29 BUTLER STREET - BUILDING JACKET 29 BUTLER STREET
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Public Propertg Department
Nuilbing Department
(Pne 0,alem (6reen
308-7,15-9595 rxt. 380
Leo E. Tremblay
Director of Public Property
Inspector of Building
Zoning Enforcement Officer May 17, 1995
Arlan & Janice Whitney
29 Butler Street
Salem, Mass. 01970
RE: 29 Butler Street
Dear Mr. & Mrs. Whitney:
Due to a complaint received through the Neighborhood Improvement
Committee hot line, I conducted an inspection of the above mentioned
property.
The complaint received consists of ladder Jacks that remain at roof for
no known reason. It appears that work has been completed.
Please notify this department upon receipt of this letter as to your
course of action to rectify this situation.
Thank you in advance for your anticipated cooperation in this matter.
Sincerely,
Leo E. Tremblay
Inspector of Buildings
LET: scm
cc: Dave Shea
Larrisa Brown
Councillor O'Leary, Ward 4
Certified Mail # P 921 991 722
v
CITY OF SALEM
NEIGHBORHOOD IMPROVEMENT TASK FORCE jurisdiction
Hist. Comm. Yes o No 0
REFERRAL FORM cons. comm. Yes 0 No 0
SRA Yes 0 No 0
Date:
Address:
Complaint: �f�ji
i
Compiainant: Phone#:
Address of Complainant:
----------------------
DAVID,SHEA CHAIRMAN KEVIN HARVEY
UILDING INSPECTOR ELECTRICAL DEPARTMENT
FIRE PREVENTION CITY SOLICITOR
HEALTH DEPARTMENT SALEM HOUSING AUTHORITY
ANIMAL CONTROL POLICE DEPARTMENT
PLANNING DEPARTMENT ASSESSOR
TREASURER/COLLECTOR DPW
WARD COUNCILLOR DAN GEARY
SHADE TREE
PLEASE CHECK THE ABOVE REFERENCED COMPLAINT AND RESPOND TO DAVE SHE.
WITHIN ONE WEEK. THANK YOU FOR YOUR ASSISTANCE.
ACTION:
RETURN. Pos*acE POSTMARK OR DATE �a o
SHOW TO WHOM,DATE AND/ RIOTED
OE IL
RECEIPT ADDRESS OF DELNERV t
SERVICE CERTFED FEE+RETURN RECEIPT - Wy
R) TOTAL POSTAGE AND FEES Z W
FU INSURANCEOC ERAGE PROVIDED- p W�
N
SENT TO; NOT FOR INTERN�RRRATIONSIORAISEEL MAIL a�
44 Q
O
Arlan A Janice Whitney
29 Butler Street
Salem, Maas. 01970 Yo
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N
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PS FORM 3800 z
-£. RECEIPT FOR CERTIFIED MAIL_
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Po-�sERA�E
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STICK POSTAGE STAMPS TO ARTICLE TO COVER FIRST CLASS POSTAGE,
CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES(see front).
_ 1. If you want this receipt postmarked,stick the gummed stub to the right of the return address of the
article,leaving the receipt attached,and present the article at a post office service window or hand
it to your rural carder(no extra charge).
2. If you do not want this receipt postmarked,stick the gummed stub to the right of the return address
of the article,date,detach and retain the receipt,and mail the article. -
3. If you want a return receipt,write the certified-mail number and your name and address on a return
receipt card Form 3811,and attach it to the front of the article by means of the gummed ends if space
permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT REQUESTED
adjacent to the number.
4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee,endorse
RESTRICTED DELIVERY on the front of the article.
5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If return
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6. Save this receipt and present it if you make inquiry.
I • .
� I
ARTICLE
_ P 921 991 722 :•
UNE,. Arlan & Janice. Whitney
NUMBER •
29 Sutler Street
Salem, Mass. 01970
* FOLD AT PERFORATION t p, WAL •
INSERT IN STANDARD#10 WINDOW ENVELOPE. .>. E E D T I F I E D
M A I I E &, CIILJII� `��°'
ENDER:
• Complete items t and/or z for additional services. I also wish to receive the
• complete items 3,and 4a a b, following services(for an extra fee):
• Print your name and address on the reverse of this form so that we can return this card
to you. 1. ❑ Addressee's Address
• Attach this form to the front of the mailpiece,or on the back if space does not permit.
• Write"Return Receipt RAquested"on the mailpiece below the article number,. 2. ❑ Restricted Delivery
•'The Return Receipt Fee will provide you the signature of`the person delivered to and the
date of delivery, Consult postmaster for fee.
3.Article Addressed to: 4a.Article Number
A^1�3n & Jttntce: ffltitnev
P 921 991 722
�,, Lutlov Street 4b.Service Type
CERTIFIED
7.Date ofeliv ry
5.Sig tur —(Addressee) 8.Addressee's Address
(ONLY if requested and fee paid.)
