3 CEDARHILL RD - BUILDING INSPECTION Zk The Commonwealth of Massachusetts
Board ul'Building Regulations and Standards CITY
i� y J Massachusetts State Building Code, 780 C'MR. 7'"edition OF SALEM
'wj RevisedJo.wun•
n, Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. :aAY
4�jJj}Yfl One-or Trvo-FumilP Dwelling
This Section For Official Use Only
Building Permit Number: 1 Date Applied:
Signature: �l'�'"0 /0
Huilding Commissioncri Inspect f Buildings Date
SECTION 1:SITE INFORMATION
I; �F r/y dress ,� / 1.2 Assessors Map dr Parcel Number
dd 1 q�
1.la Is this an acce led street?yes no Map Number Parcel Number
IJ Zoning Information, 1.4 Property Dimensions:
Zoning District Propose)Use Lot Area isq 11) Frontage(11)
1.5 Building Setbacks(B)
From 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 Sawage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zane? Mmicipel O On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record, /� ,/` /
N"I C R n Lct✓�� CPd4 R i
Nome(print) Address for Service: -
t7 IZZA
Signature Tclephom
SECTION J: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) O 1 AdditioJ103
Demolition ❑ I Accessory Bldg.O Number of Units_ Other M Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building S _ I. Building Permit Fee: f Indicate how fee is Determined:
❑Standard City/Town Application Fee
2. Electrical S O Total Project Cost'i Item 6)x multiplier x
1. Plumbing S 2. Other Fen: S
4. Mechanical (IIVAC) S I List:
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S
Yl7o 0 Paid in Full 0 Outstanding Balance Due:
SECTION!: CONSTRUCTION SERVICES '
5.1 Licensed Construction Supervisorisor(CSL) /a/ 2-Z
/ &4 ..�-Qahofl] :u License NumM I:r rtliun ale
Name of CSI.-I holder List CSL Type ism below)
as �, n
f I Descriplion
JJ ss U I llreesiricicd to 35.000 Cu.Ft.
R I Restricted lA2 Family Dwelling
Signature .J' M M only
'I RC Residential RoutineCoverin
'elephone WS Residential Window and Siding
SF RCe jW list Solid Fuel Burning Appliance Installalion
D Residential Demolition
3_2 /t btered Home l�ttproyemest Contra ctor(HIC) IZ117 7�
Taa
nn ho�r/ TiP l�� •�t - t
I lic Compa Name or f 11C R istrant Name Registration Number
M
a - pirat on Date
re Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL S 2SC(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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Sianadu fOwner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and in stion on the foregoing application are true and accurate,to the best of my knowledge and
all.
Print Name
oa !a
Signature of Owner or Authorind Agent Date -
i5itined under the pains and penalties of 'u
NOTES'
[Number
. 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 W have access to the arbitration
program or guaranty fund under M.G.L.c. 1 J2A.Other important information on the HIC Program and
uc L)
Construction Supervisor Licensing(CS can be found in 7110 CMR Regulations 110.R6 and I IO.R3,respectively.
2. When substantial work is planned,provide the information below:
otal floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
ross living area(Sq.Ft.) Habitable room count
umber of fireplaces Number of bedrooms
of bathrooms Number of half/baths
ype of heating system Number of decks/porches
ype of cooling system Enclosed Open
). "Total Project Square Footage"may he substituted for"Tidal Project Cost"
t Y\
,. CITY OF SAL.EM, LPL-kSSACHUSETTS
• BuiLDING DEPIRT%i&NT
130 WASHNGTON STREET, 3' FLOOR
TEL (978) 745-9595
FAx(978) 740.9846
KlSIBpRr RY DRISCOL
1
MAYOR �tont.+.c St.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDCVG CONWISSIONER
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 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with tfie 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 : TV VC- C
( e of f�li�ty)"
L
(addr ss of facility)
signature of per it applicant
ICI Zslw
Ante
an.��ira,x
a
CITY OF S:U=N1, AXSSACHLSETTS
BI:ItDL\GDEPiR'r7,1E2 T
6�-o
120 WASHINGTON STREET. 3m FLOOR
TEr_ (978) 745-9595
Fla(978) 740-98.16
K)NiBFRI EY DRISCOLL THONUSST.PtE All
MAYOR DIRECTOR OF PUBLIC PROPERTY/BI;ILDL\G cONLMSSIOrER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A licant Information /P�tcase Print Legibly
/ f >/
VamC l0usitn'ssAOrganizatiotvindividuaq�yi: r i_„1 'TQflW A T p T��
Address: ,;� IS \ eQn nin
City/State/Zip: f n (q ,SS Phone a: 7k-/9'V!/ y 53/
Are u an employer?Check the appropriate box: 'Type of project(required):
L 4. ❑ 1 am a general contractor and 1 6. New construction
I. I am a employer with.�_ ❑
employees(full and/or part-time).' have hind the sub-contractors; 7 Q Remodeling
listed on the attached sheet.I
2.0 1 am a sole proprietor or partner- These sub-contractors have.' g. ❑ Demolition
ship and have no employees
working for me in any capacity. workers'comp.insurance. q, ❑ Building addition
(No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.) officers have exercised their
right of exemption per MGL 11.[3 Plumbing repairs or additions
}.El 1 a homeowner doing all worst 152, §1(4)�and we have no
myself. [No worker'comp. c 12.❑ Roof repairs
insurance required.)t employees. [No workers' I3�Olher fn.�
sump. insurance rcquircd.]
