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70 BROAD STREET - BUILDING JACKET alS�'"�\ nNMT.I CITY OF SALEM9 MASSACHUSETTS PUBLIC PROPERTY DEPARTMENT n s' 120 WASHINGTON STREET, 3RD FLOOR 7i ! SALEM, MASSACHUSETTS 01 970 TELEPHONE: 978-745-9595 EXT. 980 'YDS FAX: 978-740-9846 KIMBERLEY DRISCOLL MAYOR October 12, 2007 To Whom it May Concern: RE: 70 Broad Street According to our records, it has been determined that the property located at 70 Broad Street is a legal grandfathered non-conforming 2 unit dwelling located in a Residential Two family zone R-2 This is to determine use only and in no way is meant to confirm or deny whether said property is in compliance with all building,plumbing, gas, electric, fire or health codes. Si re y, Thomas St. Pierre Zoning Enforcement Officer Jr The Commonwealth of Massachusetts I , * Board uf'Building Regulations and Standards CITY ,�„//� Massachusetts state Building Code, 780 CMR, 7'"edition OF SALEM U Revised Juntours. Iluilding Permil Application To Construct. Repair, Renurate Or Demulish a /. :TRAY I One-sir Twu-Funnily Dwelling This Section For 911111cial Use Only Building Permit um r: Date Applied: 2 Building Cummi rl Inspeaw of Buildings Dye � �T SECTION 1:SITE INFORMATION 1.1 Prope Addws: 1.2 Assesson Map 3 Parcel Numbers �o o.�d ,S<. 1.1 a Is this an accepted street.?yes no Map Number Parcel Number IJ Zoning Information: 1.4 Property Dimensions: Zuning District Proposed Use Lot Ares(sq 11) Frontage(It) 1.3 Building Setbacks(II) From Yard Side Yards Rem 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 O Private O Zone: — Outside Flood Zone? Munki O On site di Check if esO PV spwal system O SECTION 2: PROPERTY OWNERSHIP' 21 way` O her 70 Q>-po <k So e,nl tAC`0 970 Name PrinUi Address for Service: t ianature Telephone - SECTION 3: DESCRIPTION OP PROPOSED WORK'(check all that apply) New Construction O Existing Building O Owner-Occupied O 1 Repairs(s) O 1 Alteration(s O Addition. O Demolition O Accessory Bldg. O Number of Unit_ Other Iv§peciry Brief Description of Proposed Work': fl SECTION I: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OIIIdaI Use Onl Labor and Materials S' I. Building is 1. Building Permit Fee: S Indicate how lee is determined: 2. Electrical S O Standard CityiTown Application Fee O Total Project Cost'(Item 6)x multiplier x J. Plumbing s 2. Other Fees: S 4. Mechanical (IIVAC) S List: S. Mechanical (Fire Suppression) S Total All Fen:S Check No. _Check Amount: Cash Amount: 6. Total Project Cost: S �S-'L),� O Paid in Full O Outstanding Balance Out: 5 - -410 �0J1tQOwA-A-,,, rr� r SECTION S: CONSTRUCTION SERVICES 4.1 Licensed Construction Supervisor(CSL) Number I:vpintiun 0Jig Name of#.'St.- I lulder IJ%I CSL r)PC(mv below) r 13mriolion Wdre U I lntestrictd to 35.000 Cu.Ft. R Restricted 1&2 Family Doellin Signature / MIM oral mJ Z-X z Z - 751 RC Residential Rouline Covering W. Residential Window and Sidin fcicpfwxte SF Residential Solid Fuel Burning A liance Installalkin 0 Residential Demolition 3.21111fgbFred HID improvement Contractor(HIC) �!✓� 39 tic - me r —Repst tiara Nu ber MCC ompany Na ur IIIC Reytju�t Name / J 1 Ad y7�37,) ji d1 y Expiration Date Signature Telephwtt SECTION 6: WORKERS-COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. IS2. 12SC(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? Yea .......... No...........O SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT as Owner of the subject property hereby 1 Cj�Y\S� Y �e to act on my behalf,in all matte" authorize relative o aut ized by this building permit application. Si u Ow Dote SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION I. C h r I-Aeolfy r JOCS "j(J5 ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are We and accurate.to the best of my knowledge and Print N (C? SignalureeoofI( rwror Authorized Agent Da1e Si under tha sins and mltiea of u NOTES: I. An Owner who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will ad have access to the arbitration program or guaranty fund under M.G.L.e. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.R6 and 110.1113,respectively. When substantial work is planned.provide the information below: - Total Iloors area ISq. Ft.) (including garage, finished basement/attics.decks or porch) Gross living area(Sq.Ft.) Flabilable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of healing system Number of decks/porches Ty Pe of cooling system Enclosed ()Pen ), "Total Project Syuare Footage"may he substituted for'?oral Pmject Cuss" r Jr CITY OF SlU EM, NL-kSSACHUSETTS • Bt:ILDIING DEP:IRT\IEINT 120 W 1SHNGTON STREET, 3" FLOOR TEL (978) 743-9595 Fnx(978) 740-9846 KlJIBERLEY DRISCOLL 1Z.4YOR THo;`us ST.PYERRs D1RECi'OR OF PUBLIC PROPERW/BLMM:G COMMISSIONER 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: (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signature of permit applicant 4 date dcbrialLJxo !e CITY OF S:u sm, AXSSACHi SETTS BUtLDNG DEPARTNLF—NT • 120 WAS14LNGTON STREET. 3'a FLOOR T1Er_ (978) 745-959S FAx(978) 740-9846 KIJ(BFRi FF.Y DRISCOLL T•F1Oh(A5ST.P1EARB MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%LUtSSIOrER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrfeians/Plumbers 4 Ifillcant Information / Please Print Legibly Name(ousitw•&organizaation'individual):4 U li of es t1jj%.4 Address: 1 /J 4r 9 O.+? S/ City/State/Zip: 'S -/Fol i14. U 15720 Phone li: /� -7l3 83445 78 717 Are you an employer?Check the appropriate box: "Type of project(required): 4. ❑ I am a general contractor and 1 6. New construction I,❑ 1 am o employer with * have hired the subs:ornractors ❑ employees(felt and/or r partime). listed on the attached sheet ?• ❑ Remodeling 2.❑ . gip a sole proprietor o partner- ,hip and have no employees These subcontractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its t0 ❑ Electrical repairs or additions required.) officers have exercised their right of exemption r MGL 1 I.❑ Plumbing repairs or additions 3.❑ 1 ys a.homeowner worke doing p.work c b152,§1(4),and we have no 12.❑ Roof n myself. e re aired. t comp. employees. [No workers' ' insurance required.) 13.❑ Others comp. inwrance required.] •Any uPPltc:an 1h,g dtockr box r1 map alw.rill out the seelim below showing their worker'compenwiun Puticy inGnmatiun. t 1 L.meuwmen who submit this affidavit indicating they ne doing all work and then hire mtsida contrmora most suhmit a new a Dd2vit indicting ruck :c,mi mars thug chuck this box meat anxhed an additiorat sheet showing the none of the subeontracton and their worker'cam Policy infornsntion. I am an employer that la providing workers'compensadon lnsuranee for my employees. Below is rbe policy and fob site information. Insurance Company Names rn (�_� eI Policy q ur Selt Teti. Lic. N: Y u A/, `f� J � 5 1 _�J ratio,Date, ✓��d �jy' City/State/Zip: Job Site Address: '/�.� l 'G Attach a copy of the workers'compensation policy dectaratlon page(showing that policy number and expiration data). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to SI.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to 5250.00 a Jay against the violator. 11e advised that a copy of this statement may bs: furwarded to the Office of Investigations of the DIA for insurance coverage verification. 1 do hereby certify aide At Ins and penuldes of perjury Nrut the information provided above is true and correct Da( : l (� Phone Official use only. Do not write in this urea,to be completed by city or town off vial i City Or Town'. __, . . Permitfl.lceese p _...__. .-- IssuinK Awhorily(circle one): 1. Board of Ilealth 2. BuildinU Department 9.Cityirown Clerk 4. Electrical Inspector 5. Plumbing lu.spector 6.Other Contact Person: _ __. ... Phonet/: [ Information and Instructions Massachusetts General Laws chapter IJ2 1"equres aII ell 1ployers to provide workers* compensation tA)r their employees. Pursuuu to tihis suatute, an employed is dctined as"...every prison in the service of another under any contract of hire, rxprejs or implied, oral nr written." , An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more .1 the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the rccmver or trustee uf.un individual,patmership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,cunstruction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." .1GL chapter 152. §25C(6)also slues that"every state or local licensing agency shall withhold the Issuance or renewal of a license air permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of cumpliance with the insurance coverage required." Additionally, \,IGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the pertomhance utpublic work until acceptable evidence of compliance with the insurance ,requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking ilia boxes that apply to your situation and, if necessary, supply sub-contractors) name(s), address(es)and phone nunhber(s)along with their certittcatc(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for continuation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should he VChuned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or of you are required to obtain it workers' compensation policy,please call the Department at the number listed below. SeiF insured companies should enter