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11 FOREST AVE - BPA 16-396 The Commonwealth of Massachusq�pEC�10�4A1 SERd CES Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780��R SALEM LUIO A 22 A ID (wised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a ^^nn One-or Two-Family Dwelling ` 1 . a This Se boa For Q$icial Use Only'. 1 Building Permit Nt tuber.` { Date Appli : Building Official(Print Name) a Signature , Date ?SECTIONJ,SITE INFORMATION ' 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers I.la 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 R) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rem Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP'' 2.1 Ownert of Record• Q 7� 1�a" A�t� LU135I Tz s LE�LI M� Name(Print) City,State,ZIP it 170ce5Z (vi 7LI1 0/N8 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': b t ts/ a GQA,•Z EY:3— C 'P\2A.41,]�7 -tr�y7)Pel- TCAIL 5F cocvrn l3 s SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs:Labor and Materia Official Use Only ls = ` 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:: 2.Electrical $ ❑Standard. City/Town Application,Fee , ❑Total Project Cost3,.(ttem 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List:. . 5.Mechanical (Fire $ Total A11Fees:$ suppression) - '/ Check No. Cheek Amount: Cash Amount: 6.Total Project Cost: $ IF /0 0 Paid in Full . O,Outstanding Balance Due. P .i"r?„*):.,SECTION 5: CONSTRUCTION SERVICES 5.1 Constructron Supervlr`L soicehse'(CSL) License Number Expr Name of CSL Hdldei '`�� r'ry J-`� Pi':.1 J i a 1 List CSL Type(see below) No.and Street Type Description C y�� r © `�b� U Unrestricted(Buildings u to 35,000 cu.ft. R I Restricted l&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofirig Covering WS I Window and Siding / /� SF Solid Fuel Burning Appliances /�I S4�- (.J�—t I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ' 7�� CA L10L 6-- �� 4� y HIC Comm N e o HIC Regisqan t N e C Registration Num er xpirati n Date �j &o�d`�bw Ati 519 No:and$tree�� M2 Dt r O� 7%J ",a 6/q 3 Email address City/Town,( State,Z•I,P 7 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 7ai 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. Ldt e= a e Print Owner's or Authorized Agent's Name(Electronic Signature) Date NOTES: . 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.aov,`oca Information on the Construction Supervisor License can be found at www.mass.aov/dns 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SALEA A ASSAaA SE M BEnDmDEPAFamEw 120WASTDIK,9tpNMUTs31 RDM ]kL(978)745.9595. PAX(978)740.9846 RiMBRRiFYDRIS�IL MAYOR 9HCMAs STYMIU F DntEcrca oFPLa rcmcam/stujnaGo3affmom Construction Debris Disposa/Affidavit (required for all demolition and,renovation work) in accordance with the sbcth edition of the State Building Code, 780 CMR, Section 111.5 Debris, and the provisions of MGL coo,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 deposit 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: (name of facility) (address of facility) Signature of applicant c/ 2 Date The Commonwealth of Massachusetts tm Deparent oflndustrialAccidents I Congress Street,Suite 100 Boston,MA 02114--2017 wivmass gov/dia Wo w. rkers'Compeasation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FU FD WITH THE PERM rnNG AUTHORITY. Applicant Information Please Print Leerbly . Name(Business/organmton/Indivliduatl): Address: 3z - C,tyiStateiz,P:_ � .4, OM62 Phone M Are you an employer?Check the appropriate box: Type of project(required): 1. I am a employer with employees(full and/o pan-time).- 7. New construction 2.0 I am a sole propr aunt or partnersh p and have no empl ,,M)l forme n MY capacity.[No workers'"comp.insurance required] 8. 0 Remodeling 3.01 am a homeowner doing all work myself.[No workers'comp,insomnce required]1 9. 0 Demolition 4.01 sin a homeowner and will be hiring contractors to conduct all work on my property. I will 10 0 Building addition ensure that all contractors richer have workers'compensation insurance or are sole 11.0 Electrical repairs or additions propnetors with no employees. 5.01 am a general contractor and I have hired the subcontractors listed on the attached sheet. 12.0 Plumbing repairs Oi additions These sub-contramors have employees and have workers'comp,insmance.i 1 13.0 Roof repairs 6.0 we are a corporation and its offices have exercised their right of exemption per MGL c. 14• Other !1 {� 152,§1(4),and we have no employees.