6.S ature—(Agent)
PS Form 3811,November 1990 DOMESTIC RETURN RECEIPT
United States Postal Service w
c-ESc
Official Businessj;l
PENALTY FOR PRIVATE
USE,$300
IIII111111111IIIIIIIIIII1111111111IIIIIIIIIYIIIII111
INSPECTOR OF BUILDINGS
ONE SALEM GREEN
SALEM MA 01970-3724
CITY OF SALEM
NEIGHBORHOOD IMPROVEMENT TASK FORCE Jurisdiction
Hist. Comm. Yes 11 No ❑
REFERRAL FORM Cons. Comm. Yes ❑ No
SRA Yes ❑ No 11
Date:
Address: Z9 xo�
Complaint: J��"F�x
U
Complainant: Phone#:
Address of Complainant:
DAVID,SHEA. CHAIRMAN KEVIN HARVEY
UILDING INSPECTOR ELECTRICAL DEPARTMENT
FIRE PREVENTION CITY SOLICITOR
HEALTH DEPARTMENT SALEM HOUSING AUTHORITY
ANIMAL CONTROL POLICE DEPARTMENT
PLANNING DEPARTMENT ASSESSOR
TREASURER/COLLECTOR DPW
WARD COUNCILLOR DAN GEARY
SHADE TREE
PLEASE CHECK THE ABOVE REFERENCED COMPLAINT AND RESPOND TO DAVE SHEA
WITHIN ONE WEEK. THANK YOU FOR YOUR ASSISTANCE.
ACTION:
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
�
Massachusetts State Building Code, 730 CNIR SdMar Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This Secfton.ForOfficial Use On
Building Permit Number' 64
Building Oftcial(Print Name) G gna Date
SECTION I: SITE INFORIVIDATION
1.1 Prop y r dppress: ( 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
f3 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION2:, PROPERTY'OWNERSHIPL
2.1 Owner'of le or
'Seevi hC 'e {O(ty
Name(Prriint)�.p- City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ MtmberofUnits_ I Other ❑ Specify:
Brief{{des Lion ol�.E�roposed W k2: �
�5S i Lion `tpos d c1 Slcw��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ j QUA d� L Building Permit Fee S Indicate how fee is determined:
❑ Standard City/town Application Fee
2. Electrical S • i -
- ❑'Cotal.PtojectCost, (Item6)xmultiplier. x
3. Plumbing S QQ(,t:�� 2. Other Fzes: S
I. Mechanical (HVAQ S List:
5. Mechanical (Fire S
Suppression) Total .mt Fees: .$
d� Check No. Check Anwunt:__Cash Amount:-
-6_ l'atul Project Cost S 0 Paid in Full 11 Outstanding Balance Due: _--
sEcfION 5: CONs'rRucrION SERVICES
5.11 cotisstruction Su tervisur License(CSL) /A G _ 095-30 '0 1-3 O` c(
License Number B.Xpiration ate
_Name o—`f-CCSSL I lulder
List CSL Type(sae below)
16 �C, AGUE
. and freer 'type Description
U Unrestricted Duildin s u to 3i,000 cu. R.)
_ �(� l R Restricted I,k2 Famil Dwellin
/Town, State, ZIP t �f Masonr
RC Rootin Coverin
lVS Window and J'idin
SF Solid Fuel Burning Appliances
I Insulation
'rely hone Email address D Demolition
r5.2 Registered Home Improvernentt.Contractor(HIC) l Oq (gyp 4 (t 3a �GYI
HIC RegistrlattioonNomber E.epiration Date
I IlC t'otnpany Name or I"I{�C�R,e$$tstrant Name i 1 �S `,t
1T W�llO� sG �QV �1EC:SOJUI( \ (¢l C
Nand l3treet nnn Email address
Ci.y/TToown, State, ZIP� h Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. t52. § 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 .......... 13 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 beha f, 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 is applic, on is true and accurate to the best of my knowledge and understanding.
- 1-3
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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. 112A. Other important information on the HIC Program can be found at
a w%v.m:tssuovi oca Information on the Constriction Supervisor License can be found at svww.mass.govAlL
2. When substantial work is planned, provide the information below:
"rota) floor area(sq. ItJ._ (including garage, finished basement/attics, decks or porch)
Gross living area(sq. (.) 1-labitable room count
Number of fireplaces Number of bedrooms — -----_--
Number o f bathrooms Number of halt,'baths
rvpe of heating system . -- _ Number of decks/porches
1'ti pe of coohm' sy,tuu --------"--._ ._-- Enclosed ____Open _
1 ..rot.tl Payee[ Oyu ua Foot t in:ty be sub;titut d tor' For. l Project( au
The Commonwealth of Massachusetts
m ° Board of Building Regulations and Standards CITY OF
�q! l Massachusetts State Building Code, 780 CvIR Revised MarALEM SdMar
1 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Family Dwelling
This Section Foi Official Use Only
4Building Permit Number: Date A lied:', .
Building-Official(Print Name) - S natur - Date--
SECTION 1: SITE INFORM ION
II.I- r dress: 1.2 Assessors Map& Parcel Numbers
(Q ty Ai 11
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Municipal if yes❑ unicipal ElOn site disposal system ❑
SECTION 2:, PROP RTY O NERSHIP.'
2.1 Ownert of Record: JC e G
�u2�
Name(Print City,State,ZIP
as ` � -a/
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': a t r G^CA 1Z 1
5-t�e— Q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only,..
Labor and Materials
1. Building $ 1. Building Permit Fee $ ^ Indicate how fee is determined:
�. Electrical $ Cl Standard,Cityffotbn Application F ee
` ❑ Potal Project Cost'(Item 6)x multiplier x
3. Plumbing $ 3, ab ` 2 Other Fees: $ 9
1. %,Iechanical (ICVAC) S List:
5. Mechanical (Fire $
Su� ression) Total All Fees: $
I— dlJ Check No. Check Amount•. Cash Amount'..
6. 'I'otal Project Cost. $ /rf, UGU ❑ Paul in [ull 0 Outstanding Balance Due:
or
SECTIONS: CONSTRUCTION SERVICES
5.I Conshvction Supervisor License (CSC.) C 57ni5- L /3 aoV 4Z
F
License Number Expiration Date
Name of CSL I[older
List CSL Type(see below)
No. and Street C Type Description J
Unrestricted(Buildings u n cu. I2.