their self-insurance license number on the appropriate line. City or"town Officials Please he sure that the affidavit is complete tmd printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill nut in the event the Office of Investigations has to contact you regarding the applicant. lll.asc be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple pernitllicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address" the applicant should write "all locations in (City or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.c. it dog license or permit to bum leaves cte.)said person is NOT required to complete this affidavit. I he Office set lnvesrigations would like to thank you in advance fur your cooperation and should you have sly questions, please do nut hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents OfAce of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-877-MASSAFE Fax #617-727-7749 www.mass.gov/dia ! " RightFax C1-2 11/4/2010 7 : 04 : 53 AM PAGE 3/003 Fax Server CERTIFICATE URANCE OF INS ISSUE DATE i 11/4/2010 THIS�CERTD'ICA'I'E IS ISSUED AS A MATTER OF IN ORMA'IION ONLY AND CONFERS NO RIGHTS UPON'rHE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY FIE 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:ifthe certificate holder is an ADDITIONAL INSURED,the policy(les)must be endorsed.N 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 LAURANZANO INS AGCY NAME: 107 DODGE STREET PHONE FAX PHONE No,EM): (AJC,No): BEVERLY,MA 01915 E-MAIL ADDRESS' PRODUCER CUSTOMER ID is INSURED INSURER(S)AFFORDING COVERAGE NAIC# GUIMARAES,RODRIGO DBA INSURER A TRAV.DD2ECT ASSIGNMENT GUIMARAES CONSTRUCTION INSURER B 21 BALCOMB STREET INSURER C SALEM,MA 01970 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POI CRS OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDAIO ANY REQUD2EN ,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUAffiSL WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICHB.LI SHOWNMAYHAVEBEENREDUCEDBYPANCLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICYNUMBER POLICY EFF POLICYEXP LIMITS LUX ESSR WVD OdAVDDIYYYY) (T4.1/DD/YYYY) GENERAL LLUR1TY EACH OCCURRENCE q .DAMAGETG REINED S []COMMERCIAL GENERAL LIABR.ITY PREMISES(Es occwaen") 0 CLAD4SMADE 11 OCCUR MED.EXPENS'E(Nryone S 0 PERSONAL B ADV. f RCURY H OENERALAGGREOATE S GEN'L AGGREGATE I APPLIES PER'. D POLICY O PROTECT O IAC PRODUCTS COMP/OP S AGG AUTOMOBILE LIABILITY COMBINED SINGLE E LE SIT (Ee accident) 0 ANYAUTO BODMY INJURY $ (pe,perspn) 0 ALL OWNED AUTOS BODILY BOURY E (Per Accident) 0 SC.3EDULF,D AUTOS PROPERTYDAMAGE S (Per accident) 0 FURED AUTOS S 0 NON-OWNED AUTOS $ i Q 0 UMERELIALIAE OOCCUR EACH OCCURRENCE Y 0 EXCESSLC4B 0CL S.MADE AGGREGATE $ H DEDUC- Ua S N RETENTION$ $ WORKERS'COMPENSATION WC STATUTORY A AND EMPLOYERS LLUMLITY NIA LRAIS YIN ANY PROPRIEI'OR/PARTNEIU ExEGDTrvE OFHCER&,SaraER N N/A 7PJUB-985IM597 07/30/10 07/30/11 LEACH ACCIDENT $100000 'cs CL=' - (MANDATORYINNB) EL.DISEASE-EA fIOOOOO EMPLOY E Ifyea,d....becnder DESCRIPTIONOF ELDIb'EASE-POLICY 5500000 OPERATIONS bel— LIhEf DES=nON OF OPEN UONSILOCATIONSNEWCf.ES(Aftoeh ACORD 101,Add,Le-1 Rem.ks Sehekde,if more space ie regaired) 'THE POLICY DESIGNATED ABOVE IS CANCELLED EFFECTIVE 10/26/10 THIS REPLACES ANYPRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTING WORKERS COMP COVERAGE GFRTIFWATEHOLDER z.. ..'SS ,. -.. . . ., , {CANCELLATION ' ". ." CITY OF SALEM - - ONE SALEM GREEN SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SALEM,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. e.R1Zm.11ESTAHYE RhondaJo,;n.er ACCOAI)325(2009109 .' '`'6 I98S 2009 ACORD CORYOYWTTON..AII rl Ats reeerved.'. GUIMARAES CONSTRUCTION 21 BALCOMB STREET SALEM MA 01970 TONE: 978-836-7279 z. QUOTE TO: Michael detJesus QUOTE: 01 70 Broad St DATE: 10/18/2010 Salem MA01970 978-338-8021 Quantity Description Rate Amount Removing old shingles Including 5 domer 6 inch drip edge Replace front gutter Replace facing board in the back of The house Install siding in tho house And 5 domers , * ice water and black paper Replace rubber roof Price includes; labor, Dempster, Material and permit. Total GUIMARAES Quote valid for 30 days CONSTRUCTION Quotation prepared by: Rodrigo Guimaraes - 21 BALCOMB STREET 50% due up front, the other 50% due at the last day of job. SALEM MA 01970 To accept this quotation, sign here and return: FONE: 978-836-7279 Complete Name of person signing this quote: ' Date: /O / �i a / /_ �I D 0� r. : 1�t1 0 m 80 0. '11 > - �T D A N C W p n ' - ofOD 0 ice oFo�Om'r XffA..`1-fh i' egu anon License or registration valid for individul use only rn %= before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR T e Office of Consumer Affairs and Business Regulation m i_ 1 Registration: .,149839 yP m < _ _ Expiration: 2/13/2012 DBA 10 Park Plaza-Suite 5170 o c = �F -;� - f Boston,MA02116 d — _ ! M RIO CONSTRUCTION m = ' MICHAEL MERCUR16 - o m = 127 OAK STREETZ-�4-D f WAKEFIELD MA 01880. Undersecretary Not valid without signature n ° 8 November 4th, 2010 ° Effective Date: -----------.---..._...._-.. . , ° Western Surety Company LICENSE AND PERMIT BOND KNOW ALL PERSONS BY THESE PRESENTS: Bond Na Thatwe, Rodrigo Guimaraes .....___._._._....._... ...... .. ° u oi•the .City .. of in Sate of Mas sachusct is as Principal, ° and WESTERN SURETY COMPANY, a corporation duly licensed to do surety business in the State of -_Massachusetts ...,_._... ..........._.__.._.—, as Surety, are held and firmly bound unto the C;.ty„of„_Salem ...._......-.-_...-_-..-...__..._—__-.-_.-..--....-._--------- State of Massachu �Lty ...-._• as Obligee, in the penal sum of One .Thousand and00/100 DOLLARS (SI,000-_,00,_,-.---.,.,,..,. . .. lawful money of the United States, to be paid to the Obligee, for which paymentwell and truly to be made, we bind ourselves and our legal representatives, firmly by these presents. THE CONDITION OF THE ABOVE OBLIGATION IS SUCH, That whereas, the Principal has been licensed Sidewallc Bond ......--'---'— ------. . ..._.....---...._...-......... . by the Obligee. NOW THEREFORE, if the Principal shall faithfully perform the duties end In all things comply with the laws and ordinances, including all amendments thereto, pertaining to the license or permit applied for, then this obligation to be void, otherwise to remain in full force and effect until November 4th 2011 _, unless renewed by Continuation Certificate. This bond may be terminated at any time by the Suety upon sending notice in writing, by First Class U.S. Mail, to the Obligee and to the Principal at the address last known to the Surety, and at the expiration of thi[,%J"�3•bays from the mailing of said notice, this bond shall ipso facto terminate and the: Surety Sri; '�# imp "!llieved from any liability for any acts or omissions of the Principal subsequent to said t^'1!? -�..&":' a number of years this bond shall continue in force, the number of claims made Z. a the number of premiums which shall be payable or paid, the Surety's total limit of 1iWiil shall not be zt2hulative from year to year or period to period, and in no event shall the Surety's total lli{y`� i'(1iu5'yt xceed the amount set forth above. Any revision of the bond amount shall not be C4WY Lyle. n......e yy "y1@IM1`V~ ° f�N — qN day of_November 2010 ° ° llate ° Principal ° _----- Principal ° WEST'E 5URE COMPANY ° By Paul T. Bruflat, nior Vice President ' ° Form 592-1-2010 ° u b0/Z0 39Vd a3I non ONVZNVNnv-i ZBT6TZ6eL6 09 :TT 0TOZ/00/TT . w ACKNOWLEDGMENT OF SURETY STATE OF SOUTH DAKOTA 1 fie (Corperate Of ") COUNTY OF MINNEHAHA I On this __'I th__-_- day of .,November___-----...-_--__-„ .. __2010,_._...... ,before nle, the untlerslgnad officer, _ personally appeared ..__....___...... . , Paul T._Brufl�t who acknowledged himself to be the aforesaid officer of WESTERN SURETY COMPANY,a corporation, and that hews such officer, being authorized so to do, executed the foregoing instrument for the purposes therein contained, by signing the name of the corporation by himself as such officer. IN WITNESS WHEREOF.1 have hereunto set my hand and official seal. {444444ggbgyq44444444qqqq{ r S. EACH e r�NOTARY PUBLIC(M+ .._..__..._. .._:... f SOUTH DAKOTA BFAL i Notary Public—South Dakoca *gg4444444444bbhbgqqyqq4+ My COnccission Expires February 12, 2015 ACKNOWLEDGMENT OF PRINCIPAL, STATE OF _ ...... _.. . . ... .......__1 ss (Individual or Partrrern) COUNTY OP' ... _.........._..._ ) On this ..._... ----------day of_...... .. . . ...._,........, ._._..,...._........,before me personally appeared known to me to be the individual described in and who executed the foregoing Instrument and acknowledged to me that._..-he..... executed the same, My commission expires Notary Puhlic ACKNOWLEDGMENT OF PRINCIPAL STATE OF. (Corporate Officer) COUNTY OF . .........__.___—._.—.—.—_ ss On this _._..._..—.....___. day of .---)—.—....—_-_.---........ ._-._ ... . before me personally appeared .. ------..-.--....--- _ ._..... .... . .._.. .... ---- ...... ..._.__ ._ . . who acknowledged humelf/herself to be the .. ..._ ._..._.. - . of .. . . ......................