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14 CHESTNUT ST - BUILDING INSPECTION (5)
\� IL, The Commonwealth of Massachusetts CITY OF / Board of Building Regulations and Standards�\b 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 This Section For Official Use Only ` Building Permit Number:- Da Applied: -)A) /3 Building Official(Print Name) _ Signature -,'� Date SECTION 1: SITE INFORMATION 1.1 /Y PropertyCf Address: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use - Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: -7�©m /11U!!aa SIelm Aw 0/Q7a Name(Print) / City,State,ZIP /e/ CdefI-,Val' s7' 97,)' S7�e Sl No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work 2: SECTION 4(ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical ❑Standard City/Town Application Fee $ I ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: 4.Mechanical (BVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees: $ 6. Total Project Cost: $ 3G 86/ Check No. 'Check Amount Cash Amount: 0 Paid in Full 0Outstanding Balance Due:> SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number tration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description ®wPN *4 o i8 Q/ U Unrestricted(Buildings u to 35,000 cu.ft. R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Sidin SF Solid Fuel Burning Appliances 7Pl 7P q/ 9 7 I 1 Insulation Telephone Email address FD Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC Registration Number xpv ron Date HIC Company Narne or HIC Registrant Name ✓��J S�Pir i�.a � No.and Street , '' // Email address /�/BZ7Ur✓ /l?�i� !g v 7 Z!/78r97 City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... Q No........... ❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT G 1 1,as Owner of the subject property,hereby authorize 1 W f e"r`~ � —e to act own my behalf,in all mattteerrrss relative to work authorized by this building permit application. Print Owner's Name(Electr nic Signature) to SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and acccuu to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) 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.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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" CITY OF NWSACHUSETTS BUILDING DEPARTMENT p• 120 WASHINGTON STREET, 340 FLOOR TEL. (978) 745-9595 FAx(978) 740-9846 KI.,{BFRt RY DRISCOLL MAYOR THONtAs ST.PmRRE DIRECTOR OF PUBLIC PROPERTY/BUUMDJG CONMUSSIONER 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: AR,2s 4/ dI w- (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signature of permit applicant date Jcbrivl7.J�x i CITY OF SM.E:NI, NLASSACHUSETTS • BUILDING DEPARTMENT • 120 W.ASHINGTON STREET,3-FLOOR TEL (978)745-9595 FA-�t(978) 740-9846 KI\fBERLEY DRISCOLL MAYOR DIRECTOR Sr.PtERRs DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO%L-aSSIONF.A Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Arinlicant Information / J Please Print Legibly Name (9usiacS Organiratiorvindividual): L..QcG k.PGdCe'/�j��N,�a,•G L L Address: O City/State/Zip: P/,P/// Phone #: 7JI/ 7 d 9 g 7/i — Are you an employer?Check the appropriate box:i Type of project(required): 1.❑ 1 am a employer with 4, am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2_❑ 1 am a sale proprietor or partner- listed on the attached sheet. 7• ❑Remodeling Ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs///� insurance required.]t employees. [No workers' 13.❑Other 11 -)e comp. insurance required.] *Any appliucaM that cheeks box HI most also till oul the section below showing their workers'compensation policy information. 'I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new,affidavit indicating such. 'Cuss .nors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy info,,um. l am an employer that is providing workers'compensation insurance jar my employees. Below is the policy and Job site information. Insurance Company Name: Policy 4 or Sclf-ins. Lic.#: Expiration Date: Job Site Address: �7 �l�L°fdw y y� .S Ciry/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration hate). 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 S 1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations ot'tlie DIA for insurance coverage verification. 1 do hereby eerrdd und the puiinnss u�m1/d ppen�alties ojperJury that the informationt provided above Is true and correct. Sift i_— C.