R
Restricted ISc2 FamilyDwelling
;•
Cityrrown, State, ZIP Im Nlasonr
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home i rovgny\ent Contractor(11IC)
Lku-at S \ \Jv '" `�� MC Registration Number Expiriffion Date
FItIC Coppanym
r�ae/orr l[�!C,,�(�( istrant Name /� t
'\�� "�-u� -�7'*"'- C �Gau.✓At5 Yet-ct� ��d�Mw.l.0
No. S) 9/'�a 5-a Email address
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 .......... 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 —5/54zn/ �6�1 �C t
to act ny b half, m all matters relative to work authorized by this building permit application.
Print Owner's N. ne(Electronic Signature) Date
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 accurate to the best of my knowledge and understanding.
Print Owners or Authorized AVrit's Name(Electronic Signature) Date
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 can be found at
w�vw.mttss.aov%oca Information on the Construction Supervisor License can be found at www.mass gsj�
2. When substantial work is planned, provide the information below:
Total floor area( . 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 .---
I'ti'peufcoolingsy;[ein_--_ -- _—_ Enclosed _------_-Open
`�ottl PrujectSyuare I'ootagi" muy be subsrinirod for."Total Project Cost"
------- --------------
3 r
_ --- I'hc C'onunums'c;thh u(ibl;uiachusclLs
���GGG s; IluarJ ol'13ui1Jing Regulations ;,lid Sr;ulJards Cl I'1' OF
"fls"elltlsctis Slats Building Cudc. 780 CNIR SALEXI
l3tidding Permit Nppliealiun 'fo Construct, Repair. Renovate Or D- iolish Ll
R�•risri/ tLu•:n//
Onv. or rive)-Pirrnill• Dsrcllin,Y
This Section For 013ieial Use Onl
building Permit Nunsber: Date: p ied: _
--IT'1—Un-0—A&W W int Nmne) .v ro
SIg11alU )OIL•
1.1 Propl;ySECTION I: SITE INFO IATI
Address:I e': 1.2 Asses rs Parcel Numbers
I.In Is this an acre led street? es no Slop Nunther Parcel Numher
I.! Zoning Information: 1.4 Property Dimensions:
Sa l� �cr m
Luring District 11n,powd l/st Lot Area(sy 11)
Promuye(It)
I.! Building Setbacks(ft)
Front Yurd Site Yuma
RequiredProvided Required side
Required Rear Yard Provided
1.6 1Yettr Supply-(M.G.I.V. 40,§!a) 1.7 Flood Zone Informations 1.8 Sewage Disposal Systems
1416110-- Prh ulo❑ Zone: _ Outside FI Z no?
Check if es MunicipaMU)"site Jispusul:)stain D
2.1 Owners of Reeords SECTION]: PROPERTY OWNERSHIPI
No�Ykern U 'stelev" hone Wcl keys CsecP.yCJLsroh LauC/(/12c( Olga 3
Muno(Pnal //1_U CNy,SWte.L.IP .
V<®< 0v K ?Ott $ YJen� °rs 978-337 7rsr-
Nu.,mJ tercet rely hung
P Elnuil Address
SECTIONls DESCRIPTION OF PROPOSED WORKs(check all that apply)
New Construction D Existing Building Owner-Occupied ❑ Repairs(1) Mr IAlteration(:) ❑ Addition D
Demolition ❑ Acctssory Bldg.❑ Number of Units_
Other D .Specily:
Brief Description of Proposed Work": e- yai/ ty ccP
�ttP S , ,3 Oc7ztaors wt .laws 4 oor ,�_
-`s-..SY-o .cam r l(-- `— _✓sal /¢c rh- Y � 2Xr Y-11vs
0.< J
SECTION 4: ESTIMATED CONSTRUCTION COSTS
ltenl Estimated Costs:
ILahur;md \Ialerialsl Official Use Only
I building S 6';� r� I. BuilJiug Permit Fee; S Mdlcate how fee is JetermineJ:
'. l:'leorical S ❑Standard City Tusvn Applicalion Fee
t I'Iunihing S ❑Tulal Project Cost'(hens 6).1 multiplier x
'. Other Fees: S
:. \1"11.miad ill\ \('I i List:
1lcchunie•II it r
i \u . rcaiUnl 3 rotal \IlFces: S
n i'otal Project Cnsl: 3�r1
/�Js�� ❑P.lid 1n Full I](hnslanding 11 It.uCcc Due:
�a o
r '
f'1)Ntil'Rll("f1()N tiF.MW F.S
2n13
�,1 ('onstructiun Supenizur License(CSI.1 / /0—/q
�p,�6�_ .. . . -
I icvn,e Nuuthvr I\pir;ni,m I);ne
Va/nudl'SLIL•Idcr IIil01
Na. .utJ Slrcvt it l lnreatrialed I tIll111,
ddin s li m 1S,U01)cu. Il.l
0 7 6 Kt.IricltJ ?P Dticllin
CY'il)i faun,Stele./I ' KC• K,hHin Cat vrin
µ g µ'inflow.mJ Sidin
'•— SF SuliJ fuel Burning Appliaticcf
1 (ems.•cost I Insulution
_,SYeve"e s � p oelnouunn
Talc bona rulailaddrv.i net' g-/S7.c�13
5.1 Registered Ilume Imprurement Cuntractor IHIC) /YS`CSa
Ste 1/e— h+S IIIC' It¢gialrui°n Number I wirilin, Uuw
sf'EJ2act y�C'o Mt_cx s-sc
1111:t'onlpuo) N�mc o�N' ltvylslrunt Na11W yt cT
SC0.✓}1, G ( o t:mail addre4s
N .�JiSVta tvs ti Z)--76 _ 63S�---
Ci !Town,State ZIP relc hung
SECTION 61 WORKERS$CONIPENSATION INSURANCE AFFIDAVIT(M.G.L C. 1l3. 1SC(6))
Worker Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atlldavit will result in the denial of the Issuance of the building permit.