____._.._._.......... . a corporation,and that he/she as such officer being authorized so to do, executed Cie foregoing instrument for the purposes therein contained by signing the name of the corporation by hlmselMiLrseif as such officer. My commission expires Noutry Public td PIP U `V Z z c O ¢ G y m ¢ c Z o, fsl Z t u L) o 60/E0 39tfd N3Ignod ONVZNFiNnv-1 Z8T6TZ68L6 05151 0TOZ/b0/TT N Western Surety Company POWER OF ATTORNEY KNOW ALL MEN BY THESE PRESENTS: That WESTERN SURETY COMPANY, a corporation organized and existing under the laws of the State of South Dakota,and authorized and licensed to do business In the States of Alabama, Alaska, Arizona, Arkansas, Callfomla, Colorado, Connecticut, Delaware, District of Columbia, Florida, Georgia, Hawaii, Idaho, Illinois, Indiana, Iowa, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts,Michigan, Minnesota, Mississippi,Missouri, Montana, Nebraska,Nevada, New Hampshire, New Jersey, Now Mexico, New York, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Tennessee, Texas, Utah, Vermont, Virginia, Washington, West Virginia, Wisconsin, Wyoming, and the United States of America,does hereby make,constitute and appoint . Paul- T. Druf l_at . of .......... _ .. .__....... . Sioux Falls....__. . State of ...._..... . South, Dakota... .. , its regularly elected as Attomey-in-Fact,with full power and authority hereby conferred upon him to sign, execute, acknowledge and deliver for and on its behalf as Surety and as its act and dead,the following pond: One .S1dLw&1 L_Bond.ri ry.--�_.° ...._.:...._...._.._..... . _......... ..... bond with bond number. 2asad662--------------------..__.—...... --. ...............-------..._..-------.......... _.....,.._....__..................... .. .._ . .. . for Aodrigo_Cuifnaraes.. as Principal in the penalty amount not to exceed: $_i.:.000,..00. western Surety Company further ear flan that the following Is a true and exact copy of Section 7 of the by-laws of western Surety Company duly adopted and now in force,to-wit Section 7. All bonds, polieles,undertakings, Pewera of Attorney.or other Obligations of the corporation shall be executed in the corporate name of the Company by the President, Secretary,any Assistant Secretary,Treasurer,or any vice President,or by such other otlieers as the Board of Directors may authorize. The President, any Vice President, Secretary, any Assistant Secretary, or the Treasurer may appoint Attomeys-in-Fact or agents who shall have authority to issue bonds,polloles,or undertakings in the name of the Company. The corporate seal is not necessary for the validlry of any bonds,pollcles,undertakings,Powers of Attorney Or other obligations of the corporation, The signature of any such officer and the corporate seal maybe printed by facsimile. In Witness Whereof, the said WESTERN SURETY COMPANY has caused these presents to be executed by its ,__,__„$eni QS Vi.ce President__, with the corporate seal affixed this ._.___-_Lh___day of -,_2010 ATTEST By W E S T E N `T% A N Y L.Nelson,Assistant Socrotary Paul T. aYUI'I Senior Vice President �iotucca�?�Yrccvao,��+J J� ` y�.....:. b h. STATE OF SOUTH DAKOTA COUNTY OF MINNEHAHA yy a✓ti�'. ...i.� ';� ,s- JW✓�. On this _ 4 th day of November -_„ _.__.. 2010 -_, before me,a Notary Public,personally appeared Paul.T. Eruflat and L. Nelson who,being by me duly sworn,acknowledged that they signed the above Power of Attorney as ,,_Senior vice President and Assistant Secretary, respectively, of the said WESTERN SURETY COMPANY, and acknowledged said instrument to be the voluntary act and deed of said Corporation. ibbbbbb444444444444vww4ww f D. KRELL 'r NOTARY PUBLIC ,e SFL SEAL s SOUTH DAKOTA rr +bbbb44444Vw4444444rm4444� .. ... My Commission Expires November 90,2012 Notary Public P Form F19769-2006 rt V0/V0 39Vd 83IsnD8 0NVZNtianv-1 Z8S6SZ68L6 09 :TT 0I0Z/V0/SI ISSUE DATE CERTIFG'ATE„0 INSItANCE3010 PUS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO.RIGNTS UPON TILE CERTIFICATE HOLDER.TNIS 'CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND,EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW:THIS CERTIFICATE OF INSURANCE DOES NOT CONSTT =A CONTRACT BETWEEN THE ISSUING INSURERB),ATTITIORTLED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER - IMPORTANT:.If.the.certi.icate holder Is an'ADDITIONAL INSURED,the policy(les)must be endorsed:N SUBROGATION IS WANED,subject to the +terms and conditions of the policy,certain policies may require an endorsement.A statement on this certificate does not-confer riglits:to.the'-,: .,.-.-_. :certiflcatetioldef-inlieulof:such,endorsement(s. i .PRODUCER COWACT ---- "" 'LAURANZANOINSAGCY -" ' N�IE` - -. PHONE FAX .. . 107 DODGE'STREET _ Iaq No,E:e): INC,No): BEVERLY,MA 01915 .. E-MAIL ADDRESS: PRODUCER CUSTOMER ID i INSURED INSURER(S)AFFORDING COVERAGE NAIC# GUIMARAES,RODRIGO DBA INSURER A TRAV.DIRECT ASSIGNMENT GUIMARAES CONSTRUCTION INSURER B 21 BALCOMB STREET INSURER C SALEM,MA 01970 INSURER D INSURER E INSURER F COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS M TO CERTIFY TEAT THE POIS=OF INSURANCE LJSTED ME W HAVE BEIN ISSU TO THE WSU NAMED ABOVE FOR THE POLICY PERIOD II ICATED. NOTRTTISTANDINO ANY REQUIREh ,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 POISCIFS DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF sum POLICIES.LII-I'S SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR TYPE OF INSURANCE ADDL SUER POLICY NUMBER POLICY EFF POLICY ESP L TS LTR INSR W VD (4"D (MM/DD GENERAL LLIBILTTY - ._ -- - .._ . - EACH OCCURRENCE S y -- DAMAGE(Eaoc EO $ . . O COMb1ERCtA1L GENERAL LLABIILTTY '. --. . — - - —- .. _ ._.. -..-_ PREM6ES occurrence) _- ._. _.. .., SdED.EXPINSE(Asry one - 'S ._ +Q_CLABAS AfADE_LO OCCUR._ . __.... ^. ....�._. MAMY ❑� (! '. :GEN'L AGGREGATE LaML APPLIES PER I- - .- ❑POLWY -❑PROJECT ❑ LOC .. :. - AGG Ir PRODUCTS-COW/OP S AUTOMOBILE LNBII.ITY -- - -COMBDdFD SINGLE S LIMIT eccid N) ❑ ANY AUTO BODILY INJURY S Wer Person ❑ ALLOW AUTOS BODr-YINJURY S a Accident) ❑ SCHIDULID AUTOS PROPERWDAMAGE S (Per eccidmt ❑ HR2ID AUTOS _ ❑ NON-OWNIDADTOS _ ❑ UMBRELLALiAB ❑OCCUR EACHOCCURRENCE S ❑ EXCESS LIAB ❑CLARAS-MADE AGGREGATE $ ❑ DMUCTIBL£ S ❑ RETIISHONS S WORKERS'COMPENSATION WE STA1IrTORY A AND EMPLOYERS L MITY N/A LDS YIN ANYPROPRIETOR/PARTNER/ N FDA 7PJUB-9851M597 07/30/10 07/30/11 LEr'cflwccmErrr $100000 EXCLUDED? (MANDATORY IN Me) I"W -EA SI00000 Eyes,dssmbe order DESCR]PTIONOF JEL DISEASE-POLICY 1500000 OPE ONSbsl. DESCRIPTION OF OPERATIONSILOCATIONSNEFDCLES(peach ACORD 101,Additional Remarks Schedule,if more space is required) THE POLICY DESIGNATED ABOVE IS CANCELLED EFFECTIVE 10/26/10 THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE BOLDER AFFECTING WORKERS COMP COVERAGE CITY OF SALEM ONE SALEM GREEN SHOULD ANY THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN SALEM,MA 01970 ACCORDANCE WITH THE POLICY PROVISIONS. ANRORIED RFPRffilrAT1VE Rlw+Idcr'Jo,,rl.eF %;;1CCC412D'Z ', 049i@9 :s:,c, �� N` ;�.�.r,.-:e:�,•e<;zaaa� � .�h�., �..,;�, �" .,, r.^ ..w .. ..8+19&�=2u09AG4RU'C`6TRT'QRA ON,±311r' htsFeselWetl:-: 7 --- Fhe Cbnumonsveahh ol'(b9asNachusclls l I uard of Building Regulations and Standards Cl l'1' OF ti,\L1:\I) btassachusetts State building Code. 780 ChIR /(,•ri ad iEu•'u// I e. Building Permit Application 'ro Construct. Repair, Renovate Or Demolish a (Ire•fir Tu u•Funrilr Un ellint,� This Section For Oliicial Use Only Building Permit Number: Date A plied: )Jjgz s Ct ✓ 2 Molding Ol)icial(Print Mune) S' aiurc Datc SECTION I:SITE INFORMATION I. ropeyy��y Address: 1.2 Assswrs.Nap Parcel Numbers b I'Slt✓llda2ft �• _ I.la Is this an accepted s reel?yes_- no Map Nunsher Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: zoning District Proposed Use Lot Arco(sq III Frontage(II) 1.5 Building Setbacks(R) Front Yard Side Yards Rua Yard Required Provided Required Provided Required Provided 1.61VAter Supply:(M.G.I.e.40.154) 1.7 Flood Zone Informations 1.3 Sewage Disposal System: Public❑ Private❑ Zone: — Outside Flood Zone? Municipal❑ On site disposals)slum ❑ Check if cs❑ SEC71ON2: PROPERTY OWNERSHIP' 2 kO/,wnerl o Reeard ikb qe Iv SIr3 L �'��or'L /t'I4 D/ 0i7e Mine(Pant) City,Still,ZIP p �OR No.and Street falephona Email Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Spccily: Brief Description of Proposed Work": 48 a ,ham Q et — SECTION 4: ESTIMATED CONSTRUCTION COSTS Items Estimated Costs:i l.ahor; Ofclul Use Only I. Building S I. Building Permit Fee: S Indicate how lee is determined: '. Illccirical S ❑Standard Gry+Tosvn Application Fee ❑Total Project C'ostr(Item 6)x multiplier 1. I'huuhing S ,. Other Fees: S- — J. >Iccl(.usical III% '1 i Lisle Vct;1moical (Fire -- S'u ireulUn) S rotal .\Il Fces: Q (heck No. Check Amount: Tot C.(>h \iuotmt: al Project Cost: i ' 0 p D 0 P.tiJ in Full -- 0 Outstanding lial.mec Ouc: St.'( 11ON5: 5.1 ('unstructioliSul)cnisort.icellse(('Si.) -�Ycx;'- I icensc Nitildcr 1:\piralion Mite .... icr I 1't PC Dc"riplion InrcstricWd I liklildit, 5 110 10 34.02)cu. ILI 0 ltaIricicd M2 F."Ild [)%wllill Cit\iToml.Stale./II' M Sljsoll RC R,wiin Oncrin WS Windolk md Sid'Jl j� - SF solid Fuel 1111ming Appliji1cc1 I 111sidution Do iolition I,-tared Home Improvement Contractor(111C) 111C licilistraflun Nwnhcr \pirafion Dut 11U!o!�pill line of I L q strunt 41110 4 V,U. J 5vusr F'Mail a rem Iq 207're ev 7 C/Town,State,ZIP rA.