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24 CLIFTON AVE - BUILDING INSPECTION (5)
The Commonwealth of Massachusetts y I Board of Building Regulations and EM W Standards CITOF SA Y Massachusetts State Building Code,780 CMR,7 edition Revised Jammy Building Permit Application To Co ct Repav,R ovate Or Demolish a 1,2008 One-or T o-F ily Dwelli Thi Section r Officialkse Only Building Permit Num - ate pplied: Signal=: 0 -Z'� - 30 l Building Commissioner/ fBui ' Date S N .SITE INFORMATION 1.1 Properly Address: 1.2 Assessors Map&Parcel Numbers Lla Is this an acceptedstrecryes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(it) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Pmvided 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 O Check if yes❑ SECTION2: PROPERTY OWNERSHIP' 2.1 Ownerr of Record: Mlk-iF-r A-VE Name(Print) Address for Service: (old- - Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other 9 Specify: Brief Description of Proposed World: d75ZlA417 5/D/n/€, /iyc�au,�/ay �F ?eAeYk-i �rn/nfs SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs' Official Use Only Labor and Materials 1.Building $ J. Building Permit Fee:$ Indicate how fee is determined: 2 Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6,Total Project Cost: $ �� ❑paid in Full ❑Outstanding Balance Due: lU /"��i• �� 441 a SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) �4` 6� 3 I I I z�rz Z�7AIZID15t, aA License Number Expiration Date Name of C -Holder 11_1.6 Lis[CSL Type(see below) Ad Type I Dcscription U Unrestricted to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling Si /� �4 M M Only S I —-I 8 9v RC Residential Roofing Covetinig Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) 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 provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .........;b1 No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE 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. Signature of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION 1, ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the pains and penalties of NOTES: I. 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementfattics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" r CITY OF &U.&N4 XWSACHLSETTS 120 W.iSHINGTON STREET,r FLOOR 'I1F L (978)745-9595 FAX(978)740-98" KIMBEAIEY DRISCOLL MAYOR THoMAs ST.P1ERa6 DIRECTOR OF PUBLIC PROPFITY/BL'BDLNG CONDUSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly dame(Businessga.Orniratiow(ndividual): LM �tJ6 .yC'-[1Q1J Address: 4-1 Pe—t ITT -D-f - city/state/zip: 67U10P-err MA 021 0 Phone a: z91 Are you an employer?Check the appropriate box Type of project �,� P ro 1 (required): 1_L7 t am a employer with 3 4. ❑ 1 am a grnetal contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ 1 am a sole proprietor or partner. listed on the attached sheet 7. ❑Remodeling ship and have an 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.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.[No workers'camp. c. 152.§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.0 Other camp.insurance required.] •Any appamm that dncYe bra 91 must also rill mat the section balmy abnwing their waters'ca mpensarion policy information, •I locnom ten who submit this affidavit indicting they am doing an work and then hue oamide cammcbm must submit a new andava itdbatiog such Tontmctom that chuck this bate mud ataclsd an addiuwnl shoot showing the mate of am tubeosuamas and their waders'comp,policy infasmdm, com l am an employer that is providing workers'compensadon lnsarence for my employees. Below ha the poBry and jab site information. �n Insurance Company Name: Policy#or Self-ins.Lie.#:W G 2 - 3� 1 S — ' b b —o 11D Expiration Date: C)b 17 [ /7,ot I Job Site Address: 7:1 City/Statelzip: S�'*TM M P, Attach a copy of the workers'compensation policydeclaration page(showing the policy number and expiration daft). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby cerd ender the pains and penalties of perjury that the information provided above is true and corren SiLnat re VI) Date: d: OJjcial use wdy. Do not write in this area,to he completed by city or town a flxiai, 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#• Ai CITY OF S.U.