[No workers'comp,insurance required] 'Any applicant that checks box#1 mast also 5a out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. :Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub=contractors have employees,they most provide their workers'comp.policy number. I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / 1 Insurance Company Name: [� E2 (1•` V-4 `Policy#or Self-ins.Lic.#: S 305-6 3y Expiration Date: � y Job Site Address: Toees? GSty/State/Zip:_Skf"M #A C/ c( ?0 Attach a copy of the workers'compensation policy declaration page(Showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penalties ojperjury that the im" adon provided/above is true and correct Signature: Phone --?I ) Official use only. Do not write in this area,tabs completed by city or town ofchiL City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector 6.Other Contact Person: Phone#• Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with then certificate(s)of insurance. Limited Liability Companies(LLQ 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 confinnation of insurance coverage. Also be sure to sign and date the afdavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested,not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy,please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant that must submit multiple permittlicense applications in any given year,need only submit one affidavit indicating current policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax #617-727-7749 Revised 02-23-15 www.mass.gov/dia j r WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE POLICY Liberty Mutual. INSURANCE AR INFORMATION PAGE 175 Berkeley Street Boston,MA 02116 Issued by LM INSURANCE CORPORATION 27243 Policy Number WC5-31S-328305-036 Issuing Office 016C RENEWAL OF: WC5-31S-328305-035 Issue Date 04-13-16 Account Number 1-328305 Sub Account 0000 1. Insured and Mailing Address RICHARD COLE DBA RICH COLE CARPENTRY RISK ID 000251970 39 GOLDTHWAIT STREET LYNN,MA 01902 Status 01 — INDIVIDUAL Other workplaces not shown above: SEE ITEM 4. PREMIUM- EXTENSION OF INFORMATION PAGE 2. Policy Period: The policy period is from 05-14-2016 to 05-14-2017 12:01 A.M. standard time at the Insured's mailing address. 3. Coverage A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states listed here: MA B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits of our liability under Part Two are: Bodily Injury by Accident $ 100, 000 each accident Bodily Injury by Disease $ 500, 000 policy limit Bodily Injury by Disease $ 100, 000 each employee C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here: SEE END WC 20 03 06B D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE 4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and Rating Plans. All information required below is subject to verification and change by audit. Code Premium Basis Total Rate per$100 Estimated Annual Classifications Number Estimated Annual Remuneration of Remuneration Premium See Extension of Information Page Minimum Premium $ 500 -+. (MA) Total Estimated Annual Premium $ 500 Premium will be billed ANNUAL Producer 0004-162816 BEACON INSURANCE GROUP INC 528 LORING AVE SALEM MA 01970 WC 00 00 01 A 01987 National Council on Compensation Insurance,lnc. WC 00 00 01 B (CA) Ed. 07/01/2011 All Rights Reserved Page 1 of 1 Insured Copy v' fascia -$226 18-16'and 2-10'2x6s pressure treated `$77 2-12'and 1-16'2x12s pressure treated 4'-10 1/16" "$800 3-8'x10"tapered fiberglass columns - .. +-- I �x- —$95 2-16'1"x12"cellular PVC fascia -------- _ ___--_-___—_ --_—__----_ Ili li li j j R "$150 2-12'and 3-10'1"XS"cellular PVC fascia -$50 7-4'x10"construction tubes iii i I I i II -li it ili ." it it 1 ' $1750 Decking i i i j Ali 'PI -$34 1-16'4"x6"pressure treated `$28 1 sheet Y"pressure treated plywood j III I! I 'II pressure treated 2x6s lli!`$500 Hanger hardware,nails etc. "$800 Railing 'll j j II II II Ilj!j as„ `$100 3 Lattice panels -- ----- --- _— _-- II — II ry $zoo Concrete I ;.ii i i I i it it it i!I I �± -$aglo , 710"xa'construction l;ii it illll II:I i i I i I II !I it illi I � tubes I i I I i i I it it it ills I II a� !i i i I i it II it lil I it �.� !i i i I i it it I, III h 'm II li li 'li Ii IIII 3 new tapered fiberglass © r:In II li jj III °I' load bearing columns > 'II 5'-85/16" _ li III (column and footing for this Oj li Ali — O corner had been previously replaced and inspected in 8/2006) 1-1'1/2ii 1 II II 'I! II I I I II I II II ,I II II 'll I III 12-7 i I I I I I I I II II I'I II I I II II II II I ' i' Richard Lobsitz it ii ill ii Fr01 ii 978-741-0148 II jl it it 11 it 11 Forest Ave. Front porch deck rebuild 6'o"