Signed AffidavitAttaciia Yes .....••••
SECTION 76: 0WNE AUTHORIZATIONTO BBCOM1IPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BVILDIN 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.
I AV-1
NofY'�`r�SS1�G�e OWa
Print Uwnci s Name lEleettvnie Siunul°n)
SECT R ION 7b:OWNER" O AUTIIORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the informatiun
contained in this application is true and accurate to the to the best or my knowledge and understanding.
�+eeVe s�es)`c�vtQllvtS — f)utc
Prim(awOW:++'r \uduvvad,\culIII Nauw 111 ttn nn Slynluuc)
vo'res:
I. ,liar hires an ui
registereJ inbhelHume h�proPementerinit lcuur IctorIHIC) Program), Will L r owner`have access to 'hearbitration
In fund
m;u under
M.the Conslfuctio t Super sat cr t eto can be found at
rmation on the C Program c'ntbat1bund at
program or guar lit)
\\'hen substantial Iwrk is planned, pru+ide the infunnatiun below:
I including garage. linishcd basement attics, decks or porchl
rota) tlour area I:y. 11.1 --- _ ilabil.lble roust count
(.iraii lit ing.lrea I sy. It _.... ... .... . .. \anther of bedrooms -
\unlherol'lirvplacei ,. .. _ - \unlhcrofhall'hatha
\unlherafhathrourtts - \unlhcrol'daki, porches
i1 k pe of ha.ltmg i),Icm tiller I'ncla+cJ
1'�pe III'a t'ling . clam
t "I JI,11 Proic,l i,illllre 1:001lc'e' 111;1\ he Nlh.11ltltCd lilt I,dJI i'fa�eQ C'J,1..
- --` >iac<uchusctts-Dcpurtntent of Pu61ic Fa(ch -
9 Board of Buildim_ Re_ulatious and Standards
Construction Superaisor License
License: Cs 1005M
STEVEN DESJARDINS
16 PULPIT ROCK RD SUITE 2
PELHAM, NH 03076
Expiration: 10/1412013
C"•nnwi>.i.•ner Tr=: 4818
ze xmzovz Us a o0
Office o Coasamer
HOME IMPROVEMEMT CONTRACTOR Tom.
. .yE=. .,; RegL4tradorc 145950 - DBA .
>" Expiraton: 31 W013
Sl'E17E DESJARDINS CONST
STEVE DESJARDINS -
5 CARLISLE LN �' `• A .
pELHAM,NH 03076 - Uaderneeret"7
OSHA. 012371797 {�
c Steve Desjardins
Gcr«SL�eT,'�s:c�`ep'n Ksaftie
` 11iGZ G-L' Ut4[yr _ f1Rril -)009
var_
CITY OF SALEM, TNLxSSACflUSETTS
3 131: mD4G DEPARTJI&NT
I� 130 WASHINGTON STREET, 3"FLOOR
`0 TEL (978) 745-9595
Fmx(978) 740-9846
1CIMBERLEY DRISCOLL
1ANYOR THo.\us ST.PIERRa
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSL\(ISSIONER
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 iMGL 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:
(name of hauler)
The debris will be disposed of in
Z- L. 5
---- (name of facility) �-
--- loge it �.. Sa lei ili/,c
(address of facility)
signature of permit applicant
ante
CITY OF S:U.ENI NL-kSS.ICHuSETrs
BUILDING DEPARTMEJIT
` z - 120 WASHNGTON STREET, 3-FLOOR
oe TEL. (978) 745-9595
FA)I(973) 740-9846
fUJIBERLEY DRISCOLL _
MAYOR T Hows ST.PiERRH
DIRECCOR OF PUBLIC PROPERTY/BUILDING CO'XMSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information 1� _ Please Print LepibiV
Name(Business.Organizatiowindividual): �7eye ,�c.�$�Ct.V• ly`� LC C
Address: 13 RI Cr 14M,
City/State/Zip: /r/C.-dSuv(t /y d _50 S! Phone lt: 60 3-63J---;Za S
Are you an employer''Check the appropriate box: 'type of project(required):
I A am a employer with 2..S_ 4. Q 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hind the subcontractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These subcontractors have S. [] Demolition
working for me in any capacity. workers'comp. insurance.
9. ❑Building addition
(No workers'cump. insurance 5. 0 We are a corporation and its
required.] officer have exercised their I0.❑Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL t LEI Plumbing repairs or additions
myself. (No workers'comp, C. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.] t employees.LN'o workers' I3,�Other!'ePcttl^
comp. insurance required.]
'•Any applicant our checks box#1 must also till Out the wclioo below showing their workew'compensation policy nu;Ornatlom
I h.aeownen who submit this affidavit indicating they am daing all work and then him outside conttactora most submit a new alndavit indicting such
$'Ontmctors that check this box must attached an addid.nal sheet showing the name of the subadntractom and their workers'camp,policy infamution.
I um an employer that if providing workers'catnpensatlolt insurance for my employees Below Is die polley and fob site
information. / _ ��p
insurance Company Name., (}LJC14�'( _t'l.-5< cc) ,
Policy 4 or self-uu. Lic.,/it:: S�W C, Ave 3,70 Expinttion Date' //_(?_t
Job Site Address:R,?F7cTI4V— 5*-d City/StaudZip: ✓:Ci ter'a•1 Q 0I470
Attach a copy of the workers'compensation policy declaration page(showing the poiley number and expiration date).
