30 FEDERAL ST - BUILDING INSPECTION _ The Conunonwealth of Massachusetls --
b Board of Building Regulations and Standards ll(
L , / Massachusetts State Building Code. 7SO CNIR. 7"i edition
Building Permit Application To C;(n/torah Repair. Renosate Or Demolish a R rr„J./ nni n
— -
T Se-non For Official Use OnlyX11 I
—7
I� Building Permit Nui ncCr
Signature: - �- -_`- -----
Buddin ( nus,iou rr In,l , yr r o mIJwgs -
C"PION 1: SITF: INFORAIATION _
!.l Proverb .Xddrrss: 1.2 Assessors Map & Parcel Numbers
I.11a Is this an accepted :MAP Number _ Panrl \umhei
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sy ti) Fontage ills --
1.5 Building Setbacks Ift)
Front Yard Side Yards Rear Yard
ReyuirrJ Provided Required Provided Required Pn.sided-
' I
F.I
pply: (VI.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On srtc Jis weal systcin ❑
Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
of Recor �L / cs (�
v _ /`�/ D i"1 �O FPVI n a / J Sr Pam)
Address for SerVice:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction ❑ 1 Existing Building ❑ Owner-Occupied ❑ Repairslsl ❑ Alterationls) ❑ Addawn ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Spccity: - -�
Brief D--scripnd1 o o os f Proped Work': _Sf�Z 6L
U 2
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials; _ __
I. Building S 1. Building Permit Fee: $ Indicate husk tee is daenninad:
❑ Standard City/Tuwn Application Fee
'_. Electrical $ ❑'rural Project Cost' (Item 6) x multiplier x _
1. Plumhing i 2. Other Fees: S
1. IVtechanieal (HVACI $
List: AG21 W----
5. Mechanical (Fire S ---
Sim ressionlfntal All Fees: S
Check No. Check Amount _ ('a,h AMI'Lint
j�Fr rutal Project Cost: 'S 9 d UCJ 11 Paid to Full 0 Outsemd(ng Balance Due_------
SECTION 5: CONSTRUCTION SERVICES
5.1 L.icenscd Construction Supervisor (CSIJ
�¢ - -�-- C l
_ otL p �D Q l-r) I_li:n.r Nunthrr I.\pu.uiollr-
\,rmr at CSl.- IfolJer
- — �� Llol CS I. Tt lie(.ce heluw t
Desetl loom
\ddrels
l'nt csil 1,led lu)[it ji.IN 10( FI.I
D(76
Restrteledl 1,142 F.umh Dwelhnl-
]I_n:cure p 11 \IawnnUnfs
L RCt I<r a kttu(n�c (lt.irl ml __-
1'e1cphune —Ws I Pc.id.'ulidl \l indut. .old
SF lZ idenu,tl S IIJ I-uel Iluimn__ \h them: Imt.ill_ui, u
D Itesld.•nt Ltl Diuwhutm - __ __
5.2 Re istered 11 mel!lmprovernent Contractor (111(-')
lllC Con pang .Name or HIC Rcgutt-anl ,` I Reeutrat m .\uwh'l
d dL I
\ddrQ is
e3J-�SZ^Q 70 , Lrptrall,tn n.tte —
I afu t elcplLmc —I �
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (NI.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and s ohmitted with this application. Failure to pnn ide
this affidavit will result in the denial of(he Issuance of the building permit.
Signed Atfldavit Attached? Yes .......-. 2r o ...
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 un my behalf, in all matiets
;e:utive to .vork authorized by this building permit application.
i
Signature of Owner ------------ — Date_ ---
SEC 76: OWNER( OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare i
tha he statements a fi rmation on the foregoine application ale true and accurate, to the best of my knowledge and
—14 f1 � --
_ da�a /o
Print ame
Signature ut wrier . thorized .Agent Uate
Si me-under J1e a and penalties of er u )
NOTES:
I. An Owner who obtains a building permit to do his/her own work or an owner who hires an umeg sterrd contiaclor
(nut registered in the Hume Improvement Contractor (HIC) Program), will not have access to the uhni.nion
program or guaranty fund under M.Q.L. c. 1-12A. Other important information on the HIC' Progr in and
Construction Supervisor Licensing (CSL) can be found to 780 C'MR Regulations I IOR6 and I IO.RS, tespecosely.
