29 CRESCENT DR - BUILDING PERMIT APP z, - — Vile Commonwealth of Massachusetts -- -
a/ ;,i►y Board of Building Regulations and Standards CI'1'1' OF
1 I J Massachusetts State Building Code, 780 CMR SALENI
1 J � Building Permit Application To Construct, Repair, Renovate Or Demolish a ReriavJ.1/rrr?0/l
One-or Two-Farm(,Dwe(litog
This Section For Official Use Onl
Building Permit Number: to Applied:
Thudding 011whil(Print N;une) Signature r Da3
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Nlap& Parce umbers
1.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
inning District Proposed LJsc Lot Area(sq It) Frontage(It)
I.S Building Setbacks(R)
Front Yard Side Yards
Rear Yard
Required Provided Reyuircd Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposals)s stem ❑
Check if ycs❑ P P >
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
t .
N;une(Prinntpt) City,aLIP
Nu rutrK,r �ai n ^w� cP ' FI7iQ7
"relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ .accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: / y- za ( ,,
SECTION q: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllcial Use Only
(Labor and .Malerials) y
1. Building S I. Building Permit Fee: 5 Indicate how fee is determined:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier _ x _
i. Plumbing S ?. Other Fees: S
a. .\lcchv,ical lB1':1C) g List:__ __yIJ���
s \Icehanirit (Fire
To Su,xessiont S tal All Fces: S "
Check No. ('heck Anwunt: _-----Cash Amount:
6. Total Project Cost S __ ...
��gS0 � ❑Pail in Full ❑Outstanding Balance Doc:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL) ° 2,(
License Number 1[cpiralion Dale
None r C'SI. Iluldcr
/ List C'SL 1)pe(see heluwl
l3
No. and Street 'I')pe Description
U Unrestricted(Iluildin',s L10 m 35.000 cu. tl.)
_ — 4 _ � '� ___ R Restricted M 2 FamilyDoelling
l'itylfow n..'tut ,c;/IP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
4 L)-ZJ J— I Insulation
Felc hone [:mail address D Demolition
/" .
5.2 Registered Home Improvement Contractor(HIC) -iJ ` — 7 �p L r)
/'yg wt l �' f s., ( ✓�e.n. d../a , .,a III 'Registration NumM:r I:ynrouun Date
111C C'ompan) Name or I IIC Itegistrunt Name
No. and Sued ¢ 03 J O;Z L11
3 Email address
City/Town. State, ZIP 'felt hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No........... ❑
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.
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 this application is true and accurate to the best of my knowledge and understanding.
Prim s o uhorized Agent's Name(Flectrunic Signature) Dale
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 Hume Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under NI.G.L.c. 1 q2A.Other important information on the HIC Program can be found at
tt]sq ncr>..�.]s, ,�e.r Information on the Construction Supervisor License can be found at t)"tk.mpss yy 'dp,
2. When substantial work is planned, provide the information below:
Total fluor area(sq. ft.) (including garage, finished basement attics,decks or porch)
Gross living area(sq. 11.) ._ _ Habitable room count
Number of fireplaces.------ -- _ _--- Number ol'bedroon]s
Number of bathrooms Number ofhalf haths
F)lie of heating s)stem Number of decks, porches
I')pe of cooling ,)Steil] _ - ., Fncloscd _ _. - Open .
t '•foul Project Square Footage"ma) he substituted fix•Total Project Cost.
: + CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Ntslxt
1 i.^\1tA11n.Nt:It l•.j18CL•1' • SAIf•.N,1tr.1\1.\t.111 W l n JI97,^.
11:1: )4''15•vi'/5 a 1't.r v7M•IIC.'1sM
Workers' Compensation lnsurance :Ullduvit: Builders/Cuntracturs/Electricians/Plumbers
1111c3nt Inrimnalion
Ple•4� ins Le 'AI
V;IITO t livancavi)raanvatinlvinJwuluulE�Wr,(!_ .fi,•t1 �g�, (
�thlresx:_ /ate /y s ✓� Ste: !
