15 CHESTNUT ST - BUILDING INSPECTION � o q-
The Commonwealth of Massachusetts
CITY OF
Board of Building R r p$£gid Standards SALEM
9 Massachuse's' State 00-Q�gaVQR%a Revised Mar 2011
O Building Permit Application TSotCtonstruct,Repair,Renovate Or Demolish a
J One-or o lia 41
(� This e6 ion For Official Only
1 Building Permit Number: I Date plied:
1 Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
l� c�+t�s��u� �
1.1a 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 it) Frontage(It)
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? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Own"'of Record:
Name(Print) City,-State,ZIP
/S r,fw rlx Lua ( —C3/5Yi
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ JExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ er ❑ Specify:
Brie Description of Proposed Work :
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 g ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
Mwt L_GfD a-b C�o2o ( 31
SECTION 5: CONSTRUCTION SERVICES
5.1^Construction Supervissoor License(CSL) _ �-
1 ) O�OAJAI-- icense Number Expiration a e .
��L Holder
C /T;�j T '/ 7 �T— List CSL Type(see below)
No.and Street � //W/ / Type _ Description.
U I Unrestricted(Buildings u to cu.ft.
R Restricted l&2 Family
Dwelling
City own,State,ZIP M Masonry
RC Roofing Covering
WS I Window and Siding
7� Solid Foe]Burning Appliances
1
I Insulation
Tele hone Email address D Demolition
5.2 Rep' tereddHoome Improvement Contractor(HIC)
AW�� .�l L14 MC Registration Number E on to
HIC Company Name o HIC Re istran Name
E
No.add S �j Email address
City/Town,State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.E.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...........❑
SECTION jai OWNER AUTHORIZATION TO RE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES.FOR BUILDING PERMIT .>
I,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.
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 in application is true d accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Dat
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
x»vw.masssovloca Information on the Construction Supervisor License can be found at www.mass. ov€ /dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
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203 WASHINGTON:ST.#256
PRESERVE SALEM.MA o1970
QJ: E R V ICE.S` carpentry l painting)roofing_i gutters PHONE:978.745:8745
'FAx:978.745.3676`
SALES@ PRESE RV ESE RV ICES.COM
Pete Gordon Date Bid:5/14/2015
15 Chestnut St Estimator:Sean O'Connor
Salem, MA 01970 Mobile:(978)395-7737
(617) 756-0199 Email:sean@prese"eser ices.com
peterkarensalem@hotmail.com
SCOPE Replace the deck on the rear of the home with a deck of the same size and layout. The owner
is responsible for dealing with the Historic Commission. Preserve will pull a building permit and do all
inspections. The cost of the permit is included.
CARPENTRY*
Remove the existing deck. Dispose of the existing deck. Install new cement footing. Digging the holes
will disturb the ground and adjacent shrubs and walkways. The cost of repairing shrubs and walkways
is not included. Strip the siding where the deck will be attached. Install ice and watershield and a copper
termite shield on the wall. Build a pressure treated structure. Install new flashing. Install pressure
treated railings and flooring.
PRICING
Basic $9695w..
Sales Tax $ 0
Total Price $ 9695 including Labor& Material
Payment Terms: 20%deposit(day of start); 30%progress; 50%e of job Mc/Visa/Amex
Sean O'Connor Customer ignature '
**
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-Note: If we are powerwashing your home the windows may be streaky post washing. If you wash your
windows on a regular basis, you should wash them after we wash the outside of your home.
*The cost of paint is included in the above price except for the following: Benjamin Moore Aura
(a new line of Benjamin Moore paint) exterior paint will cost an additional $15 per gallon; other
specialty products prices will be given on a per product basis.
**Above additional prices includes all discounts.
***The carpentry portion of this estimate is valid for 60 days and the painting portion is valid for
365 days.
**** Warranty: Craftsmanship: Kyron Inc. DBA Preserve Services warrantees all exterior
painting against blistering and peeling for a period of 2 years. The only exclusions are: wooded gutters;
walked on surfaces; and structural problems such as but not limited to "mill glazing." Should peeling or
blistering occur we will fix the affected area including labor and materials. For the warranty to be valid
the invoice that was presented at the time of completion must have been paid in full.