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 tine
of uP to S250.00 a day against the violator. 13e advised that a copy of this statement may bo forwarded to the Office of
Investigulioas of the DIA for insurance coverage verification.
1 do hdreby certify under the p�uin,,s nand pen�uldes of perjury that tee Lnfurarullon provided above is true and correct.
Date: zo-
I'hnne,9• 3— G` 3 S— ';Z0 t-6
OJJicial use only. no not Ivrite in dnir area, to be completed by city or town ;jjlc1aL
City Or Town: _..... . Pcrmit/1.Iceme# _--,_-.--
Issuing,%ulhorily(circlo one):
1. hoard of health 2. Building Department 3.Cilylrowo Clerk 4. Electrical inspector 5. Plumbing impector
6.Other
Contact Person: . Phoned:
(
From:Colleen Bogacz FaxID:9784549343 Page 1 of 1 Date:10/122012 09:30 AM Page:1 of 1
------ STEVE-3 OP ID: CB
a`o�ro CERTIFICATE OF LIABILITY INSURANCE 10112„2
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 pollcy(les) 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 endorsements.
PRODUCER 978459-8681 NTACT
NAME:
Francis Provencher Insurance 978454-9343 PHONE
Agency, Inc. AIC No Ext: AIC Na:
530 Rogers Street gWRESS:
Lowell,MA 01852
INSURER(S)AFFORDING COVERAGE NAIC A
INSURERA:GUARD INSURANCE
INSURED Steve Desjardins, LLC INSURER B:Peerless Insurance Co.
13 River Road INSURER C:
Hudson, NH 03051
INSURER 0:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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.
LTR TYPE OF INSURANCE NS POLICY NUMBER MMIDD MMIDDrYYYY LIMITS
GENERALLIABILITY EACH OCCURRENCE $
COMMERCIAL GENERAL LIABILITY PREMISES Es occurrence $
CLAIMS-MACE 171 OCCUR MED EXP(Anyone person) $
PERSONAL&ADV INJURY $
GENERAL AGGREGATE $
GEN'L AL, REGATE LIMIT APPLIESPER', PRODUCTS-COMPIOPAGG $
POLI CV PRO IEITLOC -
AUTOMOBILE LIABILITY $
COMBINE LIMIT
—
AUTOMOBILE BINEt 8 1,000,00
B ANY AUTO BA1006627 10/27/11 1027/12 BODILY INJURY(Per person) $
ALL OWNED X SCHEDULED BOD4OCCURRENCE
Perecddenn 4
AUTOS AUTOS
NON OWNEDPROGE $
X HIREDAUTOS X AUTOS Per
UMBRELLA LIAB OCCUR EACNCE $
EXCESS LIAB CLAIMS-MADE AGG $
DED RETENTION$ $
WORKERS COMPENSATION X OTH-
AND EMPLOYERS'LIABILITY A Ann PROPRIETORIPARTNERFXECUTIVE VfN NIASTWC248370 11/17/11 11/17/1 EE.L. ENT $ 100,000
OFFICERIMEMBER EXCLUDED?
A (Mord.tory in NH) EL.DISEASE-EA EMPLOYEEt$ 100,000
Ityes describe under
DESCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT 8 500,000
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Aaach ACORD 101,AdtliOonal Remarks Schedule,if more space Is required)
CERTIFICATE HOLDER CANCELLATION
SALEMMA
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
City of Salem
Building Dept. -
120 Washington Street AUTHORIZED REPRESENTATNE
Salem, MA 01970
001988-20�10 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
10/12/2012 10:43AM FAX 9789572772 COUGHLIN INSURANCE 16 0002/0002
,acoRo` CERTIFICATE OF LIABILITY INSURANCE °A 011212012rn
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(les)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 endorsement(s).
PRODUCER NAMEACT. Colleen A Coughlin
Charles J Coughlin Insurance PHONE (g7g)g57-3588 ac No
PO Box 10
Dracut, MA 018260010 p-A SS, c011een@coughlinins.com
INSURER(S)AFFORDING COVERAGE NAIC r
INSURERA: Main Street America Assurance 29939
INSURED Steve Desjardins LLC INSURER B: National Grange Ins Co 14788
13 River Road
Hudson,NH 03051 INSURER C:
INSURER D:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: 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 PoLICY EFF PO npy xP LIMITS
LTR 0 POLICY NUMBER MO MOLT
A GENERALLIABILIItY MP12174Q 09/08/2012 OW08/2013 EACH OCCURRENCE $ 1,000,000
COMMERCIAL GENERAL LIABILITY PREMISES(Ed occurrence $ 500,000
CLAIMS-MADE VOCCUR MED EXP(Any one person) $ 10,000
PERSONAL&ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGG $ 2,000,000
POLICY W
PRO 1-1 LOC $
B AUTOMOBILE LIABILITY 8212174Q 09/082012 09/082013 OMBINeD[SINGLE LIMIT $ 1,000,000
Ea ANY AUTO BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AlfT05 AUTOS
NON-OVVNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Pereccitlar[
B UMBRELLALIAD OCCUR CU12174Q 09/082012 09/082013 EACH OCCURRENCE $ 5,000,000
EXCESS UAB CLAIMS-MADE AGGREGATE E 5,000,000
CEO RETENTION$ $
WORKERS COMPENSATION WC STATT OTRH-
AND EMPLOYERS'LIABILITY
YIN
ANY PROPRIErORIPARTNER/EXEDJTIVE ❑ NIA E.L.EACH ACCIDENT $
OFFICERNEMBER EXCLUDEW
(Mandatory inW EL.DISEASE-EA EMPLOYEE S
II es describe under
DESCRIPTION OF OPERATIONS be. EL DISEASE POLICYLIMIT 8
°ES M"ONOFOMMnONSILOCATIONSIVEHICLES (Atterli ALORD tO1,AEtlklonal Remarks SNetlWe,Mmore space la requlrerQ
Carpentry
CERTIFICATE HOLDER CANCELLATION
Fax#:(978)740-9846
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
City of Salem, Massachusetts THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
Building Department ACCORDANCE WITH THE POLICY PROVISION&
120 Washington Street,3rd Floor
Salem,MA 01970 AUTHORIZED REPRESENTATIVE
OO 1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
l
Steve Desjardins, LLC CONTRACT 1# 887
13 River Road
ISSUE Hudson, NH 03051 MW DUO:
p: 603-635-2056 29 BUTLER ST.
