BUMMING DEPARTMENT
' 120 WASHINGTON STREET,3w FLOOR
TEL (978)745-9595
FAX(978)740-9846
KI.N{BFRT i+-Y DRISCOLL
THo
MAYOR I`l�s ST.PIERRfi
DIRECTOR OF PUBLIC PROPERTY/BI:ILDI;VG COMMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Tattle(Business/Organizationandividu ): -
Address: k
City/State/Zip: h i0 Phone#:
A e an employer?Check t ro rate box: Type of project(required):
1. �am a employer with--� 4. [11 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached shcet.+ ?• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance, 9. ❑Building addition
[No workers'comp,insurance 5. ❑ We are a corporation and its
required.[ officers have exercised their
1013 EIectrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Pt repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.Woof repairs
insurance required.)t employees.[No workers' 13.0 Other
comp. insurance required.]
•Any applicant that checks box pl must also fill out the section below showing their workers'compensation policy information.
t I fumeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
'Contructors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I am an employer that is providin workers'compensation insurance jar my employees. Below is the policy and,fob site
information.
insurance Company Name: V q
Policy#or Sall-ins.Lic.# ,f ��d 4o Ir Expiration Date: c512Aht0ZV
Job Site Address��� !/, ���_ d City/State/Zip: le
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 S1,500.00 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 advised 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 uler 30e pains Pe !tl of perjury that the infartnation provided above is tr and c rrect p
> t re• Date:
Phon #:
Official use only. Do trot write in this area,to be completed by city or town ofciat
City or Town: Permit/License 1#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other...
Contact Person: _ Phone#:
f CITY OF SOU EL 11►L�SS.�CH SETTS
13UUMLNG DEPARTMENT
120 W.A.SHLNGTON STREET, 3'0 FLOOR
TEL (978) 745-9595
FA.X(978) 740-9846
ICI�iBERI_EY DRISCOLL
MAYOR THot*w ST.PiERRE
DIRECTOR OF PUBLIC PROPERTY/11UUMING CONMaSSIONER
Construction Debris Disposal 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 c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:( ame of hauler)
The debris will be disposed of in
,:7,o a & d
(name of facili }
(address of facility)
signature of pe it applicant
! i -/
date
dcbrisafr.doc
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300.111 OU04
gourd of Building Requiaitioins and 5tandatds space..'.
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faAura to posss."s'a.current editiari aline thfsz canes.
State gutlt#ing Code is cause for reXocallon.
ic#or�ttetion about this license.
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DATEIMMfOD/YYYY)
A65RD CERTIFICATE OF LIABILITY INSURANCE
i0a� 0311912018
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 INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the policy(les)must be endorsed. It 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).
aaooucER CONTACT
nAkk:_1 -__Maryellen Goodwin_ __.__
DAVID E ZEILER INSURANCE AGENCY INC PHONE (781)595_207 FAX
dYAIL ...�.,.......... —_
Aooaess;_ma ellen®davldzeller.com
370 LYNNWAY INSURER(S)AFFORDING COVERAGE NAIC N
-_
LYNN MA 01901 INSURER A: LM INS CORP 33600
INSURED INSURER 8
HEIGHTS ROOFING INC wsuRERc:
INSURERD
190 HAMILTON AVENUE APT 3 INSURER E:
LYNN MA 01902 1 INSURER F
COVERAGES CERTIFICATE NUMBER: 248481 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
r i 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
_ ....�.. _.._ ..-_....._.,..r.,....
k. 'lNSR - ��, .0.�.._._._.._._..._.,.,..__—...,..�...__,..__....,:POLICY EFi_P�!
TYPE OF INSURANCE POLICY NUMBER MIDWYYYY LlMrts
i CO"ERCIALGENERALLIAMIITY....._ - .. -
EACHOCGiIRRENCc
_ CLA NIS-MAD_ «J OCCUR PREMISESpEa o ffenw, S
— _ NIA PERSONAL ADV INJURY S
GENT AGGREGATE LIMIT APPLIES PER GENERALAGGRES47M
PRO.
�;.POLICY,_.�..)ECT LOC PP.ODuC S•COMPfOPAGG S
OTHER _...