-ha.. SECTION M WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a. 152.1 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 or the building permit. Signed Affldavit Attached? Yes..........Q No...........0 SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1. as Owner of the subject property,hereby authorize o1(1,e,-ea,;, to act on my behal in oll-vatte live to work authori ad by this building permit application. 141nn—nerlj Name(Mccina U416 ,me Signature) SECTION 7b:OWNEWOR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under/ e p an enallies of perjury that all of the information cot ine in this application is true and accurate 4d 0 b t iy knowledge and understanding. By col entering n in'h y i n a a a pp EC'r' '06 �jb be low, Print Owner's "on 6 Nn 1-15%! I. n 0%�oier%%hu oblains a building permit to do his her own work,or an owner%0o hires an unregistered contractor I P have access to the arbitration (not registered in the Hume Improvement Contractor 11-110 Program),Nvill aa 1 .1111 can be fourld at program .1111 or 6'I uar.111t) 11, rograin or guanult) Nod under M.G.L.c. 142A.Other important infurmalion on the HIC Program -fit, I lot I Information an the Construction Supervisor License can be found at%% ��t 2 2 11 so st'111 t1al%" 11 . Mitrisubstantial%kork isplanned, pro%ide the hilormatiun below: rota) llour area(.,+ 111 garage, finished basement attics,decks or rorchi (iron li%ing area iiq. 0 1 Ribitable roum cotmt Number of hedrooms \mnherol hathrooms \k1111hVr of liall h.1111i I\pc of licmiog S)swill porches 111 J'e ofcoollllo N.1 Stem I oi,d llroj o Squarc Fool,lcc'11G1% he suhsfuacd I*or 1'olal lirtljcct 015C y w J < CCI'Y OF S:Vm, NWSACHUSE ITS LE UCILDING DEPARTMENT 120 1' ASHIINGTON SHEET, J FLOOR TEL (978) 745-9505 F.'a(979) 7. 0-9844 �lSIpERLHY DRISCOLL NLAYO:t THOAL\S ST.PIER" DIRECTOR CF PULIC PROPERTY/aun-or,:(,CONNISSIONER Workers' Compensation Insurance AtIldavit: Builders/Contructurv/Electrlclans/Plumbers 16 t llleant Information /l lease Print Leaibl .Name(n11.1l W14o0(Vn11360n.I tallVld11a1); Address: �v�r�j p C� CityiStatc/zip:,�j/t�/� /L�t- OI!7d none N: /'d 7 L 2j� Are you an employer?Check the appropriate bast Type or project(required): 1.❑ 1 am a employer with 4, ❑ 1 am a gentaral contractor and 1 6. ❑New construction employees(full and/or part-time).• have hired the subcontractors 2.❑ ],am a sole proprietor or partner• listed on the attached sheut, t 7. ❑ Remodeling .,hip and have no cmployeea These sub•contracton have g. Q Demolition working for me in any capacity. workers'comp,insurance. 9• C3 Ouilding addition (No workers'.camp,insurance 3. ❑ We are a corporation and.its required.) officers have exereiud.thcli 10.0 Electrical repair$or additions I. I am a homcuwnor doing all work right of exemption per MGL I LQ Plumbing repairs or udditions myself.(No workers'comp. C. I52,`i 1(4),and we have no 12.0 Roof repairs insurance required.)r employees.(No workers' l).❑Other Gump, insuruncarequircJ.) •alms uppllc:ue dW ahv<aa bet API must Aw fill out the wcliw buiow ahowina their wmlen'compenwdon policy innirmunon. 'I N+ euwmne who whmit this antrinvit indlwing'hry un doing all,wrk and then hire wiside coolraetao must nthrell a new anidarihindloling Sush :(%,ni cwn thtl chcsh thin boa mail mxhud m eddidu"MI AMI Showing the Maine ofthe wb. iumwn and their warlim'wmp,policy information. 1 mre un empluyer that is prutoldhig workers'cumprnrallon Lrsurance jar my emp/uydrst Below/s du polley undJub site in/urnrurinn. -� /s/ l_ _ Insuruncu Company Name: �✓�aG/`��5 9or 7 p z I'ulicy 4 or Self•ius. Lic.Ht � � Espimlion Data: ! 3 tub Sild Address: -2D ✓O/�'�w'af . �✓f/i�/s+�r �ry' Cityismte/zip: A�lX "Vf iom7z> . INA a copy of the workers'compenTatloo policy declaration page(Thawing the policy number and uplratioo dato) Ktilures to wcuru euverage as required under.Suction 29A ul•bIGL c. 132 can(ead to the imposition of criminal penalties of a tire up to 11,300.00 and/ur one-year imprisonment,as well as civil penalties in the form off STOP WORK ORDER and o lina ar up to S-']0 M a Jay against rile violator. Ile advi.md that a copy of this.,latemunt may bus rurwardcd to ilia 001co of Invc,tigations of the 01A for insurance,coverage veriticatiun. /du hereby certify undet thr pains m1J prnu/r/rs�,/perjury•hut du inlunnullun provided above is lrur aura correct 0ara: 01/icial ime.oily. D,r nor wfire in diLr area, ru }e cuuryleted by oiIt or lawn al�flria[ City of 1',ova:.__-. ._ ._. I'crmitAkcnae _-- hnuiu�Atilhurily (circle )ag): I'. hoard of health !. lluildint, Dvii,11 11ltcnl I. ('ity,faun Clerk 4. ba¢etrled Inylcclor i, Pllmibint: Impeeov G, lhhcr - -- ----._. Phone J: ACO RD ,, CERTIFICATE OF LIABILITY INSURANCE DATE(MMDD 05/01/2012 YVV) PRODUCER (978) 927-8420 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE Lauranzano Insurance Agency HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Beverly KA 01915- INSURERS AFFORDING COVERAGE NAIC# INSURED INSURERA:Pe= America Insurance CO Rodrigo Guimaraes INSURER B:Travelers Guimaraes Construction INSURERC: 21 Balcomb Street INSURER D: Salem MA 01970- INSURERE: COVERAGES 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD'L POLICY EFFECTIVE POLICY EXPIRATION LTR INSRD TYPE OF INSURANCE POLICYNUMBER DATE MNVDDNY DATE(MMIDDNY LIMITS A X GENERAL LIABILITY PAC6905437 03/09/2012 03/09/2013 EACH OCCURRENCE S 1,000,000 X COMMERCIAL GENERAL LIABILITY PREMI ESES RENTED S Ea occ rr lOOr 000 PREMI $ CLAIMS MADE OCCUR / / / / MED EXP(Anyoneperson) $ 5,000 PERSONAL B ADV INJURY $ 1,000,0001 GENERAL AGGREGATE S 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPIOP AGG $ 2,000,000 X POLICY PP8 LOG AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS / / / / BODILY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS / / / / BODILY(Per accident) $ (Per accident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / OTHERTHAN EA ACC $ AUTO ONLY: AGG S EXCESS/UMBRELLA LIABILITY / / / / EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE RETENTION S C g 1I H $ WORKERS COMPENSATION AND / / / / r& LAMITS OER EMPLOYERS'LIABILITY E.L.EACH ACCIDENT S ANY PROPRIETOR/PARTNER/EXECUTIVE OFFICERIMEMBER EXCLUDED? / / / / E.L.DISEASE-FA PLOYEE11 If yes,describe under E.L.DISEASE-POLICY LIMIT $ SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONSILOCATIONSNEHICLESIEXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION (978) 745-9595 5641 (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City OE Salem FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE Public Properties Department INSURER ITS AGENTS OR REPRESENTATIVES. 120 Washington Street AUTHORIZED REPRESENTATIVE 02 Salem MA 01970- - O ACORD CORPORATION 1988 ACORD 25(2001/08) r .Page 1 of 2 INS025(0108).05 ELECTRONIC LASER FORMS.INC.-(800)327-0545 Office 111.1ww"A;066itegud0"`laN License or registration valid for individul use only f HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: �. Registration :149839 Type: Office of Consumer Affairs and Business Regulation Expiration ili)2014 DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 TRIO CONSTRUCTION MICHAEL MERCURIO 127 0AK STREET WAKEFIELD,MA 0 Undersecretary Not valid without signature i i lassachusetts - Department of Public Safch 9 Board of Building Re,,ulations anti Star.d:u•ds Construction Supervisor License License: CS 91942 MICHAEL L MERCURIO 127 OAK ST WAKEFIELD, MA 01880 o— ��- Expiration: 1(4/2013 ('nnmissiuner Tr#: 9263 GUIMARAES CONSTRUCTION 21 BALCOMB STREET SALEM MA 01970 TONE: 978-836-7279 QUOTE/CONTRACT j: TO: Miko de Jesus 70 Broadway St QUOTE: 01 Salem MA 01970 DATE: April 27, 2012 703-338-8021 ' lt; Description Amount Demolition of old deck on I st floor Demolition of brick stairs Reframe and installed new wood posts for new deck Install Azzeck decking Built the wood railing and floor for deck iI Build stairs Digging holes for concrete pole base } 8"center tube and concrete and inspection tR i �pflaF � Ax;aee s q ' Y e; t Total Price includes: Labor, Material, Dumpster, and Permit. U$ Price Quote valid for 30 days. Quotation prepared by: 10 GUIMARAES 50% due up front, the other 50% due at the last day of job. CONSTRUCTION 21 BALCOMB STREET To accept this quotation, sign here and return: SALEM MA 01970 Complete Name of person signing this quote: FONE: 978-836-7279 J Date:/ �� /� RightFax N3-1 5/9/2012 7 :23: 48 AM PAGE 2/002 Fax Server Air-i0lP CERTIFICATE OF LIABILITY INSURANCE IN DATE IM09/ D01 YYV) TWISX�ERTIFICATE 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 and endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER CONTACT NAME: LAURANZANO INS AGENCY PHONE FAX IAID,Na,Ext: UI 107 DODGE STREET PRODUCER BEVERLY,MA 01915 CUSTOMER ID N: 7242D INSURERS)AFFORDING COVERAGE NAIC q INSURED INSURER A: TRAVELERS PROPERTY CASUALTY COMPANY OF AMERICA GUIMARAES,RODRIGO DBA GUIMARAES CONSTRUCTION INSURER B: INSURER C: INSURER D: 21 BALCOMB STREET INSURER E: SALEM,NIA 01970 INSURER F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: HIS IS TO CERTIFY THAT THE POLICIESOFINSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THEPOLICY 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 PERTAN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERM,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LMTSSHOWNrMY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADD SUB POLICY BEE DATE POLICY EXP DATE LTR TYPE OF INSURANCE L R POLICY NUMBER (MKDDIYYYY) (MMNID\YYYY) LIMITS GENERAL LIABILITY -ACH OCCURRENCE $ COMMERCIAL GENERAL LIABILITY DAMAGE S( RENTED $ CLAIMS MADE 0 OCCUR, REMIEMISES(Ea occurrence) MED EXP(Any one person) S ERSONAL&ADV INJURY $ GEN'L AGGREGATE LIMIT APPLIES PER-. ENERAL AGGREGATE $ POLICY 0 PROJECT LOC F RODUCTS-COMP/OP AGO $ AUTOMOBILE LIABILITY COMBINED SINGLE $ ANY AUTO LIMIT(Ea accident) ALL OWNED AUTOS BODILY INJURY $ SCHEDULE AUTOS Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per acadenq UMBRELLA LIAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DEDI/CTIBI E $ RETENTION $ $ A WORKER'S COMPENSATION AND WC STATUTORY OTHER EMPLOYER'S LIABILITY Y/N UB-5059P868-12 02/28/2012 02/2812D13 LIMITS ANYPROPERITOR,PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ OFFICER/MEMBER EXCLUDED 100,000 (Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000 DESCRI DESCRIPTION under EL DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS below DESCRIPTION OF OPERATIONS/LOCATIONSIVEHICLES/RESTRICTIONS/SPECIAL ITEMS THIS REPLACES ANY PRIOR CERTIFICATE ISSUED TO THE CERTIFICATE HOLDER AFFECTINO WORKERS COMP COVERAGE THE WORKERS'COMPENSATION POLICY DOES NOT PRO VIDE COVERAGE FOR OUIMARAES,RODRIGO. ..._- . m..m. -.