City.Srarc.7.ip7 0 Phone if. ��8 Roy o C
Are) u an employor7 Check the upproprlute box:
etm J cm lu cr with 4. 1•)Pe nlprll act(required):
P ) ❑ I mn a general contractor and t
employees(full and/ur part•tiole).• huva hired the.vuh•cuntractors 6. 0 '•w construction
2•❑ !sun a Iola prnprictor or pJnncr• listed on the arched sheet : �• Remmleling
ship and have no ampluycel These subcontractors have
LsnysalL
her ma in any capacity, workers'comp, insurance. g' O f)amolition
ers'cunnp. insurance 5. ❑ We are a rnlperstinn and iu q ❑ DuilJing uJJititm
utylccm have axercisud their 10.0 Electrical repairs or additions
owner doing all work right of exemption par IOICI, 11.0 Plumbing repoirtl or additions
•o wnrkurs'comp, c. 152,§I(4).and we have no 12.0 Rtluf repuire
equired.)t cmpluyccs.(Ke workers'
wirrx insurance required.) 15.0 Uthar
iI>.yiphcaa ihm cEvcta tqa el mum also fill"the wcnml twbw
'I I�malw lurk and than hint %,tunlpenuuitwl lwlicy mlurmutilvk
rr1h wtW tllDmin box mmdavil ilhw.sine ihuy ue Juine ml.curt and ihm hire IwnilM cumncton an"'"aFmif a new mmdeed inkl wing wet.
•r..nlnwllln iAm aha'at Ihie(W mum Jnahwl nil addilitekll..Pan alnwine tdt name ofthe rut•cawrackwe and thew wwterm,corny.pulley Inflamm ue,
/ntn un tvuployrr Dior lr prvviJ/ng rvorkerr'rutnpenrnNon i htrunnnce/ur ray erop/uperr. Brluly is for pu/ley and/u1 xi/�
w/urvn"Ummi,
Imuramw Company Valor._
Policy N or Sdr•ins. Lie.H:
EApirullon Data:
lob Sitr• -\ddn ss: '� Csr - ...(at jr..ra. /ya.I)C'uyBtataGp;
.►each a copy or Ile workers' campCrilatlnn policy daclarullun page(showing the Polley number and expiration dute).
Failure to,aeure witeruge as required under Scuiun 251%ul•JIOL c. 152 can lead to the ilmposition ot'criminal penalties of a
tine up trt.S 1 500.00 Jndlur uae•year imprislnuncnt,J.� troll Je cull pcnalllcs in the 1'unn of a STOP WORK ORDER'and a Pint
orup In i_'SQ.(M a Jay.Iduinst life violater. lie advised that a copy urthis mulcinum may be I'urwarded to the Office ur
iiI\'�p11�Jllnlla u1 :Ile UlA for in�ur.u:ce covcrJgc tcriliutum.
/du hereby t erlii y hinder the r mid penohJcx ujprr/ury/btu than in unnutlon/� provided ubuve it true we/correct.
ri • : .:I o� oe3�
U//Jrwl rrr♦un/y. Ov not noire in 1/1"urge, to be rurnpleled by city or tolvtr o//lrimA
1
( itv or -I'nwn: Pcnnit/LIn•nsa la i
Issuing.\W Purity (rircte noe):
II. RIIlyd .If IleJltJt 2. Ihuldinq Ikp:utmenl 1. I:ill,Toml Clerk 4. Electrical lospectur :, I luolbinq linyeetor
6. I)thcr
l'nuact I't nun;
I'hunc J:
I
I
Information and Instructions
1 son in the service of another under ally.unrract of hire,
\L1�5•IG 11aSCm)(.1emCfal Lawa chapte[ I J2 fegUl[a5 all elllployera to pfovije workers' compenxruon tit[heir clop uyces.
I'ur.u:uu totius slatuta, an e/nplarrr i. :It
cd as"...every Pe
%press or implied, oral or svrilten." of an two or more
�n etnplupdr is Jatined as"an individual,partnenhip..lssocianoa,corporation ur other legal entied ty, Y
a the (oreljUing engaged In a joint enterprise,and Illalading the legal representatives entity,employing
ng enn vlo «s employer,
However he
iecmver or uustea ul.ut iudivuJual, prtmershlp,assoewtiva r Other legal entity,employ ti ' P Y
owner's a dwelling house having nPr�noilree has threa apartments and who resides thereln,ur the occupant ul the
'lion of(cpair work on
Jwclling housd of another who a urtlenutt thereto s hall r.jons to do not because of suchtenance.culluemploymcnt be deemed tube an employer."
or on the vruunds or building aPD
-,IGL chapter 132. §25C(6) also states that "every state or local licensing agency shag withhold the Issuance or
renewal of a license or permit to operate a business or to coo lion a buildings IN the l
with the insurance coverage required."
;Ipplicsnl wlto has not produced acceptable evidence of comp
�JJitionalty, �IGL chapter l 51, §25C(l)states"Neither the conunonwcahh our any of its political with t e hiss shay
enter into any contract Coe the perfomtunca ul'public work until acceptable evidence ul cunnpli once with the insurance
reyuiremcnts of this chuptdr have been presented to the contracting authority."