SALEM, MA
f: 603-635-2057 ATTENTION: MOE DEMERS
steveddes1 @comcast.net
REGARDING:
CLEAN UP WORK
DATE: October 12, 2012
CUSTOMER#: M09915
Estimate Expires Reference Start Date Completion Date Rep
STEVE DESJARDINS
We submit the following specifications:
# DESCRIPTION Amount
1 INSTALL NEW REAR DOOR WITH STEEL ONE LITE DOOR, KEYED KNOB&DEAD BOLT, RE-TRIM
2 INTERIOR DOOR FRAME
3 INSTALL 3 NEW 24"OCTAGON WINDOWS,TRIM INTERIOR OF WINDOWS
4 INSTALL 2 NEW 12"SIDE LITE ON FRONT ENTRY RE-TRIM INTERIOR SIDE LITES
5 CELLAR STAIR- INSTALL 2X4 STAIR CAGE AND ONE#75 HAND RAIL
6 PND FLOOR STAIR INSTALL T OF 6010 OAK RAIL ON WALL
7 ALL NEW WORK TO BE PAINTED ON EXTERIOR&STAINED ON INTERIOR , FRONT DOOR EXTERIOR
8 TO BE SANDED&PAINTED
9 REPLACE MISSING ELECTRICAL PLUG PLATES
10 ADJUST FRONT ENTRY TO CLOSE PROPERLY
11 TOTAL JOB COST 6,250.06
Total 6,250.00
TERMS&CONDITIONS All product to be new and all work is to be done in a workman like manner, according to standard practices. Any
deviation or alteration from the above specifications will require approval of all parties.
WARRANTY Manufacturer's and labor for one year.
ACCEPTANCE: The above Terms, Conditions and Descriptions are satisfactory and are hereby accepted.
ACCEPTANCE: The above Terms, Conditions and Descriptions are satisfactory and are hereby accepted.
Submitted by Date Accepted by —°� Date
TORGO SOFTWARE ..TomoSoflwammm 01996-2009 ALL RIGHTS RESERVED - Pagel Of 1
\� , The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 730 CM SALEMR Revised dhrr 2011
U Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This SectionForOfttcial ilsBOft
Building Permit Number:;'. (( Date Apphed>.
Building Official(Print Name) 1, St
SECTION I-SITE It
1.1 Pro erty A dress: 1.2 ssessors Map Si Parcel Numbers
o s^S+—
L l 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(R)
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 yesO
SECTION la; PROPERTY'OWNERSHIP! '
2.1 Ownert of Record: L n ��C
roc r�L: 1 a Pat it-- S o f m
Name(Print) L City,State,ZIP `
c �, I ii,f�i i Ci—G `i io 6— lit�
No.and Street - Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO'(che.ck all that apply) '.
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other X Specify: _
Brief Description of Propose ork3:
SECTIOtN 4: ESTINLATED gONSTRUCTION COSTS-"
Estimated Costs:
Item Official Use Only_,
Labor and Materials
1. Building S 2_Ljo I. Building Permit Fee:S' Indicate now fee is determined:
. Electrical S ❑Standaid.CitylTown,ApplicationFes'
❑'totalPiojebtCostt(Item.6)smultiplier ems,
3. Plumbing S 2. OtherFeea: S tl
I. M-chanic l (I IVAC) S List: !LE (J
. Mcchanic.il (Fire S
51lp E:i!imt) _ Ibtel All Fees:.S
Check No. —Check Aumunt: cash Autount
n l'nfal 1'rnjccf Cult: S Q ZC7�, O(J ❑ Paid in Fall ❑ Outstandim,.. t „ ISoLutce Du.::
r ,
SECTION 5: CONs'i-RUCTION SERVICES
5.1 Construction Supervisor License(CSL)
1 \ n A License Number Gs irati n Date
Name ofCSLIfolder n
'(� 1 List CSL'fype(sae below)
z7K( V-k'8flt)D r � Type Description
No. and Street -
U Unrestt
Buildings u to 35,000 cu. R.
cn n \)Q_PS rnC •C C I EP Z 3 R Restric .unil Dwellin
Citylrown,State,ZIP M Mason
RC RootinWS WindoSF Solid Fg Appliances
�I'15_ t)�Z10l Insulatirele hone Email address D Demoli
5.2 Registered Home Improvement Contractor(MC) 141( q. / S
Y\ --f-3�1. (_ r .-0 - ^n HIC Registration Num Expiration Date
I IIC Comp y Name or 111C R I tra�tt Nmne
( =orip �t • i�or r
.f and Street Email ad ress
Ka_n J,k� YY�n a tSz v�i 1 �t i 5 nFs�� Email
CityyTown,State zip Tele hone
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 .......... No...........0
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: 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 accurate to the best of my knowledge and understanding.