__.e._........................ CERTIFICATE HOLDER CANCELLATION CITY OF SALEM SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED 120 W ASHINGTON STREET BEFORE THE EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTgTdVE SALEM,MA 01970 y C ACORD 25(2009/09) _ _e 19BU-20 RD CORPORATION. All rights reserved.�W RightFax N3-1 5/9/2012 7:23: 48 AM PAGE 1/002 Fax Server FAX To: GUIMARAES RODRIGO DBA GUIMARAES CONSTRUCTIO Company: Fax: 9787409846 Phone: From: Prasad,Rakesh Fax: Phone: E-mail: NOTES: Certificate of Insurance 5059P868 02-28-2012 This communication,including attachments,is confidential,may he subject to legal privileges,and is intended for the sole use of the addressee.Any use,duplication,disclosure or dissemination of this communication,other than by the addressee,is prohibited, if you have received this communication in error,please notify the sender immediately and delete or destroy this communication and all copies Date and time of transmission:Wednesday, May 09, 2012 7:23:12 AM Number of pages including this cover sheet:02 � I The wealth of Massachusetts s� CITY OF Common �� Board of Building Regulations and Standards SALEM Massachusetts State Building Code 780 CMR Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or Demolish a One- or Two-Family Dwelling Section Foi Official Use .� ' pt5 J'7 � Build ng Permit Number Daf Applied BurldmgO letal,(PnntNam�) z� _ .St natures Date SECTION 1 SITE LNF T 1.1 Property Address: n 1.2 Assessors Map & Parcel Numbers 1.1a Is this an acceptee 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: Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ElPublic❑ Private❑ Check if yes[] _:SECTION2 PROPEI2TXOWNERSHIP'`' ; 2.1 Owner'of,Rgcord:` %;leyy" mil. ill �� 7L7 Name(Print) City, State,ZIP No. and Street -� Telephone Email Address SECTiON'3;DESCRIPTION OF PROPOSED WORK_(check all t at-apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other El Specify: Brief Description of Proposed Work': c SECTION 4 ESTIMATED,CONSTRUCTION COSTS ` , . ' Estimated Costs: Item Labor and Materials �' Official Use Only d1Bildg PertFee $ ''Indtcatehowfeeisetemin 1. Building $ ed. ❑,Standard Ctty('Tbwn,ApplicationFee, 2. Electrical $ D. TofaHrolect Cost (Item 6)x multiplier x 3. Plumbing $ 4. Mechanical (FfVAC) $ Ltsc 5. Mechanical (Fire $ Total All Fees $' Su ression Check No., . _.. Check-Amount. Cash Amount 6. Total Project Cost: $ ❑Paid in.FuHl ❑ Outstanding Balance Due SECTION 5e CONSTRUCTION SERVICES 5.1 Construction Supervisor Li e�ise(CSL) !/��C ,)l Licen�mber Expirat on a e Name of CSL Holder �i� ^c ! i:2 `ilk ��r� �g List CSL Type(see below) lk} No. and tr t � �T -Type , , Desectpfion _ i U Unrestricted Buildin s u p to 35,000 cu. ft Cny/Town, State,Z t © � R Restricted l&2 Family Dwellin • M Masonry RC Roofin Coverin WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Tele hone Email address D I Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Re istration Number Ex ra n Date HIC Co n a e I 's ant Name No. a reet Email address City/ o n, late, ZIP Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G7L: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 Issuanc,916 the building permit. Signed Affidavit Attached? Yes .......... No ........... ❑ SECTION 7a OWNER AUTHORIZATION.TO BE COMPLETED.WHEN OWNER'S AGENT ORCONTRACTOR APPLIES FOR'BUILDING PERMIT"` I, as Owner of the subject property,hereby authorize ��_ ��iyj� to act on my behalf, in all matters relative to work authorized by t is building permit application. 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 i his application is true and accu to t the be of m knowledge and understanding. Print Owner's or Authorized Agent's Name(Electr nic Signa ure ate 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.tnass.<_>ov/oca Information on the Construction Supervisor License can be found at ww•w.mass.eov/dos 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"may be substituted for"Total Project Cost" 10/10/2012 23:08 FAX to 00 HOME IMPROVENtEN r CONTRACT bZ-� PLEASE READ THIS �L Sold. Furnished and Installed by: Branch Name, Boston Date: [��T "rIID At-Hoirw Services, Inc. d/b/h The Home Depot At-Home Services 345A Greenwood Suva.Unit 2, Wurccslcr,MA 01607 Toll Free (800)657-5182; Fax (508)756-8923 Branch Number:31 Federal ID#75-2698460: ME.Lic#C 02439:RL Cont.Lie# 10427 /� w� C/�I'L.ie#HIC.050522:MA[-look improvement C(IntMetnr Reg.# 126893 Installation AddYCFS, -7_n_Ev�,di:?C� J/ &;� / __ �evrw ^111 City State zip Purchuser(s):_ Work Phone: Home Phone: Cell Phone: Home Address:_-- _ - (lf different from Installation Address) City State Zip Ii mail Address(to receive project communications and I lome Depot updates): . . ... ....._-_.. ._._..... 100 NOT wish to receive any marketing emails front The Hama Depth l'tntert Infornnatio)t: 1!ndecsi ncrl ("C"astnnter'")- tic owners of the properly homed all the alxrve installation address- agree•% to huy. :nxl 'CI 11? At-I ionic Servic,:s, Inc. ("I'he Monte Depot") agrees uh furnish. deliver and arrange for the installation ("Ins[allal ion") of all niaicriads decciihod on the below and on iha rel'creucod Slice Sheet(s). all of which are incorporated into this Contact by lhis rcferencc, :dung with any applicable Slott+ Supplculedl and Payment Summary attached hercw and any Change Orders (collcetit•cly, "Contract"): .Nib#: am naiwr .' Products: SpecSheet(s)#: .. — ProjectAnionnt ❑ltoaliar, �jSidinF �Winduws [�blsu)ulinn w�vy6s ❑Oatters/Cm•cn ❑lint 1pnon 111 �]Ruoling ❑Sitting ❑Windmas [j Insulmiuu ❑Guttcrc(Covers ❑Entry lloors []_—.__._. .-... ... . ❑Kooning ❑Siding ❑ Windotwct [] Inwdminn i ❑Gutter./Curers ❑Hoeg•Denies❑---.... . _ I � ❑Knnting ©Siding ❑Windmvs ❑Ineuhnion QCiutirn/Coven ❑Iinlry[)ours ❑. � �Mhtimi nt 25%r l)elxwjt ofContract AnxwM due upon execution of this conlracl. 'Total Contract Amount \taitM Putti:han:n niay not dcyxxvll uxtre than one-third of the CouuitctAnxmnt. (:11nwnier agrees Iha(, initrlcdiately upon compleiiun ill'the work I'or each Product. CaStlphler Will execute it Cotoplcliun Certificate (olio fur each Miducl as dclillutl by an individuid Spec Sheet) Mid pay any balance due. As applicable, each C'usumter antler Ibis Contract agrees to be jointly and severally obligated and liable hereunder. The Ilonic Depot reserves the right to issue it Change Order or lenninlne this Contract or:iny individual Product(s) included hcreid. :d its discretion,if'rhe Hume Depot ar Its authorized%eivice provider determines that it cannot perform its ohligaliMIS title to it structural problem with the hone, cnvironlnenml haiards such as mold, asbcaos of lead paint, other safety concerns. pricing treys or bucausc work required it)complete the job was not included in the Contract. 1'ayntent Sunmtary, ?"he Payment Summary 8_Ea included as Pau of this Comae!, sets forth Ate toad Contrite[:anutuu a1111 payments required for the deposits and findpaymenishy Product (us applicable). NOTICE TO CUSTOMER ER You are entitled it)a completely filled-in copy of the Contract at the time you sign. Do not sign a Completion Certifit•ate(note, there is one Completion Certificate for each listed Product as defined 113 individual Spec Simets) before work on that Product is complete. lot the vent of termination of this Contract. Customer agrees in Pay 'I he Ilonie Depot the costs of materials, labor, expenses and services provided by The Ilntne Depot (or Aothoriretl Seri,ive Popp ider through lhr dale n1, lernlinaliou, plus any other nationals set forth in this Agreement or allowed under applicable law. THE HOME DEPOT ALAY WITHHOLD AMOUNTS OWED TO THE HOME DEPOT' FROM THE DEPOSIT' PAYMENT Olt OTIIFJR PANAMENTS MADE, WITHOUT I.INH•r1NG TIH?IIOME DI{PO'l"S O'I'HI;R RENIF:DIPS FOR RF.