Applicants `the boxes 1 to our situation and if
Pica a fill out the workers' compensation affidavit completely numbers)along with their cortilicata(s)of
necessary,supply sups-eoneracrors)n une(,$),addresg4:s)and p with no cm to tses other than the
insurance. Limited Liability Companies(LLCworkers'tcomladnSetioned Liability ainsurance'(If an)LLC or LLP door have
ineunbers or partners, are not required to carry px submitted to the Department of Industrial
employees,a policy is requited. Be advised that this affidavit mayad dale The aRmem of
,%ccidents for confirmation of insuratico co'anon. Also be for the penn�oralicense is being requested,not he �pdavit should
be returned to file city or town that the uPD uestious regarding the low ur if you are required to obtain u workers'
Industrial Accidents. Should you have any q
compensation policy, please call the Deparanent it the number listed below. Self-insured companies should coot chew
self-insurance license number om the a ro note pine.
City or'rown Offlclals
av
Of the a davit for you to fill out in the anent the OlToo of Investigations has to contact YOU regarding the applicant.
Plrasa hee sure that the affidit is complete:and printed legibly. The Department has provided u space at he ttam
I'I.usc be sure to fill in he pumniUlicetlse nutnbor which will be used as t reference only submit
nr. In addition, is applicam
illatmust
us f'orm'uiun tifunece teary)land n�inderP'loblSite Address! the applica na hould write"all l affidavit
u�ifuns inicatine``i�ty ur
tawny."lr copy of he nett:uff1d nit hat has been offlciully stamped or marked by the city or town Inay be provided to the
out each
applicant
ant as proof a hums Owner a valid ciiizan isdavit ls on obtnirile ro a license or pejurc lnnit not related to any bustinesslor comust mer
cial al venture
1 i.c. a dug li ansa or permit to burn leaves etc.)said person is NOT required to complete this affidavit. umuons,
I he )I lice 1d Illve\flgatWna would like to think you It adv:kllcv for your cooperation alld should you ha\'e,mY q
please Jo not hesimtc to give us a call.
the Ucparnncnt's address, tole pnana aThe Commonwealth of Massachusens
Department of Industrial Accidents
Office of lievadgadons
600 WashinetOn Street
Boston, MA 02111
'Pei. 0 617-727.4900 ext 406 or 1-877-MASSAFE
Fax M 617-727.7749
www.man.gov/dia
1 I
CITY OF S.U.E.NI, NWSACHUSETTS
BIALOLNG DEPARTNONT
110 W.uHLYGTON STRM, Yo FLOOR
I-EL (978) 745-9595
,F.ut(978) 740-984d
Kl.%tHERLBY DRISCOLL
MAYOR Tuows ST.PIERRS
DIRECTOR OF PCBLIc PROPERTY/narlLYG COMMISSIONER
Construction Debris Disposal Afriidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit ft is issued with the condition that the dcbris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c
111, S 1 SBA.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
s; atureofpermitapplicant
_ WZ 1
dace
i
;.hr, if I.
Howell and Sons Remodeling,Inc. Estimate
107 Harantis Lake Road
Chester,NH 03036 Date Estimate#
1/14/2011 119
Name/Address
Denehy,Rob
29 Crescent Drive
Salem Ma.01970
Project
Description Qty Rate Total
Kitchen Cabinet: Cut existing refrigerator cabinet down in height so 400.00 400.00
that new refrigerator will fit. Have new doors made to match
existing. Cut out wall behind existing refrigerator so that new will
slide back more.
Kitchen Floor: Tear up all existing layers of kitchen area flooring. 1,900.00 1,900.00
Prep floor boards for new hardwood flooring install to match
existing floor heights and style. Sand and finish with 3 coats of
poly.
15x 20 ADDITION 1,500.00 1,500.00
Footings: Addition will be-built on(ally columns set 4'below grade
level as code- -
Lumber: Framing` 13,000.00 13,000.00
Roofing: To match existing house. Addition only. 3,500.00 3,500.00
Windows and Door: 6 Andersen awning style windows,and 1 triple 6,000.00 6,000.00
pane Andersen french door unit.
Siding: To be vinyl and match existing house. This to include new 2,900.00 2,900.00
gutter install. -
Electrical: ALLOWANCE 2,500.00 2,500.00
Plumbing: ALLOWANCE 2,750.00 2,750.00
Insulation; Jones Boys Insulation Co. 1,200.00 1,200.00
Fireplace: Gas direct vent unit. ALLOWANCE 3,500.00 3,500.00
Sheetrock: Blueboard and Plaster finish. 2,500.00 2,500.00
Painting: All new plaster to be painted. Trim to be paint grade. 1,250.00 1,250.00
Flooring:.New hardwood flooring. Sand and Finish 3 coats. 3,000.00 3,000.00
Finish Trim: To match existing and be paint grade. 1,850.00 1,850.00
Deck: New deck off of addition(20x14) Maintenance free 10,000.00 10,000.00
material,pt frame.
