57 AURORA LN - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7 h edition OF SALEM
Revised Jmrumy
Building Permit Application To Construct, Repair,Renovate Or Demolish a I, 2008
One-or Two-Family Dwelling
This Section For fficial Use Oilly
11j / Building Permit Number: /fAf
e f
Signature:
Building Commissioner/Inspecto of Buildings ate
SECTION 1: S_ E ORMATION
1.1 Pmper Address: 1.2 Assessors Map&Parcel Numbers
S7 Hvr»t^a Is„e Salea,
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Toning Information: 1.4 Property Dimensions:
,ti,et(ts
Zoning District Proposed Use I Lot Area(sq ft) Frontage(ft)
1.5 Budding Setbacks(B)
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 ifyes❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner of Record:
Q.:si� �aola.5le�n S7 Aurofa La vie r50.letM
Name( Address for Service:
o(adCe��1 979 TgAl 2-93q
Signature . Telephone
SECTION 3:DESCRIPTION OF PROPOSED W ORW(check all that apply)
New Construction❑ Existing Building lR,' Owner-Occupied Repairs(s)X Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work-:
��7�pn/ C'�b iw T Ch Av✓� G/� �2+�-.i� C'rn�-�r'771.f?<
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor 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:
5.Mechanical (Fire $
Su ression) To[al All Fees: $
2 ei Check No. Check Amount Cash Amount:
6.'Total Project Cost: $ 7� /3� � ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Constructiork Supervisor(CSL) � /Expiration/ a 2�
uoense Number Expiration Dar
Name of CSIf Holder s List CSL Type(see below)
`) lhhr rQro_ ST n I' 1� (�
Address Type Description
U Unrestricted(up to 35,000 Cu.Ft.) -
R Restricted 1&2 Family Dwellin
M Masonry ly
RC ResidentialCovering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2'R/egistered Hoe men e Improvement Contractor(IHC)
SIC �r,'Kenh cz
HI C Cy mpany Name or Ci1C Registrant Name —� Regslreliun Number
Aadre 1,6 / /,/ 7 /ZO
7� on re
S l e ephoz
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLGL.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure it)provide
this affidavit will result in the denial of the Issuan of the building permm.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER' GENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject prop"hereby
authorize ,f to act on my behalf,in all matters
relative to work authorized by is building pet application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, �6),)4 1&-5-1*/C 5 ,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�h n a s( r\V S
Print N
lee. i zo-o 9
Sigotafe of Owner or Authorized Agent Date
(Signed under the rains and penalties of 'u )
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 nnr 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.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage,finished bttsemardlattics,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"
i CITY OF S.U.E;NI, \t'IASSACHLSETTS
BUILDING DEPARTMENT
• l'_'O WASHINGTON STREET, Ya FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DRISCOLL
THOMAS ST.PII?1tRH
.MAYOR
DIRECTOR OF PUBLIC PROPERTY/BVILDING CO%IMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (BusitnsiOrga tizatio t In lividual): Pk17t11 KITCHENS BY HASTINGS, INC.233 7174 FAX 721 233 3101
36 BROADWAY
Address: SAUGUS, MA R19OR
City/State/Zip: Phone #: 7fl- 7i3 — 7/ 71
Are y r au employer?Cheek t e appropriate box: Type of project(requh ed):
1. I am a employer with 4. ❑ 1 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 1 �• 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 10.❑ Electrical repairs or additions
required.] officers have exercised then
3. 1 am a homeowner doing all work right of exemption MGL I LEI Plumbing repairs or additions
❑ g P,b P P� g
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees. [No workers' 13.❑Other
comp. insurance required.]
Any applicant that decks box#1 most also fill out the section below showing the*workers'wmprnsvion policy infutmation.
•1 kM owns who sulunit Mir attidavit indicating they are doing all work and then hire outside contaµtpis must submit a rcw affidavit indicating such
:Cunum•ton that deck this bore mun-t anachod an additional sheet showing the name of the s,bt nuoctois and their worknn'comp,policy infomta6m.
l um an emplayer that is providing workers'compensadon insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name: /�IJIG�G aL� �fVSyYfJit/cam �p��LJrrtiy
Policy k or Self ins.