(:OVLRY OF SUCH A:\1Oi:N'l'S. Acceptance and Amihorization: Customer agrees :old uoderstauuls thin Ibis Agrcenpanl is the entire MHCC)ncnl IkMCCII Customer and The [ionic Depot with regard to the.Products and installation services and supersedes all prior disctissiunN and ;Igi"Cant:pin.either oral or Wridan, relating in said Products and la,lallation. This Arrecincnt cannot be assigned or amended except by a Writing signed by C'ustonter and The I lame Depoi. Customer acknowicdges and a,roes chat Customer has real- undoiNiands, voluntarily accepts lha terms ol'and has rcceived a copy of this Agreeinenl- 10/10/2012 23:08 FAX. 1¢)1102 Home Addrews: (If dif2rcnl From installation Address) City State Zip E-mail Address(to receive project conlnuuiieutions and home Dept updates): 5I DO NOT wish to receive any marketing,entails from The Home Depot Prvljecl Information: Undersigned ("Customer'), the owners of flit-properly located at the above installation addles.agrco%to buy, and 1-111) At-lloale Services- Inc. ("rhe Name Depot") agrees to fill nish, deliver and arrange for file installnl inn ("Installation") of all materials dcscrihed un the below and on 1110 iel'crenced Spec Shecos). all of which all; iucurpnriacd into this Contact by this reference. along with toy applicable Stale Supplement and Paymcnl Stln imuy ntached hcr'eu, and any Change Orden Icollectively. "Contract"): Job ill: nno-m:d 1e.•trr+n.ry Products: _ Sprc Stlecl(sl#:_ Pr��jrt�t;�mmnrt �... []Rai ning �ISiding MWindawa ❑ htwiatirn, (_]C.wlers I C•oveiz ❑Rntry toms E3 , ❑Roofing Sitting ❑Winduu•, ❑ Imsulatioa ..._.. . ... . i ❑Cringe/Covers ❑entry Drnns ❑ ,_ ' - ❑Roofing ❑Sitting ❑Window Inwlutiin ❑Curren/Covers ❑entry Dears $ . .. []Rnofin•• ❑Sitlin• N'inaiows ..___. __. .. - ...._..-_- .. ._..--,..... !- ❑ ❑ Inwtatiun ❑Guucrs/Covvn ❑11u q•Doors ❑„ __ lithtimunt 25r/114:posit of Contract Arranmt doe ution exmutiral if this Lvratrac4, Tidal Contract Amount Yinirre p,ur•hasets nary not JLyn„i1 nu,"•tram arte•1Binl nl'Ihr Conh:rctAutlront. ��`�/ ,___ Customer 11"recs that, ionnediatdy upon utalpiCtiou of the work tier Ouch Product, CusnanOr will execute it C01111 lo1011 C'erlificutc tune for each Product ❑S defined by as individual Sec Sheot) and pay any balance doo, As applicable, each Customer under this Comrtct :rtrec,m he juinl ly.uud severally obligated:Ind liable hL:rL:uader. The Hones Dopol re,ervcs the 61glit to issue a Ultimpe Order or terminate this Coulract orally individual prudul'i(c) included herein. ill its di,crction, il'I4c home Depot or its aulhori/Od service prnvldCr dOlCrnliuLa thilt It Lal,»ai I,el'Inr111 In nhlrgailOrin Lllh; Iu It hb-LIC'[LIRII .problem wilh the home, cnvironmomtul hanuzls eut•h m meld, asi)O<r0S 01' lead paint. 0;110 ntd'ely ConccrnN, priein8 autos or LICCAUSLI work nlptirr.d to complete thejob was not included in the Contract. Payment %ununary: The Payment Sunanury As a_ I included :Is p:u•t .d this C'onu-atct. sets forth the: tot:J Conh:ICI anuaull ;Ind ptlyulCuts required for the deposits and final 1mytnetiN by Product (as applicable). NOTICb:TO CUSTOINIFA You are entitled to it completely Iilled4ri copy of the Contract at the lime you sign. Do not silin a Completioll Certificate(1111te: there is one Completion Certificate for eneli-listed Prtulmet-us-ddhied by.individual Spee Sheets)-before vtvtrtt•nn that Product is complete. In the event of terrninulioo of[his Contract, Customer agrees to pay The flame Depot the costs of materials, labor, expenses and services provided hy 'rite home Depot or Authorized Service Provider through the date of tcrntllL:lliau, plus an} other amounts set forth fit this Akreunt¢nl or allowcYl under applicable lain- "fill( MONIES DEPOT MAY vYIT11110LD AMOUNTS OWED TO 'fill., HOME DI?PO'1. FROJ•1 THE. DEPOSIT PAYMENT pill". OTHE(t PAY:1iF-NTS MADE, WIT11011T I,11MITING THE 110NIF. DM:MPS OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS. #ccewance and Authorization: Customer aglWN uud understands that thi, Ag eenent is file enlin, agreeumnl between Cbstonler :ind The Home Depot with rel-ard ill Ihc-Prlulucic❑id installation aer•icps and UjlCrNCLLS all prior(lilt ussions and agre.emenb.. Mlwr oral ur wi itten. gel:ding to said Products and Installitlion. 'phis Agn:eutcla cannot ho as,ipued or :ancndcd except by it w\litiug signed by Cuslomcr and pile (tome Depot. Customer acknowledges and ugrees that Customer has read- understands. volunnaily accept, the terms of and bus received a copy ill this Agreement. *,, C I Sub" ' tcd tr.: XeL _ Date Sal cs Consultal Signaler GG -p---- Date .. ........__..-. .. ..... ... __..... ._------. Telephone No. Customer a Signature DuLC Sale.Consultant ).icense Nu. ,. .... _ _ CANCELLATION; CUSTOMER "WAY CANCba. TfIIS L�..�ly,i� a:i,•i AGREEMENT WITHOUT WITHOUT PENALTY OR OB ,11GA PION BY DELIVERING WRITIEN N(YrICE, TO THE )IONIF I)I:IKI'r 11Y ,11DNIGII.1. ON 'I'Iifi '1'IIIRD 1111SINENS DAY AI' ER SIGNING THIS AGREEMENT. THE SUPPLEMENT ATTACHED HE.RET0 CONTAINS A FORM TO I;SI•; IF ONE IS : SPECIFIIII ALLY PRESCRIBED ii1' LAW IN CUSTOMER',';S I'MV. NOl t r-I!!DUI P ION%I IIAC". 1N"I.(rNiyl i 10N.S.IIM ,I.t 1 1:1)ON I'ill:151AVll.;l still l%I) tki oral •A I tllP l'f,N I It 14': 10-04.1'1 (' $;' Whill'. RptPt)I,Hlp YpI1rh4 Cuulamc- The Cornrnompealth of Massachusetts Department oflndustrial Accidents Office of Investigations UIP 600 Washington Street Boston, MA 02111 www.ntass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (Business/Organimtiordlndividual): OD Address: agn ✓►l CY4 P�' �/ City/State/Zip: Phone.#: '� � Are an employer? Check the appropriate box: Type of project(required): I. I am a employer with �(M(/ _ 4. ❑ I am a general contractor and I v� » have hired the sub-contractors 6. ❑ New construction employees(full and/or part-time). 2.❑ I am a sole proprietor or partner- listed on the attachedsheet. 7. ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. employees and have workers' 9. ❑ Building addition [No workers' comp. insurance comp. insurance.$ required.] 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions myself. o workers' co right of exemption per MGL y [N comp. 12.g�Roepairs insurance required.] t c. 152, §1(4),and we have no employees.-[No workers' 13. Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all 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 subcontractors and state whether or not those entities have employees. If the subcontractors have employees,they must provide their work='comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name: � 6�I Ire 6 1Gi Policy#or Self-ins. Lic. #: Expiration Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration pa a(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 $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,da gainst the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of/the DIJk for insurance coverage verification. f do hereby c tify un er t a' sand It' afperjuty at the information provided above i true and correct. Si nature. - Date: !� Phone#: Official use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # 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 #: t�l Massachusetts -Department of Public Safety 1 Board of Building Regutatrens and Standards License: CSSL-099699 ROBERT POCZOBUT , 172 WHALENS LANE_' < ` Salem MA 01970 - J,.G.- Expiration Commissioner02/08/2014 O face of Consumer Affair and Busin�sR, gulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improv�el� ontractor Registration '-�-- Registration: 126893 `�— Type: Supplement Card . Expiration: 8/3/2014 The Home Depot At-Home Servilee V RICHARD"FALLONE 2690 CUMBERLAND PARKWAY SU Iff - 0 ATLANTA, GA 30339G_ �;f Update Address and return card.Mark reason for change. � Address F] Renewal F] Employment E Lost Card i OPS-CA1 0 60M-0 04-G101216 r AIN f (m i� DATE IPn:nIDOr!';'i_fN--.,'I CERTIFICATE OF LIABILITY I A I 02/2?/2D1?. -THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION CNLY AND CONFERS NO RIGHTS UPON THE CERTI'c"ICATE HOLDER. THIS i 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 BET'WEEM THE ISSUING WSURER(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 certiflcate does not conifer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1-666-966-4664 CONTACT NAME: _ Marsh USA Inc. PHONE IIPA No a I- E- homedepot.certre(luest@rnarah.com homedepot.certreQnest@rnarah.com p DRIESS: Two Alliance Center, 3560 Lenox Road, Suite 2400 Atlanta, GA 30326 INSURERS AFFORDING COVERAGE NAIC# Fax (212) 948-0902 INSURERA: Steadfast Ins Co 26387 INSURED INSURER B: Zurich American Ina Co 16535 The Home Depot, Inc. New Hampshire Ins Co 23841 Home Depot U.S.A., Inc. INSURER C: P _ 2455 Paces Ferry Road NW INSURER D: Illinois Natl Ins Co 23817 Building C-20 INSURER E: NATIONAL UNION FIRE INS CO OF PITTS 19445 Atlanta', GA 30339 - INSURER F: Illinois Union Ina CO 27960 COVERAGES CERTIFICATE NUMBER: 25776028 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 ADDLTYPE OF INSURANCE INSR BURR POLICY NUMBER MMIDPOLIUmVY MM DDFF Y IEXP LTR /YYYY LIMITS A GENERAL LIABILITY - GL04887724-02 03/01/1 03/01/13 EACHOCCURRENCE $ 9,000,000 AMAGE O N D X COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence $ 1,000,000 CLAIMS-MADE PLI OCCUR MED EXP(Any one person) $ EXCLUDED _.