2 ANDOVER ST - BPA-10-821 REPOINT 2 CHIMNEYS r \
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7'x edition OF SALEM
14 Revised January
(V1�, Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Fanyry)Dwelling
This Section or Official Use Qtdy
Building Permit Numb D Applied /
Signature: 1/0� ( —
Building Commissioner/Inspector of Build' Date
V ,c SECTION VSITE INFORMATION
1.1 _ perty dress: 1.2 Assessors Map&Parcel Numbers
l.la Is this an accepted street9 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(R)
Front Yard Side Yards Rear Yard
Required Provided Requited Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Pubflc Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
ame ' Address for Service:
- 6 f"
Si Teleph e
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building-P Owner-Occupied ❑ Repairs(s) & I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Pro sed World:
�hiVtk t�jy C VV% V-\ S.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs' Official Use Only
abor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ /
4.Mechanical (HVAC) $ List: �f P o t//�
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) c,a(...q cfja4l1 O
r `�"J CnA\CA l_• r"1f'.\Me'riLGU License Number Expuauon Date
Name of CSL-Holder.-
.SA n t 1•QC. List CSL Type(see below)
A Y L TyDe Description
AMI
• _ U Unrestricted u to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
CI")SS- L°I�lft-�" � RC Residential Reefing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.1�, yeoe d Hmnent Contractor(HIC)
�2
\3q llp
Inc Com y e or HIC Registrant a Registration Number
3 Nim�n\� v\� G( \G i QQA(Zw�c71� WIC � � It �avtl
Address
Expiration Date
Signature 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 ..........00 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
-OWNEWS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
J �
I, I as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative towdrk authorized by this building rmit annlicah�n�
Si arre of Owner Date
TION 7b:OVtNEAr,dk AUTHORIZED AGENT D CLARATION
1, -Pa 1 O CCl (L.2e 0.-- ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. V\y G::5
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of
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 and !
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
P.Correia Construction
Phone : 978-979-4876 / 978-979-4437 E-mail: scunha25@comcast.net
Contract
Bill To: David Trainor Date: 05/08/2010
25 Beckford St
Salem, Ma. 01960
Job Description:
In this project will consist of:
Chimney Work
• Grind out all existing mortar on both chimneys and re-point using sand, mortar and Port-
land cement mix
• Remove shingles around the chimney
• Install Ice-Water Shield a minimum of 3' around the chimneys be able to guarantee the job
• Install new shingles to replace the ones remove
• Remove existing flashing around the chimneys
• Install new flashing with a 2" deep into mortar joints and re-point and with it extending in a
reasonable perimeter to the chimneys
All work shall be done in a professional and timely manner according to standard practices and
conforming to State Building codes.'
I
"*Please note all materials, rental of machinery, clean-up and labor are included in price.*
Deposit$ 3,000.00
At the end of the job: $ 3,500.00
Total : $ 6,500.00
Thank You for Your Business
\�at� �G arantee for 10 years/
U
Homeowner Signature: Date:
Contactor Signature: Date:
CITY OF S. .F.N1, .•LkSS.A.CHUSETTS
• ButI.DING DEPARTMF NT
130 WASHINGTON STREET,3'a FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KI\1BERLF-Y DRISCOLL
i�fAYOR THOMAS ST.PIERR6
DIRECTOR OF PUBLIC PROPERTY/BVILDLNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business.Organizatioevindividual): !C l/�C)Q-ee\CA Cc, �.asltzsg c4i on
Address: �3 J UWa"A
City/State/Zip: �{O ��I t NVk- O�CL(00 Phone#: ggcl— Ll 6 r)
Are you an employer?Check the appropriate box: Type of project(required):
1.1p I am a esnployer with 1_ 4. ❑ I 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 sheet.: 7. ❑Remodeling
ship and have no employees These sub-contractors have B. ❑Demolition
workingfor me in an capacity. workers'comp.insurance.
Y lour tY• 9. ❑Building addition
� [No worker'comp. insurance 5. ❑ We are a corporation and its
required.) officer have exercised their 10.❑Electrical repairs or adtlitions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof re irs
insurance required.)r empcomp.insurance uinsf 13.�Otber - Pn i✓t F r�n M {
P re9 1 I
Any applicant that checks bos UI must also fill WE the section below sealing thetr workers'cmapematioo policy information.
I Inmeownas who submit this setidwit indicating they am doing all work and then hire miside comanctoas must submit a new,afidavit indicating sun$
:Co n uctora that check ibis box must attached an additional shoat,bowing the tutme of the su6avnbepous and their wodo ns'count,policy infottttatioe,
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and fob site
information. {�^
Insurance Company Name �E'� ` `uOl,' YES J
Policy#or Self-ins.Laic.#:WC ` 3A� IS- '21 T 9 CZ-Ol c1 Expiration Dater 1\ 0-0,\ 0
Job Sire s Address: r� &C—& d S} City/State/Zip: , e�. "\G �G
Attach a copy of the worker'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 2SA 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 imprisortment,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 D[A for insurance coverage verification.
i des hereby certify Under the pains card penalties Of perjury that the information provided above is true and Coma
Sienantre: Date• l 1l �o�d� � I
Phone#: �llk- 4% fl Co
Official use only. Donor write in this area,lobe completed by city of town offWaL
City or Town: PermitHJcease#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person:- Phone#:
NOTICE- NOTICE
TO TO
EMPLOYEES EMPLOYEES
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street,Boston, Massachusetts 02111
617-727-4900 - http://www.niass.gov/dia
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will
give you notice that I (we) have provided for payment to our injured employees under the
above-mentioned chapter by insuring with:
LIBERTY MUTUAL INS. CO. (CASUALTY)
NAME OF INSURANCE COMPANY
150 Liberty Way, Dover, NH 03820
ADDRESS OF INSURANCE COMPANY
W C1-31 S-373899-019 7/11/2009—7/11/2010
POLICY NUMBER EFFECTIVE DATES
NAME OF INSURANCE AGENT ADDRESS PHONE#
PAULO CORREIA DBA 33 HIGHLAND PARK
P CORREIA CONSTRUCTION PEABODY, MA 01960
EMPLOYER ADDRESS
EMPLOYER'S WORKERS' COMPENSATION OFFICER(IF ANY)DATE
MEDICAL TREATMENT
The above-named insurer is required in cases of personal injuries arising out of and in the
course of employment to furnish adequate and reasonable hospital and medical services
in accordance with the provisions of the Workers' Compensation Act. A copy of the First
Report of Injury must be given to the injured employee. The employee may select his or
her own physician. The reasonable cost of the services provided by the treating physician
will be paid by the insurer, if the treatment is necessary and reasonably connected to the
work related injury. In cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for such attention at the
NAME OF HOSPITAL ADDRESS
TO BE POSTED BY EMPLOYER