Dumpster: Dumpster can on site. 600.00 600.00
Permit Fee: Salem Building Dept. 500.00 500.00
Thank you for your business.
Total $58,850.00
Nlassachusctts - Dcparhncnt of Public Safctc
1 Board of Building Reg4ttions and Standards
Construction Supervisor License
License: CS 86200
JOHN E HOWELL
107 HARANTIS LAKE.RD
CHESTER,NH.03036
Expiration: 8/2/2013
C,nnmisvi„ner x Tr#: 20565
Office of Consumer Affairs&Bdsiness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: -163407 Type:
� V _ ti Expiration:
6I16 W3 DBA
HO ELL AND SONS REMODELING
JOHN HOWELL + �`
107 HARANTIS LAKE RD,
CHESTER,NH 03036' ,; _ Undersecretary
From:M.R Shaw Insurance 978 745 8584 08/08/2011 09:04 #522 P.001/001
i-� OP ID: MS
acoRO" CERTIFICATE OF LIABILITY INSURANCE Dar0 n'»vl
�..�� os10811oanl
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 entlorsement s .
PRODUCER
976.744d540 NAMEACT
M.R. Shaw Insurance Agency Inc 978-745-8584 PHONE ! F
P.O. BOX 4428
ADDRESS:
DES _-
EMAIL
Salem,MA 01970 -PRODUCER .--_—_-------
.._._____.__
M.R.Shaw Insurance Agency Inc _-e_rTQME81D.N;HOWEL-1
INMREIIR(S WING COVERAGE HAD
INSURED Howell&Sons Remodeling Inc. INSURER A_Workers Comp Ins, Plan Of Mass
c/o 14 Laurent Road INSURER B:Patrons Mutual Insurance Co.
Salem,MA 01970 INSURERC
INBURERD_ - ___ _ -,,,_ ___,
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISIONNUMBER:
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.
LTa TYPE OF INSURANCE AMISR MD DD UB POLICY NUMBER MM%Uo EFP ! M... LIMITS
I GENERAL LIABILITY ! i EACH OCCURRENCE
_'__$ 1,000,00
B X COMMERCIAL GENERAL LIABILITYICTRO011744 04/06/11 04/06/12 ''1SAMAFET6—REITrEO -i
t PREMISES IEa occmrenc) �g 60,0_O
.i CLAIMS MADE ; X 1 OCCUR 'MEDEXP(MyonePanan) `$ 6,00
PERSONAL&ADV INJURY $ 1,000,00
1 GENERAL AGGREGATE 2,000,00
GEN'L AGGREGATE LIMIT APPLIES PER: -PRODUCTS-COMP/OP AGO s ..Z,000,00
POLICY, PRO- LOD $
AUTOMOBILE LIABILITY I 'COMBINED SINGLE LIMIT $
- - 1 (Ea accident)
ANY AUTO BODILY INJURY(PP,persw)Y$ -
T ALL OWNED AUTOS BODILY INJURY(Per am en!
SCHEDULEDAUTOS R -�
F PROPERTY DAMAGE
HIRED AUTOS ! (Per accident)
NOWOVMED AUTOS '$
UMBRELLA LIAR- OCCUR EACH_O_CCURRENCE _ 5
EXCESS LIAB �I_
CLAIMS-MADE LAGGREGATE -----
1 1 DEDUCTIBLE -
i I RETENTION $ ! i $
WORKERSCOMPENSATION WC STATU OTH-j
ANOEMPLOYERS'LWBILI Y YIN i --- DAY X'
A ANY PROPRISTORIFARTNERIEXECULVE ❑iNIA WC2.31S-377083-011 04/10111 04/10/12 E.L.EACH ACCIDENT _ !$ 500,00
OFFICERNEMBER EXCLUDED?
I (Mandatory In NH) 1 E.L.DISEASE-EA EMPLOYEE $ 600,00
IF yec.deccriEeender
DESCRIPTION OF OPERATIONS below I E.L.DISEASE-POLICY LIMIT $ 600,00
1 I
i
DESCRIPTION OF OPERATIONS)LOCATIONS/VEHICLES(AttecN ACORD 101,Additional Rom*.$dhedi,t,it more cpaza Ic ropvimd)
RE
SIDENTIAL CARPENTRY&REMODELING
CERTIFICATE HOLDER CANCELLATION
978'7W- 9IF 4(o SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
City of Salem,Ma ACCORDANCE WITH THE POLICY PROVISIONS.
Salem,MA 01970
AUTHORIZED REPRESENTATIVE
,r�y�Bj�u�..1nr�r�
M.R.S�II/�^ [ / Ga6..^—
IVIW8-2009 ACORD CORPORATION. All rights reserved.
ACORD 25(2009109) The ACORD name and logo are registered marks of ACORD