- X LIMITS OF POLICY XS PERSONAL B ADV INJURY $ 9.000,000 X OF SIR: $lM PER OCC GENERAL AGGREGATE S 9,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: - PRODUCTS-COMP/OP AGO $ 9,000,000 X POLICY PRO- _LOC $ JECT B AUTOMOBILE LIABILITY HAP 2938863-09 0 03/01/13 COMBINED SINGLE LIMIT Ea accident 1,000,000 X ANY AUTO BODILY INJURY(Per person) $ ALL OWNED SCHEDULED BODILY INJURY(Par accident) S AUTOS AUTOS NON-OWNED - PROPERTYDAMAGE S HIREDAUTOS AUTOS Peraccid,. IX SELF INSURED PHY DMG - $ UMBRELLA LIAR OCCUR EACH OCCURRENCE $ _ EXCESS LIAR CLAIMS-MADE AGGREGATE S _ DED I I RETENTION$ S L. WORKERS COMPENSATION WC019736915 (ADS) 03/01/3. 03/01/13 X WCSTATU- OTH- ANO EMPLOYERS'LIABILITY D ANY PROPRIETOR/PARTNEWEXECUTIVE YIN WC019736917 (FL) 03/01/3. 03/01/13 E.L.EACH ACCIDENT $ 1,000,000 OFFICER/MEMBER EXCLUOED7 N❑ N/A E (Mandatory In NH) WC019736916 (CA) 03/01/1 03/01/13 E.L.DISEASE EA EMPLOYEE $ 1,000,000 I( es.describe under DE SCRIPTION OF OPERATIONS below I I E.L.DISEASE POLICY LIMIT $ 1,000,000 E Workers Compensation WC1192494 (QSI) 03/01/1 03/01/13 SIR (AOS)/SIR (GA) iM/750,000 C Workers Compensation WC019736918 (WI) 03/01/1 03/01/13 F TX Employers XS Indemnity TNSC46566397 (TX) 03/01/1 03/01/13 Occurrence/SIR 30M/1M DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more space is required) RE: EVIDENCE OF COVERAGE CERTIFICATE HOLDER CANCELLATION I r r SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE HOME DEPOT, INC. THE. EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ' HOME DEPOT U.S.A., INC. ACCORDANCE WITH THE POLICY PROVISIONS. 2455 PACES FERRY ROAD NW AUTHORIZED REPRESENTATIVE BUILDING C-20 ATLANTA, GA 30339 USA $P ©198§-2010 ACORD CORPORATION; All rights reserved. 1 ACORD 25(2010/05) The ACORD name and logo are registered marks of ACOR6,- Tthornton hd CITY OF SAI..Etit, UI SSACHUSETTS • B1:ILDLNG DEPARTMEINT N 120 WASHLNGTON STREET, 3° FLOOR ' $ TF-L. (978) 745-9595 Fax(978) 740-9846 KI,N{BFRt FY DRISCOLL MAYORTHOS(aS ST.PtERRB DIRECTOR OF PLBLIC PROPERTY/BUILONG COSL\fIS5IONER 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 l l 1.5 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: Urz.�E (a,e of hauler) The debris will be disposed of in ---- f — - (name of fI"a^ce Jt ) ____(a(fdress of facility) s nature of permit applicant date dcbrisa�7dx I'lie Commonwealth ol'Mossachuscus Board oFBuilding Regulations and Standards Cl FY OF Y I y, jklassachusetts State Building Code. 730 C NIR SALE\I 'L� ReI moll tlw•'I)// Building Permit Application 'ro Construct. Repair. Renovate Or Demolish a One-or ru u-Familr D elthi' This Section Fur icial Use Onl Building Permit Number: Dateee Ap_,plied: A --- Building Otlicial(Print Muriel Signature )( aje SECTION I:SITE INFORMATION 1.1 Proper t�SAJJress, r y Sail � 1.2 Assessurs Map ds Parcel Numbers Z( 70 )Sr�ovr�l S� re 1.1 a Is this an accepted street? es no Map Numn I'urccl Numher 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District PropowJ Use Lot Area(sq 11) Frontage(11) 1.5 Building Setbacks(It) Frunt Yard Side Yams Rear Yard Required PruviJcd Required Provided Required I'roviJed 1.6 Water Supply:(M.G.I.c. 40.§Ja) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood-Lune? Municipal❑ On site disposal system ❑ Checkif ycs❑ Record: 2,�n Ownertof SECTION2: PROPERTY OWN ERSHIPI i /' IiKQ �P us�5 Sa�el.\ MA 0/270 Mane(1'rinly, City.State.ZIP `7 0 7 C0 4 A 703 3-TT e09 No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑ Demolition ❑ 1 .accessory Bldg. ❑ nsber of Units Other ❑ Speeity: Brief Description of Proposed Work-: SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: 0111c1a1 Use Only Il..lhor:md \laterialsl y I. Building S 1. Building Permit Fee: f Indicate how fee is determined: '. Itlectrical S ❑Standard Ciry?ussn Application Fee O Total Project Cost'(Item 6)x multiplier — — x !. Plumbing S ,. Other Fees: S — - J. \1"Imnic.d ill\.\C) S List: ' S. \Icchanicul afire -- ----- -------- - - - -- . . . . tin'rressiunl S focal \Il Fees: S_2.5 C- _ ('heck No. ('heck Anunou: l',ish \moron: Tutu) Project Cost: S 7C - — _.. /5 ❑ Paid in Full ❑Outstanding BuLmce Duc: SECTION 5: CONSI-RUic-i-IONSERVICF."; 5.1 ('onitructioli Supervisor License(('Si.) q1 40 - /-7— --cilse unihcr I v ll Date I is[CSI. I'siv Is"I'vit'") ]'%PC Description No. and strvct —ki 11.1 R —iAetrictcJ Iv-2 F-111111Y MwIlink C6/1"'mi.State./III %I %lasunry KC Rooling Covcrinm liki Windowmd Siding SF solid Fucl Burning Appliances I Insulation 'I'cic hone I:inai I addrvs.4 0 Demolition S. Registered Ilyntit Improvement Contractor(HIC) plle",-eae�o — � r -- 'Ic 1) 4 1 it.vgFlratiun Nunih., f,%pirilloil IYU an Name orill itegistrunt Name N . all we Email address Citvrrown. State,ZIP relc Wane 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...........Cl - : SECTION 7m-OWNER AUTHORIZATION ll�() HE , 011IPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT ^ ') 1, as Owner of the sAect property,hereby authorize u4ce I ille e -lie to act onrin belle in tatters lativet work authorized by this building permit application. Date Print 0wncr's Nana(Electruni - ig urn) SE I 7b:OWNER' OR AUTHORIZED AGENT DECLARATION By entering In i c be w. I hereby attest under the pains and penalties of perjury that all of the information contained' his p . ation is true and accurate to the best of my knowledge and understanding. Date NOTES: I. An Owner t%hu obtains a building permit to do his.her own work,or an owner who hires in unregistered cunirnoor (not registered in the Hume Improvement Contractor(HIC) Program), will 1a) have access to the arbitration program or guaranty fund under M.G.L. c. 141.4. Other important information on the HIC Program can be found at %%\1,1% 111j,' �;,.,% ,,.i Information on the Construction Supervisor License can be found at 2. Wien iubstanlial%wrk is planned, pro\ide the information below: row (lour area(sq. ft I —('"luding garage. finished bascinctit.attics,decks or porch) Cross It%ing area 154 It I ---- - -- Habitable roust count \ianbvr or fireplacesNumber of liedroollis \uIntivir ill halt,hallis I*\ licating Noinher ot'decks, porches Ilk!ot I�iicloscd 01wil peof%:klolillu sicill loial Ilroiccl Square 1:00USC-- slay he qiboitkocd flor ,I*oial Ilrojco 01,11" 04/05/2012 08: 29 9789219182 LAURANZANO INS PAGE 01 :4CQRD CERTIFICATE OF LIABILITY INSURANCE DATE(MM,DD/`YYY) PRODUCER (978) 927-8420 04/09/2012 THIS CERTIFICATE 1$ ISSUED AS A MATTER OF INFORMATION LauranSano insurance Agency HOLDER. THIS CERTIFICATEONLY AND CONFERS ORIGHTS E S NO O THEEND EXT 107 Dodge Street ALTER THE COVERAGE AFFORDED BY THE POLICIE END OR S BELOW- aewrl MA 01915- INSURERS AFFORDING COVERAGE INSURED NAIL# INSURERA:Penn America Insurance Co Rodrigo INSURERB:Travelere Guimaraas Construction INsuRERc: 21 Balcomb Street IN RERa Salem MA 01970- IN RERe COVERAGE$ THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERI00 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. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR ADDT IN TYPE OF INSURANCE POLICY NUMBER DATE DAM CTNE DAAM MWO [ON LIMITS A X GENERAL LIABILITY pAC690g{37 09/09/2012 03/09/2013 EACH OCCURRENCE S 1,GOO,D00 X COMMERCIAL GENE LLIABILITY DAMAGE? RENTED PRE MISSES E occurrence S 100,000 CLAIMS MADE X OCCUR / MEO EXP Pne raon $ 5,000 PERS NALS ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GENT AGGREGATE LIMIT APPLIES PER:Rp- PROD CT$-COMP/ PAOG 3 2,000,000 X POLICY JE AUTOMOBILE LIABILITY / / / / COMBINED SINGLE LIMIT ANYAUTO (Ee acclden0 S ALLOWNEDAUTOS / / / / BODILY INJURY SCHEDULED AUTOS (P&peHAn) $ HIRED AUTOS / / / / BODILY INJURY NON-OWNED AUTOS (Per smdenl) $ PROPERTY DAMAGE (Per ewldenD $ GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO / / / / DTHERTHAN EA ACC $ AUTO ONLY: AGG S EXCESAILIMBRELLA UABWTY / / / / EACH OCCURRENCE $ OCCUR 7 CLAIMS MADE AGGREGATE S DEDUCTIBLE RETENTION $ B WORKERS COMPENSATION AND 4349P245 02/28/2012 02/28/2013 Y I TAO I - I 10R_ EMPLOYERS LIABILITY ANY PROPRIETORIPARTNERJEXECVTIVE E.L.EACH ACCIDENT $ 100,000 Y OFFICER/MEMBER EXCLUDED? / / / / E.L.DISEASE-EA EMPLOYEE$ 100,000 If yea,deaCObe under E.L DISEASE POLICY LIMIT $ 500,000 SPECIAL PROV1310NS below OTHER IESCRIPTION OF OPERATIONS/LOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENTWECIAL PROVISIONS IERTIFICATE HOLDER CANCELLATION :978) 745-9595 5641 (978) 740-9846 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, THE HISUING INSURER WILL ENDEAVOR TO MAIL 20 DAYS WNTTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT City Of Salem FAILURE TO 00 SO SHALL IMPOSE NO OBLIDATION OR LUUSILTTY OF ANY KIND UPON THE Public Properties Department INSURER ITS AGENTS OR REPRESENTATIVES, 120 Washington Street AUTHORIZED REPRESENTATIVE Salam MA 01970- 9)ACORP CORPORATION I BUB .