-Any applicant that chucks box rl mug also rill out the sections below showing their wwkeani compensation policy infnmation.
t I hvneownen who submit this affidavit indicating they am doing all work and then him outride contmct=most sulanit a new afrdavit indicating such
=Conlmemn that chL%k this box most attached an additiumd xhmt showing the none of the sub-contractors and their workers'comp.policy information.
I am an employer that ds providing workers'compensation insurance for my employees. Below/s rile policy and Job site
information. f
Insurance Company Name: t f / --Policy Nor Self-its. Li/c.'N:J�41 79 0011 '1 0I0 Expiration Date: -� J
Job Site Address�SCl�IL Sz City/State/Zip' �4
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
line up to SI.500.00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be furwardcd to the Off-ice of
Investiguliuts of the DIA for insurance coverage verification.
Ilia Irareby cr IJ larder tha pains cord penah(rs uJper/ary tbaf the infurmarlon provided above it t ue and correct.
5.V. I Uat /
Pho gytl
official use wdy. Do not write in this ared,to be coatple"by city or'own olliciaL
City or Town• ___ _ . Permitti.lccnse#_-_..._—. _--
Issuing Authority(circle one):
I. Board of Health 2. Building Department 3.Cityiruwn Clerk 4. Electrical inspector 5. Plumbing luspeetor
6.Other
Contact Pcrsun: _ - ___ ..- Phone N:
)
Information and Instructions
assadiuscus Gcneral Laws chapter I52 requires all employers to provide workers' compensatiom for fhcir bun loyccs.
I'ursuxii to this.statute, an emplut•ee is defined as"...every person in the service of another under any contract of hire,
c.spress or implied,oral or written."
\n employer is delincd as"an individual, partnership,association,corporation or other legal entity,or any two or more
)I the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
recover or trustee of an individual, parmership,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, construction 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."
MGL chapter 152. §25C(6) also states that"every state or local licensing agency that! withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the comtnonweulth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, bIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please till out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s)name(s),addresses)and phone nuniber(s)along with their certificatc(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 confimmtion of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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 if you are required to obtain it workers'
compensation policy,please call the Department at the number listed below. Self-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 ;and printed legibly. The Department has provided u space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition, an applicant
that rout submit multiple pennit'license 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. Anew 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.e. it dug license or permit to burn leaves ctc.)said person is NOT required to complete this affidavit.
I he d)I lice lit Inve5figatdnns would like to thank you in advance for your cooperation and should you have;sty questions,
pleusc do not hesitate to give us a call.
the Deparuncnt's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
T'ei. H 617-7274900 ext 406 or 1-877-
MASSAFE
It:ci.cd -?it-us Fax H 617-727-7749
www.mass.gov/dia
OCt 3.2,2010 06:40P CROW COTTAGE 9797453116 page 1
✓ full 0 FOR BUSINESS 1.400-999-6327
t4. page No of Pages
�f7 WK TRAHANT JR. CONSTRUCTION, INC. —(2 o
4TH GENERATION ROOFING Vot
I 21.E Verona Street
IYNN• MASSACHUSETTS U1904 H.!. !IC, #141778
- 11 • (781) 844-4551 • FAX: (781) 581-0855
C'tl)f GSAr.All CD TO /2
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car �> U �V
L` JOB I ij:;ATIOY - --I
CIC.9TP.TE RIP Ci .E
We he, .tibrnit WOCH Cafion,a,d estIRIat.-I for- wP IIP.rP.IJY Gllbinit S[1C•Clll(.bh011i and C$tltlldiPC for
SPANGLE ROOF FUST RU80kR ROOF
strip entire roof ❑ Sweep entire roof clean
L R ace any bad boards up to 100 linear feet Strip entire roof
-,.. Ins II ice and;Voter barrier first three feet up root [7 Mechanically fasten down ISO board insulation
Et Install ice and water barrier in all valleys and along do mers LI Install 060 Rubber Roofing on entire roof
.,, nstall 151b. felt paper on remainder of roof F 1 Install metal flashing around perimeter of building
`inS ll eight inch drip edge LJ Flash chine I, pipes)and walls)
Io it ridge vent 13 Edge caulk all seams
! '�`f'laslj or re-Rash If peed,6 Ll Install new copper center drain
K-�- Instalf new pipe flanges CI Other
_, Install 30 year shingle LI other-_ LI Clean up all debris
U Install gutters and downspoutsD Labor and materials guaranteed 100%for five years
___.._.. . .
I!! F7 Install Vim coil
(D Install new fascia boards
I 1��2. [C-(j /hf.w 1'k� 6'1,1-Z5ha/1(j
l7 Install new rake boards
install sky fight(s) '_r ! C -- ny 7 -/Q j III
i
2ingle
6 up all debris _ I N _
and materials guaranteed10095 for five years
roofs are nailed by hand.
II Ave 4propo�ti herebv to furnish material and labor — rmrlplete In accordance with above speciRcalion: f- the sum of;
.'frtal Price(S V4 o —) • f
y°IF YOU ARE HAVING YOUR ROOF STRIPPED, PLEASE COVER ALL VALl1AMILES IN ATTIC. AS
WE HAVE NO CONTROL OVER DEEIRIS TNAT IAAV FALL TRROUGN ROOF BOARDS,
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NI tll to al gwat.owteci to u a5 SpE Iled Ali I'A Ii tiftled im tl LrkrtrJnflkP
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maul aco anv tv Ia ,urn n T.Y.e An) n.1 h1 ) dl6lpon tam ebrwe West -/�h-,:
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