AUFOMDBILELUIBIUr Y CGba1' D SINGLE LIMIT ..$
rEe cC^.1bnl;
ANY AUTO 900,L`r INJURY toot wsoni S
ALL Onw'c0 _~ UTOSULEO
AUTOS NIA SOD L"INJURY IPer 8=denq S
:tTps
HIREOAtr OS
NON-OWNED PRO°Et7'TYDA IAGc S
AUTOS Pw ewdera__,
— S:
UMBRELLALIAB ,�.._ OCCUR EAC+-OCC'RR NC - S :. .
EXCESSt.IAS CLAIMS MMADE NIA AGGREGAT,E. S
. . DIED
WORKERScOMPENSAnoN X S ,Ta E ORh
AND EMPLOYERS'LIABILITY Y I N __"•'-
ANYPR07RIETGRRARTNERfE3ffiCUTIVE E L EACHACODEN'T S 100,000
A OFFICERWEMSEREXCLUD5DI wA NIA NIA WC531S609827028 011&2019 03/20no20
(Mandatchr in NH) E L DISEASE•EA EMPLOYEES 100,000. ,
DESCRIPTION OPERATIONS 00" .. E 1.DISEASE-POLIO' LIMIT s _500,000 ..
NIA
DESCRIPTION OF OPERATIONS LOCATIONS I VEHICLES(ACORD 101.Add)Ua Ml.Ramarks Scnadulo,may be attached if more apace Is npuaao)
Workers'Compensation benefits will be paid to Massachusetts employees only.Pursuant to Endorsement WC 20 03 06 8,no authorization Is given to pay
claims for benefits to employees in states other than Massachusetts if the insured.hires.or has hired those emmployees outside of Massachusetts.
I his 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 th'Is certificate of insurance). The status of this coverage can be monitored daily by accessing the Proof of Coverage-Coverage Verification
Search tool atwww.mass.gov/1 A workers-compensaUon/investigations/
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED 1N
hi@IgFlt$ ROOflf19 Inc ACCORDANCE WITH THE POLICY PROVISIONS.
Evidence of Work Comp for Ins Purposes Only
AUTHORIZED REPRESENTATIVE
Lynn MA 01.902 Daniel M.Crowley.CPCU.Vice President—Residual Marken—WCRISMA
O 1988-2014 ACORD CORPORATION. All rights reserved.
ACORD 2$.(20T4/01) - The ACORD name and logo are registered marks of ACORD
ACO DP CERTIFICATE OF LIABILITY INSURANCE °AT�IM'o3/191201820`18"
THIS CERTIFICATE 13ISSUED 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(les)must have ADDITIONAL INSURED provisions or be endorsed.
If SUBROGATION 13 WAIVED,subject to the terms and conditions of the policy,certain policies may require an endorsement. A statement on
this cer0ficete does not confer rights to the certificate holder In lieu-of such.endorsemert(s).
PRODUCER N MaryElien Goodvnn
David E.Zeller Insurance Agency.Inc. Ar (781)595-2071 1 "Jok ao, (781)823-1052
370 Lynnway 53: maryellenodevldzeller.com
INSU )AFFWDING COVERAGE.. NAfC 0 .
Lynn MA 01901 INSURER A: Western.World
INSURED INSURER e
Heights Roofing Inc INSURER C;
190 Hamilton Ave Apt 3 INSURER O:
INSURER E:
. Lynn .. MA M 902 INSURER F:
COVERAGES CERTIFICATE NUMBER: CL1831902694
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 LTR TYPE OF INSURANCE POLICY NUMBER 1e= LIMITS
X COMMERCIAL GENERAL IJABILITY EACH OCCURRENCE S 1.000,000
ANTED
CLAWS-MADE D OCCUR PREMISES Eeomcrranm S 100,000
MEO EXP)An one mton1 5 �.0
A NPP8476177 03/Oif2019 03/01/2020 1.000.000
.PERSONALdADV INJURY S
GEN'L AGGREGATE LIMIT APPLIES PER, GENERALAGGRESATE 5 2.000.000
X POLICY Q JECT LOC PRODUCTS-COMPIDPAGG 5 2,000.00D
.OTHER•. . $
AUTOMOBILEUAB11M 9,N 0 SINGLE LnArT S .