1' nt Qwner's or A thuritcd:\gent's Nome(Gectronic Signaulre) ) Date
NOTES:
I. All Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Houle Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under I.G.L. c. 142A. Other important information on the HIC Program can be found at
% Information on the Construction Supervisor License can be Found at lrw'w.mass., a1 iu
2. When substantial work is planned,provide the information below:
Toed floor area(ml. R) --___ _(including garage, finished bascmendattics, decks or porch)
thus; living;oca(sy. tLlbitnble room count —
Number of tireplace;_---_------- Number of bedrowns _
Vuuther ut bathroom.; -----
fe )c of II0.11ing iyitelll NIIIIII]ef of deik;i I)O fChc; -...... ..... ..—___—
f}pe lfcanling ;yacln _.---_--.- Fncloied t)pcu _---_----_ - --
1. I nLll I'n q:it Squ.lro 1:1 ad.lgc"I11.1v hC illhitltl 11Jd r�'l "tA P-111i:it t•o;t'•
;. CITY OF 5:1 -&Nf2 J�L1S&: CHUSETTS
CV.
1?0 1�FtL`tGTON ST7tEET 3 FLOOR
�` ILL-(978) 745-9595
FAX(973) 7-W-9345
6bLILY01 THOUIU ST•PIEam
DnECTOR OP PuaLic PROPERTY/BLMDLYC,Co3LIIISSlONER
Construction Debris Dlsposai Affldavit
(required for all demolition and renovation work)
(n accordanco with the sixth edition of the State Building Code, 730 Ct&fR section l 11.5
Debris, and the provisions of:MGL c 40, S 54;
Building Permit is 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 :tifGL c
l l 1, S 150A.
The debris will be transported by:
(name aniautur)
'Cite debris will be disposed of in :
Yv�pS1�J10 r)
(nant¢arl'acility) S� ��
pWress—Ur taailit/)
v si3nanuryvlpermit app scant �
y . --w�+ms++....,cop_:-� ap.-. ♦ z?� s-di, r. �� W Y§ r� sb: 13 x51, <,�Ki
q r
+ t . u
CITY OF Smy_,m ItLkss kcHUSETTS
r/ BL'1LD64G DEPAAT%(ENT. -
120 WASHINGTON STREET,31a FLOOR
' TEL (978)745-9595
Eix(978)•74Q-9M
KI BERi fiY DRISCOL
THOb1AS ST.PIFxRe
NMAYOR DIRECTOR OF PUBLIC PROPERTY/BI:IID&G CO%MUSSIONER'
Workers' Compensation insurance Affidavit:Builders!Contractors/ElectriciansYPlurnber�s
ADUlicatit Information Please Print Legibly
Narne(Business;Organizza(atiorain`�dividual): Af
Address:
1 :
city/State/Zip � y�S h�aSS.o I�i 2Z Phone>E: 9�� 15-c��s 3 4
Are you an cplploycO Check the appropriate box: Type of project(required):
i*am a cmployer with 4. 0 I am a general contractor and 1 6. ❑New construction
ealpioyees(full and/or part-time).' have hired the sub-contractors '
2:Cl 1 am`a sole proprietor or pa ni:r-
listed on the attached sheet.t 7• 0 Remodeling.
ship and Have no employees These subcontractors have 8. ❑ Demolition .
working,for me in any capacity. workers'comp insurance. 9. ❑Building addition
(No workerY comp..in S. ❑ We are a corporation Anil.in 10.0 Electrical repairs or additions
Yegtdrtd.j officers have exercised their t
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workcis comp. c.,152,g1(4),and we have no 12,0 Roof re airs
insurance required.)t employees.[No workers'. 13 J�,j Other_
camp:insurance required.] Y
•Any applicant that chwita bent ll must alsu fill ounhe scctio0 below showing their worker:'cempeseatlon polity nib mation
t I htmeawntxa who submit this affidavit indicating they are doing all worts and then him outside contractors mtut submit new atlldavit indiraling etch
:Contracture that check this box must attached an additionslsheet showing the name of the suboctintractons and their workers compt pulicy infomtadon.
. I am an employer that tr providing workers'comprnsadan lsurance jar my emptoyerx"Below Is the policy and Job site '
injarmalialr.
Insurance Company Name:
Policy#or Scif--ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 line
of up to$250.00 a day against the violator. Be advised that a copy.of this statement may,be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
Ida hereby c atrrfjy�}under`thee pumps and penaldes ojperjary that the lajormatlon provided above is true and correct
Date• e, Z
Phone
QJfrcial ass only. Do not write in refs area,is be completed by city or town ojjkial ,
City or Town: Permft/I.1cense#
Issuing Authority(circle one):
1, Board of licaith 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: :_-. Phone#:'
)
>- Massachusetts - Department of Public Safety
9Board of Building Re:;ulations and Standard
Construction Supervisor Specialty License
License: CS SL 99M
Restricted to:. RF
t ,
i
PETER MILLER
281ANDOVER STREET e' t
DANVERS, MA01923
a
Expiration: 9/62013 !