`CORD 25(2001108) Page t or z 1ru INS025(010$)05 ELECTRONIC LASER FORMS.INC,-(B00)3TP0545 --- ----------- --- - ------------------ -- s �,8assuclntsMts- fDcp:u't(ncut of Public Surctc Bmtrd of Building Rerulutions :ut(1 St:uul:u'tis Construction Supervisor License License, CS 91M MICHAEL L MERCURIO k 127 OAK ST WAKEFIELD, MA01B80 Expiration: 9263 ;j . Try: 9283 GJ2. ea�/� a License or registration valid for individul use only Office o o;mer atn tees gu a on before the expiration date. If found return to: HOME IMPROVEMENT CONTRACTOR Typo Office of Consumer Affairs and Business Regulation Registration 149839 10 Park Plaza-Suite 5170 DBA Boston,MA 02116 ;E Expiration: 2f1 312014 , M URtoCON�T�UCTION MICHAEL MERC4RI � r _ 127 OAK STREET WAKEFIELD,MA 01880 r Undersecretary Not valid without signature GUIMARAES CONSTRUCTION 21 BALCOMB STREET SALEM MA 01970 PHONE: 978 836 7279 QUOTE/CONTRACT M3uZI TO: Miko de Jesus PHONE: 1703 338 8021 QUOTE: 01 Salem, MA DATE: 03/22/2012 -Quantity Description Rate Amount Demolition Frame Insulation Repair the floor Stool tub Tile Cement board ' Blueboard and plaster Trim Skin coat rollway Paint Cleaning $ 69000.00 Plummer $ 19500.00 Total Price Price includes: Permit, labor, $ 79500.00 material and dumpster. a� Quote valid for 30 days Quotation prepared by: Rodrigo Guimaraes First payment due when job started 50%, the remaining 50% due at the last day of job finished. To accept this quotation, sign here and return: Complete name of person signing this quote: -Date:O / / r CITY OF SMu EMJ NWS'ICf-iusF ITS s 1� BUILDING DEPAwrmE-NT 120 %A.\SHNGTON STREET Jru FLOUR �..� . TEL (978) 745-9595 F.kX(978)7 11-9846 !U.%113EALEY DRISCOL L NLAYO a nionits ST.P1EAU DIRECTOR OF PUBLIC PROPERTY/BUMMING COJLUISSIONER Workers' Compensation Insurance AMclrvit: BuildersJContructurv/Electrlcians/Plumbers 1DDlicant Infnrmatlon Plcase Print Legibly .Nair4InWII1v�bUr�,lNrallUlLInII1r11IU.lIY r ,Address: �i. / Rail T City/State/Zip: % 9 % (7 Phone N: / 9-�7 ,\re you an employer:'Check the appropriate brain 'type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and! S. Nuw unstruction employees(lull and/or part-lima).• have hired the sub-contactors 2.❑ lam a sole proprietor at partner. listed on the attached shCcl. t �• emadeling .hip ued have no employees These sub-contractors have V. C] Demolition working liar me in any capacity, svorkdrs'camp.insurance. '). Building addition (No workers*.comp. insurance 3. ❑ We are a corporation and its required.) oflIcers have exercised their 10,C]Electrical repairs or additions ).❑ I am a homeowner doing all work right of uxmnption per MOL I I.❑Plumbing repairs or udditiorla myself.(No workers'sump. C. 152, 41(4).and we have no 11.C] Roof r pairs insurance required.) 1 employees.LNo workers' 17.❑Other comp.insurance required.) •.vny applluun aW rhsuYr box rl cowl atsu ntl uul the weliue bvldw showing Iheir rakrni'compenution pulivy inMsmudon. 'I Lvneuwrtiv-howl....it this affidavit indicating they are doing all wont and then him uunide contractors mtut stshmll a new ailldaril indicting.;mh. :r\mlr. -Ign Ihat chsvk this box moat nrachud an.Wdiriurad.hat showing Ihr nwno of the sue.eanirurom and that,wnrbcre'comp.policy inte madoa. I urn an rurpluym that or pruvIdbig workers'comprurodun/nsuruncr far my emp/uyrra Brluw/1 du policy arseJob x/t� isrfornaallon. Irl'unuca Company Nmne: _//� Policy 4 ur Self ins. Lie. H:pPA l.t 9 wY'_ �_ Expiration Date:0—1 z Q/ lob Site Address:[/i .V yr•; � l y— ,a S �r � � � CilylStuter2:ip: 6V2C'5 G \Mach a copy of the irorke s' compensation policy declaration page(showing the policy number and expiration data). Klilura to wcure coverage as required under Section 21a\of NIOL c. 152 can Iced to the imposition of criminal penalties of a fire up to 11,500A0 and/or one-year i1riprisnnmcn4 as well as civil penalties in the term of a STOP WORK ORDER and d line of up to S2S0.(10 a Jay against file violator. Ile advised that a copy afthis latemant may be rurwardvd to ilia Oilico or lay"ligaliuna of the MA Ier insurance coverage vcriiic.stiun. /du hereby crerify uasdrr rhr prbnr and prnahyrr of perjury,hut rhr infornrutloat provided uubbuuve it true nand eorrret _ furc L /hrJ Ajar 7! CT ' / 7 U//trial nee uuly. Oa not w,itr in this area, to be cumpleted by city ur lawn nJJ/eiuL City of liar u; -- - ._. I'crmiuLlccnse i L.uinq \ulhurily (circla unc): - — I. Iluard of Ilealth !. ItuiDlln., Dep-u-lwenl 1. ( ilylrurvn Clerk 4. Gleetrle.il hl.pectur i, Phmil)ing Intpee6u b. Other CunLAt I'irtna: The Commonwealth of Massachusetts t Board of Building Regulations and Standards V a Massachusetts State Building Code, 7S(1 CMR. 7"' edition \Il'NlCllIP .\I.I"I 1 Building Permit Application To Construct Repair. Kenoyate Or Demolish a Krrise,1./euuriu, � One- or Tiro-Fumily Du ellirt,q This Section For Official Use Only Building Permit Nut er. Date Applied: — Sisn;tture: t Building Conunissioncr/ Inspector tit BuildiugS Date SECTION 1: SITE INFORMATION I I. MO #.� S6LLM )IJA 1.2 Assessors Map .fit Parcel Numbers — [A a Is this an accepted street? yes X no %lap Number P:ocel Number 1.3 Zoning Information: 1.4 Property Dimensions: `Zoning District Prt+posed Use _-_ Lot Area tsq to Frontage tit) _- 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: Zone: _ Outside Flood Zone:' Public Private❑ Check if yes❑ Municipalbg On site Jislwsal system El SECTION 2: PROPERTY OWNERSHIP' �t 2mOyynert C_.Lt Qf�2ecoFd:f / C) fOG -It�� S�• l�hi� Saje, c 2 6 rS 1(Prt �) � Address for Service: 979 - 999- 000-7 Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ ExistingBuildinglA Owner-Occupied Repeirs(s) 54 1 Alterition(s) iSll Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specity: Brief Descriptionft�(,IIof Proposed Work 2: Zr lk '� ' C � let - 7,e it Q cy�i c Syz w e__ a c A Gif� to I {e re 4Le ro--00"", o 0 u SECTI A. ESTIMATED CON UCTION COSTS YllCj fCVl`� Item Estimated Costs: Official Use Only (Labor and Materials) 1. Building S 00 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ 00 — ❑Total Project Cost' (Item 6) x multiplier x 3. Plumbing S S60 ' ?. Other Fees: 4. Mechanical (HVAC) $ List' 5. Mechanical (Fire S Suppression) Total All Fees: S Check No. Check Amount: Cash :\nuttuit:__ j b, Total Project Cost: S 700.00 0 Paid to Full 0 Outstanding Balance Due:_------ SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) , License Nunlher Fxpiration Duty Name of CSL- Ifolder List CSL Tcpe(see hcloml Type Descri Ilion \ddrrss L Unrestricted ludo 73,(IU0 Cu. 1'l.l R Resu'icted I:c'_ Fanuk Dsselhne SlgHLItUre M Nl:uonry Only RC Residential Rooting C'o�erine Telephone W's Rcsidenual \vuldU\ and Siding_ SF Reside III ial Solid Fuel 1311111111g :\ 1 lhunce III I.Illawm D Residenti:d Demolition 5.2 Registered Home Improvement Contractor 0110 HIC Company Name or HIC Registrant Name Registration Number 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 pro%ide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached'? Yes .......... ❑ No ........... O SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT (AS' e..---yeStn S C�Y�SOUp�r'r-✓ V/-c-t!�'as Owner of the subject property hereby authorize to act on my behalf. in all matters relative to :ork • uthorized hydhis building permit appiication. ire of Owner -- _-------- ----- Dote —__---- ----- SECTION 7b: OWNE`.3t OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and intbrn.!:aion,,•a the foregoing application are true and accurate, to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of perjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work, or an owner who hires an umeC_istered contractor (not registered in the Home Improvement Contractor(HIC) Program), will not have access to the:ubitr:tiun 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 I IO.R6 and 110.115. respectively. _' When substantial work is planned, provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch) Gross living area (Sq. Ft.) Habitable room count Number of fireplaces Number of hedruums _ Number of bathrooms Number of halt/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" CITY OF SALEM PUBLIC PROPERTY DEPARTMENT KI M&LIUMrsw-n, 130VA94NGWW 27frsr•SKI SUSUCH NM01970 TEL T L7JS-9S"* FAX.975-74G9W XEJ�IPTION HOM EOWNER LICENSE E Please Print Date Job Location 70 � co r,� S� _ �; 1 Home Owner Address srw. P- Home owner Telephone q 7 8- t f 4T 8- 00o 7 present Mailing Address .5ok,. - The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire who does not possess a license,provided that the owner acts,..supervisor. DEFINMON OF HOMEOWNER Person(s) who owns a parcel of land on which he/she asides or intends to reside,on which there is, or is intended to be, a one or two family dwellin& attached or detached . structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such . "homeowner"shall submit to the Building Official,on a form acceptable to the Building official, that he/she be responsible for all such work performed under the Building Permit The undersigned "homeowner" assuunes responsibility for compliance with the State: _ Building Code and other applicable by-laws and regulations. The undersigned "homeowner"certifies that he/she understands the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with said procedures and re uir7/en!/ HOMEOWNERS SIGNATURE APPROVAL OF BUILDING INSPECTOR See other side for state code CITY OF SALEM y y i PUBLIC PROPRERTY �,K •., DEPARTLIENT Construction Debris Disposal Affidavit (reiluired li)r all demolition and renovation work) In accordance n ith the sixth edition of the State Building Code, 750 C NIR section 1 1 1.5 Dcbiis, and the provisions of MGL c 40, S 54; Building Permit it is issued with the condition that the debris resulting from this work shall be disposed of in a property licensed waste disposal facility as defined by MGL c 111, S 150A. The]�deebris will be transported by:: - (name of hauler) I'he debris will be disposed of in (name of facifity) tuddress ul 1'ucililvt .Iguaturc of p: tit applicant O Ala