&M. NLkss.ICHusETPS BuiLDLNG DEPART%E&NT 120 W ASHNGTON STREET,r FLAOR 011 T EL (978) 745-9595 FAX(978) 740-9846 KIMBERL.EY DRISCOL L MAYOR THOMAS ST.PMRXE DIRECTOR OF PUBLIC PROPERTY/BUn.DLNG COMMSSIONER 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 willllbe transported by: (name of hauler) The debris will be disposed of in : (name of facility) 2� 4sli ur-157 , `p Fd$C�a/ M R (address of facility) si ahue of pe i[applicant date dcbrivlT.Jx: J LM construction Page 1 71 Prescott st Everett, MA - 02149 Contract#0267 Costumer name WORK to be PERFORMED AT: Mike Ginley 24 Clifton Ave. 24 Clifton Ave. Salem, MA Salem, MA The following paragraphs describe the work that will be performed: • Strip existing siding on the entire house ; (2 layers ) • Remove all windows and doors casing ; • Wrap the entire house with Tyvek paper; • Install aluminum flash on the bottom where the sheeting meets the foundation; • All joint flashing at the siding seam will be used the one recommended by manufacture; (we provide all flash) • We will provide Siding nails and trim nails • 1"x 8" PVC will be installed at the bottom of the entire house (water table ) • Install 1"x 6"PVC (azek board) on the Outside Comers ; • Install PVC trim @ windows and door trims; • Install pre-finished fiber cement with a 15-year paint warranty ; Additional specifications • All trims and corners are white ; • Siding is 5"exposure ; • Siding will be Hardie Plank from James Hardie. Color: • we will remove all of the job related debris ; • Customer to pay for Dumpster; • We will pull the permit from the city of Salem ; • All trims on top are included in this contract ( fascia, soffit, rakes ) Page 2 LM construction, guarantees all work (LABOR)performed for an unlimited time, if any problem occur we will cover the cost to correct the problem and meet costumer's satisfaction!! Cost for labor (nails and aluminum flash included): 8.850.00 Payment Terms: 1/3 deposit upon signing contract: $ 2.950.00 1/3 work in progress: $ 2.950.00 on completion: $ 2.950.00 Julio esaz Da Silva- Project Manager Brother Siding, Inc. 415 main st, Medford, - 781 7063291 1 Mi a Gin - Homeowner 24 Clifton ave, Salem, MA - 617 7998382 ACORE CERTIFICATE OF LIABILITY INSURANCE DATE(MM/DD/YYYY) 03/28/2011 THIS CERTIFICATE 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 an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endofsement(s). PRODUCER CONTACT NAME: Phil Conceicao Rapo & lepsen Financial and Insurance Services (ac X0 Eld): 617.783.1160 FAX Ne).617.783.2062 1103 Commonwealth Ave E-MAIL ADDRESS: Boston, MA 02215 PRODUCER CUSTOMER ID N: _ Phil Conceicao INSURER(S)AFFORDING COVERAGE NAIC 0 INSURED INSURERA: Colony Insurance Company LM Construction INSURER : Liberty Mutual Insurance Co. _ 71 Prescott St. INSURERC: Everett, MA 02149 INSURER D: INSURER E: INSURER F COVERAGES CERTIFICATE NUMBER: Proof of Insurance 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 TYPE OF INSURANCE ADDL SUER POLICY EFF POLICY EXP LTR INSR VWD POLICY NUMBER MM/DD/YYYY MM/DO/YY'YY LIMITS GENERAL LIABILITY GL3893I1806/2112010 06/21/2011 EACH OCCURRENCE $ 11000,00 COMMERCIAL GENERAL LIABILITY PREMISES Ea occurrence) $ 100,QQ CLAIMS-MADE GE TO RENTED OCCUR MED EXP(Any one person) $ 10,000 A PERSONAL&ADV INJURY $ 1,QQQ,OO GENERAL AGGREGATE $ 1,000.00 rGREGATE LIMIT APPLIES PER. PRODUCTS-COMPIOP AGG S 1,000,OO ICY PRO- LOC ECT $ AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT S (Ea accident) ANY AUTO BODILY INJURY(Per person) $ ALL OWNED AUTOS - BODILY INJURY(Par accident) $ SCHEDULED AUTOS PROPERTY DAMAGE HIRED AUTOS (Per accident) $ NON-OWNED AUTOS $ $ UMBRELLA LUIB OCCUR EACH OCCURRENCE $ EXCESS UAB CLAIMS-MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORKERS COMPENSATION WC2-315-379366-01 06/21/2010 66/2112011 WC STAru- oTH- - AND EMPLOYERS'LIABILITY Y/N TORY LIMITS ER ANY B OFFICER/MEMBER ER EXCLUDED?ECUTIVE❑ NIA E.L.EACH ACCIDENT $ ZOO,OO (Mandatory in NH) E.L.DISEASE-EAEMPLOYEEI $ 100,QQ U yes,describe under DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT I $ 500,QO DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach ACORD 101,Additional Remarks Schedule,If more space Is required) CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE Proof of Insurance Phil Conceicao ©1988-2009 ACORD CORPORATION. All rights reserved. ACORD 25(2009/09) The ACORD name and logo are registered marks of ACORD