Licenses:
Home Improvement Contractor (HIC): 123553
Protection: It is required by law that exterior painting contractors have a home improvement
contractor license. If a contractor is properly registered, you are entitled to limited protection by
the Residential Contractor Guaranty Fund up to $10,000 (The above is a only a summary of
Massachusetts General Law 142A). To check our license or our competitors go to:
http://db.state.ma.us/homeimprovement/licenseelist.asi) and check license 123553.
Construction Supervisor (CS): 93403
The Construction Supervisors license is under an individual's name, not a company name. To
check Sean O'Connor's, owner of the Kyron Inc. DBA Preserve, license go to:
http://db.state.ma.us/dps/licenseelist.gW select Construction Supervisor and license 93403.
Insurance:
Worker's Compensation:
Our policy is under Kyron Inc. DBA Preserve Services
Protection: Covers the injury of a worker employed by the contractor doing work at your home.
To check our policy or our compititions go to httv://inass.Rov/dia/ on this page go to "check
worker's compensation proof of coverage" our license is under Kyron zip code 01970.
Liability Insurance
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ACORD. CERTIFICATE OF LIABILITY INSURANCE 08/1DATEIMMDNYYY)
/2015
os�u�2o1s
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
P.O. Box 958
Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURER A WESTERN WORLD INSURANCE C
Byron Inc. dba Preserve Services INSURERS:Hartford
203 Washington Street #256 INSURER cTravelers
INSURER D Great American
Salem MA 01970- INSURERS
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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE 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.
ILTR NSRI DSOR'LD TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE DATE(MWID�IY) LIMITS
A GENERAL LIABILITY NPPS236095 05/22/2015 05/22/2016 EACH OCCURRENCE 6 1000000
DAMAGE TO RENTED
COMMERC'.AL GENERIC LIABNLITY PREMISES IS.=wen ^ 100000
CLAIMS MADE ❑OCCUR / / / / MED E(P(M areP —) 3 5000
PERSONALGADVINJUR' 3 1000000
GENERAL AGGREGATE 6 2000000
GENL AGGREGATE LIMIT APPLIES PER! PRODUCTS-COMPIOP AGG S 2000000
X11 POLICY TER LOC
C AUTOMOBILE LIABILITY 468CS5787 06/05/2015 06/05/2016 COMBINED SINGLE LIMIT 1000000
ANY AUTO (Ea accident) 6
ALLO`NBEDAUr OS / / / / BODILY INJURY
SCHEDULED AUTOS (Perperson) S
1xx
HIRED AUTOS / / / / BODILY7IJJURY
NON-OMED AUTOS (Peraccidenq S
PROPERTY DAMAGE
(Per accidenYN S
GARAGELIABILITY
AUTO ONLY-E4 ACCIDENT 3
ANYAUTO / / / / OTHER THAN EA ACC S
AUTO ONLY: AGG 3
D EXCESSJUMBREJ.LA LIABILITY ZBS0040350 06/01/2015 06/01/2016 EACH OCCURRENCE 3 2000000
OCCUR a CLAIMSMADE ACGREGATE 6 2000000
S
DEDUCTIBLE
RETENTION S g
B WORKERS COMPENSATION AND 6S60UB0523NO0914 05/20/2015 05/20/2016 X WC P STATU- DT .