—= /�^—`„//`L�/�.wtd Date- Official use only. Do not write in this area;to be completed by city or town of iciai City or Town: Permit/License# Issuing Authority(circle one): I. Board of Ilealth 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other . Contact Person: Thane#: MAY-31-2013 08 :51 AM 7OHN CIRIELLO 1 781 376 9511 P. 01 $ ♦P W." 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A00111025(7010061 TheACOFW c immilogoweveghliewdmeebeofACORD _ t Massachusetts - Deparvr+er' of ?ublic Safety Board of Building Regulations and Standards Con,t uction Supu�i.ur ., Llcense: CS-090389 LAWRENCEBMDEBRAND 30 SHERIDAN ST WOBURNMA 01801 c�mmass:cn�r 0512412014 _ 1 :i:Tce nr Coesnwa ARai:n=+Susaess lepciaion r � --HOME IMPROVEMEN, CONTRACTOR' Registration: 148422 ,� Ex iratlow �1221201'3 Incividue' ua P NCE HILDEBRAND L-VPIRENCE HILDEBRAND 30 SHERIDAN ST. WOBURN,MA 01801 Undersecretary. ,I QUALITY ROOFING RESIDENTIAL ROOFING RROPOSAUC0NT CT ,' a•- by LARRY HILDEBRAND 30 Sheridan Street 1 A DIVISION OF FERRANTE CONSTRUCTION Woburn, MA 01801 Owners Nam; ors Address 781.7139.9711 Tom Murray 14 Chestnut Street CS090389 owners ary owners Zip code owers home Phone owners wok Phma Salem 01970 978-578-0941 larryhildebrand@verizon.net prrge Address Pajed CM Pmject Zip Lode Pmjec[Phane Oeta 20-13 Quality Roofing by Larry Hildebrand,hereinafter referred to as"Contractor',hereby proposes to furnish to Owner all materials and labor necessary to roof and/or improve the above premises in a good,workmanlike and substantial manner according to the following terms,specifications and provisions: a.Description of the work and the materials to be used: New shngle_roof as per the attachment "Shingle" project details. - New-shingle—roof-Total $ 19,620.00 -_Optional:------ _ - UpigIrwile to Grand Slate 2 Mystic Slate shingles-add $4 530.00 -Upgrade 7/16 OSB sheeting on the roof.deck$5,700.00 _ Upgrade to140' of Zinc strips-on-both sides of the ridge$-1,300.00 Extra-Shingles for storage 13 square&54 bundles$2,821.00 - -Fuel charge of shingle from-Texas-$700.00 _ _- Upgrade to a Golden Pledge warranty add$1,200.06 b.Description of any areas that will NOT be worked on: This list of specifications may be continued on subsequent pages(see page number below). e.Payment:Contractor proposes to perform[he arb�ove work,(subject to any additions and/or deductions pursuant to authorized change orders),for the Total Sum of$ -3 t � /�• � 1/3 Down Payment(if arty)$ g 02'96). F?--d PAYMENT DUE WHEN AMOUNT PAYMENTS TO BE MADE IN INSTALLMENTS AS FOLLOWS: 1. Balance upon Completion By check upon receipt of invoice for draws as described under "Payment Due When" to the left 2• column. 3. 4. d. Commencement and Completion of Work: Substantial commencement of the job shall mean either the physical delivery of materials onto the premises or the performance of any labor and shall be subject to any permissible delays as per provision(3)on the reverse side of this proposal/contract. ., Approximate Start Date: Approximate Completion Date: e.Acceptance: This proposal is approved and accepted.I(we)understand there are no oral agreements or understandings between the parties of this agreement The written terns,provisions,plans(if my)and specifications in this proposal/contract is the entire agreement between the parties.Changes in this agreement shall be done by written change order only and with the express approval of both parties.Changes may incur additional charges. Additional Provisions Of This Proposal/Contract Are On The Reverse Side And May Be Continued On Subsequent Pages(see page number below).Read Notice To Owner on page two(2)before signing.Read"Arbitration of Disputes"provision on page two(2),provision 10 and the NOTICE following this provision.If you agree to arbitration,sign on the line below the NOTICE where indicated.Also,sign in the same place on EACH COPY of this contract. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES You may cancel this agreement if it has been signed by a party thereto at a place other than an address of the seller,which may be his main office branch thereof,provided you notify the seller in writing at his main office or branch by ordinary mall posted, by telegram sent or by delivery, not later than midnight of the third approved and ° p (liwnerl a business day following the signing of the agreement.See attached Garret Budlow notice of cancellation for an explanation of this right. 6-20-13 NOTE:This proposal may be withdrawn after 3 0_days fro ,16-20-13 eppmved(cuno-aaar) date if not approved and signed by both parties. Form RPC-C Copyright©1996-2008 ACT Contractors Forms(800)820.6656 www.caltorm.com Page one of 2 Total Pages