' When substantial work is planned, provide the information below:
Total floors area(Sq. FLt (including garage. finished ha]elnen Uatllc N, decks or pntchi
Gross living area (Sq. Fri Habitable room count
Number of fireplaces Number of hedrootns ._------_-_--_
Number of hathrottms Number tit h,ilt!hh. ------.
.0
I we of healing system Number tit decksi por,hcs
I)lie of cooling ,}item
?. "Ilaad Project Square Footage" m:tv he substituted tur 'Toud Project Cost" ___.J
y '
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR"IMENT
I 0 SAII \I, %l
Construction Debris Disposal Allidavit
(rcyuircd for all demolition and renovation work)
In accordance \%ith the sixth edition of the State Building Code, 780 CNIR section I 1 1.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting front
(his work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by: [I_
I name of hauler)
I lie�debris wi11 be disposedof in
m1. r—p OG
(name of facility)....
(address of facility)
lal c of per I pplicant
late
Sept- 9"
GG
We are fully licensed and insured. Proudly serving you to beautify
and weatherize our New England communities.
SCOPE OF ORK: Using the Certainteed Integrity System:
Ir Sip off all old roofing shingles down to the bare wood deck and also nail down any loose sheathing
,01foughout entire roof.
rK Apply three feet of Ice&Water shield to the leading edge of all,valleys,dormers eaves&chimneys,to
9ect and prevent from freeze backs.
Cover the remainder of the roof using Roofer Select Premium Fiberglass Underlayment.This implication is a
Bois bamer
Install n rush, aluminum drip edge to the entire perimeter of the roof,the leading
^e,and allows water to run into the g r.
�fLhimney • „ 11 r clashing.
f7l tall new vent vine flanges to all plumbing vent pipe.
C7 Re-shingle the entire roof using � �� icn - l!% dn�1�
,poofing shingles in your choice of colors.Color. ChoiceL ci��
ip and Ridge caps installed.
stall Shingle Vent Il Baffled Ridge Vent to the peaks of all of the:roof,for propel ventilatioti.
En Dumpster removal and removal of all job related debris. 0 4?r axt I' ¢i ZF 6 6 rs--
TOTAL CONTRACT PRICE�� d Includes materials,labor,tax and permit if applicable.
COMMENTS: If any deck sheathing replacement is necessary due to decay,an additional charge of$2.90 per Square foot will
be applied to the total job price.Plywood-remove&replace: $65.00/pc.Extra layers(over 2):$300.00/pc.
TERMS: Y deposit, %3 due on start date, '/3 due upon completion(Depending on roof size,most are completed in one day)
DELIVERY: 24 Weeks;Note that we are not responsiblefor delays caused by weather, suppliers, subcontractors, building
officials, asb tos atement, h'dd n damages or conditions, acciden s, acts of God or arrything beyond our control.
m
� G V
Thank You for the opportunity to submit this proposal. If you have any questions,please don't hesitate to call.
DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Please note conditions on back
Respectfull,�itted Accepted By:
NAME:
00 DATE:
oject ger STREET:
AJExteriors, Inc. TOWN: I ZIP
SIGNATURE:
TELEPHONE: 91:cc U S WS614
2 Neptune Road • East Boston; Ma. 02128-1457 • Phone: (617) 957-0904 • Fax: (617) 207-1294
,U4 Registration 4 141543
Massachusetts - Dcparlincnt of Public S:dcth
I Board of Buildin_ Rc_ulations and Standards
C,onstruation Supervisor Specialty License
License: CS SL 100329
Restricted to: RIF
ANTHONY PUOPOLO 4
12 MECHANIC STREET ,
FRAMINGHAM, MA 01701
�iL- �s iScJ� Expiration: 12/29/2011
( ...... i..nrr Tr#: 100329
Boar o of >ng egula ons an an ar s
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement,6ntractor Registration
I Registration: 141543
v S Type: Private Corporation
1 3 _ Expiration: 4/282010 Trill 266986
A.J. EXTERIORS, INC. t 111if
JOSEPH PUOPOLO d air_
2 NEPTUNE RD SUITE 340 f _
E.BOSTON, MA 02128 -a { Update Address and return card Mark reason for change.