EMPLOYERS LIABILITY TORY LIMITS ER
ANY PROPRIETOR(PARTNER/EXECUTIVE El EACH ACCIDENT $ 500000
OFFICERNEMSER EXCLUDED? EL DISEASE-EA EMPLOYEE 3 500000
If yx..descriue ander
SPEOALPROVISIONSCeh, E.L.DISEASE-POLICY LIMIT $ 500000
OTHER
DESCRIPTION OF OPERATIONS/LOCATIONSNEHICLESIEXCLUUONS ADDED BY ENDORSEMENTISPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF, THE ISSUING INSURER WILL ENDEAVOR TO MAIL
30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT
Phoenix CoImpany FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY CF ANY KIND UPON THE
650 Lincoln Street INSURER.ITS AGENTS OR REPRESENTATIVES
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OME IMPROVEMENT CONTRACTOR
egistrationation: 123553 Type:
Expiration 3/W2017 DBA
Preserve Painting =
Sean O'Connor
203 WASHINGTON
SALEM,MA 01970 - -
Undersecretary
3
Salem Historical Commission
120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970
(978)619-5685 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
Construction ❑ Moving
❑ Reconstruction ❑ Alteratior-
10 Demolition ❑ Painting
❑ Signage N Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act(M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: 15 Chestnut Street
Name of Record Owner: Peter Gordon &Karen Haves
Description of Work Proposed:
Remove rear deck and awning and install a new deck. The deck will not be visible from the public way.
Remove and replace the basement windows and doors. The windows and doors are not visible from the public
way.
Replace damaged clapboards and trim. There will be no change to the design, material, color or outward
appearance of the clapboards or trim.
Install four storm windows. Color to match the existing storm window.
Dated: June 4 2015 SALEM HISTORICAL COMMISSION
:�By 60 M`�
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the inspector of
Buildings (or any other necessary permits or approvals)prior to commencing work.
The Commonwealth of Massachusetts
Department oflndustridlAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORIM
Applicant Information Please Print JAeIbIV
Name(Business/Orgmumtion/Individual): T ��t � <• a�^K JN�/fsl ✓�/((/u�f!
Address:
City/State/Zip: Phone M 72
Are yor an employer'Check the approprfale box:
Type of project(required):
employer with employees(full and/or pan-time).• 7. E3New construction
2.Q a cy a,sliet yproNeo or pnrship and have no eploye working for me in g. Q Remodeling
capc workers'comp.iosmance required)
3.E]I am a homeowner doing all work myself.[No workers'comp.lsmance required.]t 9. ❑Demolition
4.01 am.homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition.
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with an employees. 12. Plumbing'repairs of additions
5.❑I am a general connector and I have hired the subcontractors listed on the attached sheet. 13.❑Roofrepairs.
These subcontractors have employees and have woxker's'comp.iumamcet
6.❑We are a cmpomtion and its officers have exercised their right of exemption per MGL c. 14.❑Other
152 §1(4),and we have no employees.[No workers'corms.imumoce nequhed.) - -
*Any applicant that checks box p1 must also fill our the section below showing their workers'compensation policy informedon.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside commaom must submit a new affidavit indicating such
1Contractors that check this box must attached an additional sheet showing the name of the sub-contractms and state whether or not those entities have
employees. If the subcontractors have employees,they roust provide then workees'comp.policy number.
I am an employer that is providing workers'compensation insurancefor my employees. Below isthe polity andjob-si(e
information.
Insurance Company Name: IgzJUVI
Policy#or Self-ins.Lic.#: / �1-�p Expiration Date:
^
Job Site Address: \ l &Z a City/State/Zip:
Attach a copy of the workers'compensa 'bon policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL;c. 152,§25A is a criminal violation punishable by 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
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification. -
I do hereby certify under the pains and penabies ofperjury that the information provided above is ue°Q7d correct
Signature: 4 Date• �ff
Phone#: 7
Official use only. Do not write in this area,to be completed by city or town VokiuL
City or Town: PermitUcense#
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
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,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 shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally,MGL 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 fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with thew certificate(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 confirmation 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 a 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 be sure that the affidavit is complete and printed legibly. The Department has provided a 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 fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/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. 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.e.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALEA MASSACHUSETTS
BuwiNGDEPAR7 omr
120 WAsHINGToN STREET,31m FWoR
UL(978)745-9595
FAX(978)74D-9846
KINIBERIEYDRISOOLL
MAYOR THCMAS STAERRB
DIRECTOROFP MIJUROPERTY/BiIII.DNG SSIONER
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 c40, S 54; Building Permit# I t is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
J Li
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature o f ap licant
Date