('onnnisincr Tr#: 1267
�a�omrnraixoea((�e�P/�lai.ncwJel(d '
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
mWoxpiration:
before the ex iration date. If found return to:
MEIMPROVEMENT CONTRACTOR Pegistration 128691 Type: Office of Consumer Affairs and Business Regulation
' 5/5/2015 DBA 10 Park Plaza-Suite 5170
Boston,MA 02116
NORTH SHORE ROOFING
PETER MILLER
281 ANDOVER ST g ��
DANVERS, MA.01923 r ���'�_
Undersecretary Not valid ithout signature
NORTH SHORE ROOFING
281 Andover St. Danvers, MA 01923
(978)977-3816 Fax: (978)762-4667
'M f-. 6,VArs)_2 pokA h_e,
Beauvais Builders 05/28/13
Ref. 29 Butler St.
Salem, A.
qng at,$-'� 74q
The following is a proposal to apply a new asphalt shingle roof at the above address.
1) Dismantle the large chimney that is discharged down below the roof deck and dispose of the debris.
2) Install 3/4-in. plywood over the opening where the chimney was located.
3)Remove the existing asphalt roof shingles down to the bare roof decking and legally dispose of the
debris.
4) Replace any damaged and/or deteriorated roof decking if and where needed.
5) Install 6-ft. of ice and water barrier along the entire perimeter of the roof as well as around all
penetrations and flashings.
6) Remaining exposed roof decking will be covered with 15 lb. asphalt roof paper.
7) Install 8-in. aluminum drip-edge flashing along the entire perimeter of the roof.
8) Install new aluminum pipe flanges on all vent pipes.
9) Install a Cobra ridge vent on the main roof peak.
10) Remove the existing flashing from the base of the chimney,grind out new joints,on the base of the
chimney and install new lead flashing which will be set in with mortar.
11) Install a Lifetime High Definition architectural 30 yr: asphalt roof shingle, color to be chosen by
the home owner.C C i (XK V 'vo 00d)
12) Five year warranty on labor,manufacturers limited lifetime warranty on asphalt roof shingles.
13) All roof related debris will be legally disposed of by No Shore Roofing.
TOTAL PRICE: $9,200.00
PAYMENT TERMS
1/3 DEPOSIT REQUIRED: $3,000.00
BALANCE DUE UPON COMPLETION: $6,200.00
Acceptance of Proposal - By signing this proposal you have accepted all of the terms as stated above.
Date of Acceptance a^, 3 Authorized Signature
N.S.
Peter filler
I
*Voted"Best of Boston-North 2010 " by Boston Home Magazine*
*North Shore Roofing carries liability insurance as well as workmen compensation*
*Mass. Construction Supervisor License#99622* *Mass. Reg. #128691*
ACORD CERTIFICATE OF LIABILITY INSURANCE GATE os 03/2013D1s/ (
PRODUCER (978) 74S-6464 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Rose Insurance 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 AFIFORDING COVERAGE 14AIC 0
INSURED INSURER A:Nautilus Ins Co.
Borth Shore Roofing INSURER B:Hartford
281 Andover Street INSURERC:
SURCR D:
,Danvers MA 01923— INSURER E:
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABO\/I°FOR THE POLICY PERIOD INDICATED.140TVVITHSTANDING ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT'f6 WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDS[) BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDIT1014S OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS,
INSR ADD'L POUDYEFFECRVE POLIOY EXPIRATION
Im p TYPE OF INSURANCE POUCYNUMBER DATE IMMIDDNYI PATE IN TIDPIM LIMITS
A GENERAL LIABILITY / / / / EACH OCCURRENCE0 500,000
X COMMERCIAL GENERAL LIABILITY PREM%1 H Ea oadl°mnee 0 300,000
X CLAIMSMADE FDOCCUR NN136521 OS/28/2013 05/28/2014 MEDEXPA one arson 0 4,500
PERSONAL4ADVINJURY' 0 500,000
GENERALAOGRCGATE � 0 1,000,000
GEN%ACGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/[) 0 1,000,000
POLICY T LOC
AUTOMOBILE LIABILITY / / / % COMBINED SINGLE LIMIT
ANY AUTO (Es ecclden0 0
ALL OWNED AUTOS / / / /I BODILY INJURY 0
SCHEDULED AUTOS (Per person)
HIREDAUTOS / / / / BODILY INJURY 0
NON-OWNEDAUTOS (Per wecldnnt)
PROPERTY DAMAGE
(PerecCM9np n
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT 0
ANY AUTO / / / /� OTHGRTHAN EA ACC d
AUTO ONLY ME 0
EXOESSIUMBRELLA LIABILITY / / / / EACH R N E 0
OCCUR CLAIMS WOE AGGREGATE
p
DFDUCTIBIE
RETENTION S wWeC prT s
B WORKERS COMPENSATION AND UBS422CO24 67/25/2012 07 2512013 X TORViIMlTB °L� ,
EMPLOYERT LIABILITY
ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACI•I ACCIOEW 0 100,000
OFFICERIMEMBER EXCLUDE07 / / / / El.DISEASE-EA EMPLOYFF0 100,000
If yes,descrlhe lmder
SPECIAL PROVISIONS UeM E.L.DISEASE-POLICY LIMIT 0 500,000
OTHER
DESCRIPTION OF OPERATIONV40CATIONSNEHICL"&IEXCLUSIONS ADDED BY ENDORSEMENTMPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
(978) 762-4667 ( ) - SHOULD ANY OR THE AMOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DAIS THEREOF, THE ISSUINO INSURER WILL ENDEAVOR TO MAIL
30 _ DAYS WRITTEN N0110E TO THE CERRFICATE HOLDER NAMED TO THE LEFT,BUT
Mr. and Mrs. Lepoutre FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE
29 Butler street INSUFLER ITS NTS OR REPRESENTATIVES,
Salem, MIL 01970 AUTHORIZE .PR�ENTATVE
ACORD 25 2001106 0.
( ) ®ACORO CORPORATION 19BB
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