Address ❑ Renewal ❑ Employment ❑ Lost Card
DPS-CAI 4 50M-07107-PC8490
t� 7/4 &.mw.lo(
Board of Building Regulatlo fis and Standards License or registration valid for Individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration:, 141543 One Ashburton Place Ron 1301
Expiration: 4/28/2010 Trill 266986 Boston,Me.02108
Typo: Piivate Corporation
A.J. EXTERIORS,INC._
i
JOSEPH PUOPOLO, "
2 NEPTUNE RD SUITE 340
E.BOSTON.MA 02128 Administrator Not v without signature
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
!1 �W
,IN IL Nl IN":)gKC. l l
\I\:Ua 12C WA9r11Vti r J\S'1't(LL r SI:'1'I GI97�
Ttr.t.:978-.'45-9595 • FAx. 978-741V9846
Workers' Compensation insurance Affidavit. Builders/Contractors/Electricians/Plumbersve Pn Lei
PleaLV
\ ) llicant Information
IN r �' L
Name lnuciacss/Organir:uinNlndry uluall: I
e /S1cZ— Phone i': � S 7 ' D S 6
(;Ityr-st:tte'Zip: -G f ��
Are yours employer? Check the appropriate bp"--
'Type of project(required):
i
I.❑ I all a employer with have hired the :tall-contractors
4. 1 ❑m a general contractor and 1 6. ❑ New construction
o
eny)IJyccs(null nntl/ur pare-wut).• 7. ❑ Remodeling
2.❑ 1 ;Inn a sole proprietor or partner- listed on the attached sheet. :These sub-contractors have 8. ❑ Demolition
ship and have no employees svorkers' comp. insurance. 9. ❑ Building addition
working for me in any cap:lcity.
5 We are a corporation and its 10.❑ Electrical repairs or additions
IKn worker' comp. insurance officers have exercised their
required.] i 1. Plumbing repairs or additions
right of exemption per MGL ❑ b �,p.
3.❑ 1 am a homeowner doing all work c. 152, §I(4),and we have no l2. uuf repair
myself. (Ko workers' comp. c.
employees- Ko workers' 13.0 Otller
insurance required.) I cmnp. insurance required.]
.�irphcmd quit cl:ccks box too must also till um the we lim+Ixtow shuwiny rhalr wurkui cumpensurion pulley intlirnmtiu0.
' I lomeuwners who submit this affidavit indicaims they are doing tall woik mul lien him ootsid<cuntrxton must aulm+il a new mp.lp it iy inftmg sueh.
( t t ihm hock this box mtur anxhtvl tan additional shut h 8 tl • +ante of the sub ontracwrs and their workers'comp.ryiGry infbrm:+tiun.
I nor air employer that is pro vidiag workers'compensation j)osuralleefor toffy employees. Belory is the policy and/ob tier
inforirotian.
Insurance Company Vame: rr
�'`t
?(�-�e�' -Expiration Date: =--9—
Policv_ 4 or Self-ins. Lie. P: w V V--
City,,State/Zip: D
Job Site Address:
. declaration page (showing the policy nwubcr and expiration date).
\teach it copy of the workers' cumpensrtiun policy
5:\Jl'>lGL c. 152 can lead to the imposition of criminal penalties of a
Failure to secure coverage as required under Section 2
tin. up lit S1,500.00 and/or one-year imprisonment,as well as civil penalties in the Ibnn or a STOP WORK ORDER and a fine
of up to S250.00 It day against the violator. Ile advised that a copy of this statement may be IJlwarded to the Office of
Invrsnyuunns JI the UTA or inswal ec coverage serilicatnm.
I do hereby certify iui+ler the poi n /ties of perjury that the uiforinanon provided aba a is true and vatic/
Dot•'
ZI
<ieaawrc
7
O[Jirial use ardy. Do toot write in this area. to be comp44ed by city or town oJJiciuL
Permit/License g._
City or flown:
issuing :\W lturity (circle ouc):
I. Board of Ilealtit 2. Buddill neparunent 3.Cill,fostn Clerk 4. L•'lectrical Inspector i, Plumbing Inspector
6.Other _ ---
Phone M:
Contact Person: -- -
Information and Instructions
\iaysachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees:
PurSliallt to this.Statute,an ernplgree 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
,it the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,paittlershlp,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
Oi'On the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.IGL 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, :bIGL chapter 132, 1125C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomtance 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) namc(s),address(es)and phone number(s) along with their 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(lie number listed below. Self-insured companies should enter their -
self-insurance license number on the a propriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Nzase be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
(hat must submit multiple pennitAicense 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(hat 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
f i.e. it dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he Otfiee oI lovestiganons would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call
The Deparunent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OMCO of investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
R:viseJ 5-26-05
Fax #617-727-7749
www.mass.gov/dia