Li a #: ��G Expiration Date:. - 2 0/ O
JobSireAddress: S2 All-Or4 e'e�w"� City/State/Zip: -SL61r44 , 1W,4t 91� 3
e
Attach a copy of the workers'compensation policy declaration page(showing the policy number and explradon 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.
t do kerefiWv??IYf undSpite pains and penaties of perjury that the information provided above is true end correcs
Sig n ttur Date / 2C70c1
Phone#: ;�f/— c9--f3— 7/ 7/
Official use only. Do not write in this area,to be completed by city or town ofci d
City or Town: PermidLicense#
Issuing Authority(circle one): '
1.Board of health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: _ Phone#:
Technology insurance Company
' A Stock Insurance Company
20 Trafalgar Square,Suite 459
Nashua,NH 03063
WORKERS COMPENSATION WC 99 00 01 B
AND EMPLOYERS LIABILITY 1 of 4
INSURANCE POLICY INFORMATION PAGE
Ncci Code: 39071
1. Insured: Policy Number: TWC3192555
Kitchens By Hastings, Inc.
_Individual _ Partnership
36 Broadway, Route 1 X Corporation or
Saugus MA 01906 Federal Tax ID: 042765168
Other workplaces not shown above: Risk Id:
See Extension of Information Page Renewal of: TWC3165602
Producer:
AmTrust North America, Inc.
c/o Consoles Insurance Agency
153 Andover Street,Unit 208
Danvers MA 01923
2. The policy period is from 3/13/2009 to 3/13/2010 12:01 a.m. at the insured's mailing address.
3. A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of
the states listed here: Massachusetts
B. Employers Liability Insurance: Part Two of the policy applies to work in each stated listed in item 3.A.
The limits of our liability under Part Two are:
State Bodily Injury by Accident Bodily Injury by Disease Bodily Injury by Disease
MA $ 100,000 each accident $ 500,000 policy limit $ 100,000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any,listed here:
All states except ND, OH,WA, WV,WY and State(s)Designated in Item 3A.
D. This policy includes these endorsements and schedules:
WC 00 00 00 A,WC 99 00 01 B. WC 00 01 13A, WC 00 04 14,WC 20 01 01,WC 20 03 01,WC 20 03 02,WC
20 03 03C,WC 20 04 01,WC 20 04 05,WC 20 06 01 A,WC 20 06 04
4. The premium for this policy will be determined by our Manuals of Rules,Classifications,Rates and Rating
Plans. All information required below is subject to verification and change by audit.
See Extension of Information Page
TOTAL ESTIMATED ANNUAL PREMIUM 1,745
STATE ASSESSMENT 86
TOTAL ESTIMATED COST 1,831
Minimum Premium 374
Deposit Premium �� � p [� 523
Issue Date: 1/20/2009 Countersigned by: / ((��u� -a A' c xo°moo
Authorized Representative
Kitchens By Hastings, Inc
'Ruth Goldstein 10/06/09
57 Aurora Lane
Salem, MA. 01923
SCOPE OF WORK-
Demo existing kitchen cabinets, countertops, and backsplash tile. Remove existing
soffits, Remove debris
"Remove and save existing stove and microwave
Install new laminate floor over existing file floor $3.75 per Sq Ft material allowance
Install cabinets as per plan by KBH dated 3/11106
Install new frame from ceiling to support upper peninsula cabinets
Electric.
Update electric for new kitchen layout
Install new owner supplied hanging fixture over sink
Install owner supplied track light
Install electric for appliances
Plumbing
Remove existing kitchen sink
Hook up New owner supplied sink, disposal, dishwasher
Hook up gas range (Move over 6")
Retrim window molding for stone window sill
Install owner supplied fife on backsplash of sink wall
Remove related construction debris.
7 R`0
Total construction, electrical, Plumbin $16,050.00 S6-
Total Cabinetry- KraftMaid Sedonna Cherry Cognac Finish$11,501.29
Includes tax and delivery 5% discount if ordered between 10/9 — 10/31 Sale
total would be $11066.92
Total Granite —"Rosewood" $4342.48;Includes,template& install
Total Sink /Faucet, Grid, Basket Strainer $74000 or customer can acquire
own
*sink is large "D" bowl, faucet is single handle Pullout style **
Amerock Hardware (Knobs/Pulls ) $3.25ea X 29 $100.14 Tax included
Total Complete Kitchen $32,299.54
36 BROADWAY • SAUGUS • 01906-1008
PHONE: 781-233-7171 • FAX: 781-233-3101.
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All dimensions size designations This is an original design and.must Designed: 3/11/2006
given are subject to verification on ppp���r not be released or copied unless Printed: 10/8/2009
job site and adjustment to fit job U applicable fee has been paid or job
conditions, order placed.
2)
it goldstein JAII Drawing #: ] I Scale : 0 3/8" = P