Ea eradem_
ANY ALTO ecoiLY INJURY(Per pemaon) 5
OWNED SCHEQULEI}
AUTOS ONLY -AUTOS BOOILY INJURY(Per adcdern) S
HREO- -NON-OWNED - 5
AUTOS OM Y AUTOS ONLY Per acadev0
S
UM848LLA LIAO' HCLAJMS-MAOE
OCCUR' EACH OCCLRRENCE 3
EXCESS LIAa AGGREGATE S
DED RETENTIONS S
V11010( aGOMPEN"Ti0N" P R OTH:
AND EMPLOYERS'LIABILITY TIN iATUTE ER
ANY PROPRIETOWPARTNEWEXECUTIVE NIA EL EACH ACCIDENT 5
OFFICER/MEMBER EXCLUDED'm
DAanduory in NH) EL DISEASE-EA EMPLOYEE S
11 FEaa.duoioe uFaer
DESCRIPTION�OPERATIONS below E L DISEASE..:POLICY tIM11 S
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES(ACMD 101,AcWdora,Remarks Schedule,may he atWftd H rnae space to naWmd)
Evidence of General Liability,coverage is subject to policy terms.conditions and exclusions,
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 for information Purposes Only ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHOQM REPRESEHTATM
01988.2015 ACORD CORPORATION. All rights reserved.
ACORD 28(2016/03) The ACORD name and 1000 are registered marks of ACORD
f <
Page 1 of 2
HEIGHTS
ROOFINGNC.
Proposal
Property address
37 Union St 10/27/2019
Salem, MA 01970
Dear: Cornerstone Lafayette LLC.
Based on my visit to the property located at the above address and our discussion, I have prepared the
following proposal. Please review the following outline of the general specifications and the work
required in order to complete the job to your property.
The following project/work will be completed in accordance with the building codes set forth by the
Commonwealth of Massachusetts 780 CMR:
_q-2 6/1101-7 �'✓'
Description of Job:Residential Property located at
Remove the old slate roof system and throw them in the dumpster that the we will rent.
➢ Re-nail existing roof boards where needed (using 8D Pressure Treat Galvanized Ring shank Nails)
➢ Install 3'feet of Ice&Wather Shield from roof edge,vent pipes, skylight and chimney.
➢ Apply O.C. Deck Defense High Performance Roof Underlayment after 3'feet of Ice&Wather
shield.
➢ Install WHITE heavy duty aluminum drip-edge and rake-edge.
➢ Install new Timberline Ultra HD Shingles, using 1-1/4 Hot dipped Galvanized Roof Nails.
(5 per shingles).
➢ Install aluminum pipe boot flashing on all pipes.
Labor and Materials:$6,500
HEIGHTS ROOFING INC.
73 Urban St LYNN, MASS 01904
TEL: 781-913-4404
Page 2 of 2
Work could begin within (2) weeks of acceptance and take approximately (2) days to complete,
depending on the weather. Once started, all work will be performed in a timely and professional
manner. Please note that any changes to the above listed specifications would have be discussed and
re-evaluated as expected.
Payment schedule: Payment is required in the following manner: thirty-five (35) percent of contract
sum is required upon acceptance of agreement(to be used towards the purchase of materials), and the
remaining sixty-five (65) percent upon completion of the job.
CONTRACT ACCEPTANCE: Signing this proposal means you have accepted the terms and specifications
as stated in the proposal and authorize HEIGHTS ROOFING INC to begin work at your property. In
addition, the signing of this proposal by both parties' converts this proposal to a binding contract
between the two parties.This proposal may be withdrawn by us if not accepted within 30 days.
ACCEPTED BY: SUBMITTED
Signatu Af Signature:
n con rag
or
By: By.:,... Roni Lopez, Heights Roof R Inc.
'Date accepted:_Ae Title: President/Owner
GUARANTEE:Ten 10 years roof leak repair from completion date.
The warranty shall protect the owner from damage to the building resulting from roof leakage for a period of ten (10)years,
beginning from the date of completion of the project. The warranty shall cover and include repair or replacement of any
damaged exterior structure,interior structure of the building,resulting from roof leakage directly attributed to the contractor's
workmanship.
HEIGHTS ROOFING INC.
73 Urban St LYNN, MASS 01904
TEL: 781-913-4404
v..._•.•_...- :,,.. �.:. : .-�, ,•tom - �
J ..
Office of Consumer Affairs&Business'Regulation
HOME IMPROVEMENT CONTRACTORs
TIE; ndnndual
R
i .06/04/2020.
STEVEN HIOU
i el
.STEVEN HIOU
2 NEPTUNE RD.
f _BOSTO'N,MA"021 8-
E.
1' .5 Undersecretary
L.-