11 FOREST AVE - BPA B-12-513 n 7 The C'umnwnweaI(h of Mussachusclts
/h Board of Building Regulations and Standards CITY OF
Mussachusctts State Building Code. 730 C NIR tiALE�I
Building Permit Application To Construct, Repair, Renovate Or Demolish a
lhte-ar Tit -Fumilr Dvelthik�
This Section For OBicial Use Only
Building Permit Number: Date pplied:
Building OBicial(Print Nmne) Signature Date
SECTION 1:SITE INFORMATION
1.11 Proper AJJre�ss '�_ �— 1� 1.2 Assessors flap& Parcel Numbers
1.l a Is this an accepted street?yes KS\f no Map Number Parcel Nunher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed DSc Lot Area Isq It) Frontage lR)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposals).Hun
Check if I' ❑
SECTION 2: PROPERTYOWNE HIPt
2.1 Owner f Reco el;U1�� m`
N:ur^elPyymh 1�J s Cuy.Statu,l.IP Q t 4
NO..and Street
relephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(thee all that apply)
New Construction❑ E.xisting Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other, ❑ Specify:
Brief Description of Proposed Work':
vu
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and \lateri Official Use Only
1. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard CityiTo%vn Application Fee
❑Total Project Cost't Item 6)x multiplier _ _x
). Plumbing S 2. Other Fees: S —
J. \tech;mical II1'.1(') S List:
5. \Icrhanic;d 1Pire i
tiu+ircssionl S Total .\II Fces: S_ —__ - --- -- -- --
Check No. _ _('heck Amount: C,tsh \mount:
r . Total Project Cost: 5 -� ❑Paid in Fuli 13 Outstanding BoLmce Due:
f
SECNON5: CONS'I'RlicrIONSFRVICF:S
5.1 Construction Supenisor License(CSIJl
f�.,��� v suLx,G Number
— --'-�,n) Li • Pyliratiou D;uc
cut C..S1. I a cr
IistCSI. I) Isechclulsl--__-.___.
NaDescription
Cx s� -
NLL ,IIIJ 5lrecl — ` .
PC
U I I4vcstricicJ i Buildiusup to lS,l)tln eu. 11 )
__ R Restricted I I Fail) -t,M1 n
Cigifoml Slatc./IP hlasonr
1 .� Widd'
Cuvcrin
O -- ;u,d.,, in
el BurningAppliances
nI(mailaJJnss on
5.2 Re stered a Irill'ro 'ement Contractor�C)
0 1IIC Rcgistr iiun Numlxr If.epirnliun Dutc
I IIC C'om un) of c r 11 'lie ist�u Nm le
No.miJstn:y L•'Inall address
City/Town,State,ZIP Telephone
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........... 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 on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nano(Electronic Signature) Dale
SECTION 7b:OWNERI 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 applicatio Is true and accurate to the best of my knowledge and understanding.
�ZOLN OTC ,-J,,- J� �y
1'riut lwer'.i or Autltorired Agent's Namc I Ficclrunic Signature) Date
NOTES:
I. An Owner svho obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
out registered in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration
program or guaranty fund under.I.G.L. c. 112A.Other important information on the HIC Program can be found at
IIIIII Ka" �;n -'.1 Information on the Construction Supervisor License can be found at p l ,.nlei:yn ,III,
2, \Then substantial work is planned,provide the information below:
Total lloor area(sq. fl.) _ I including garage, finished basemenCattics,decks or porch)
Gross living area I sq. 11.l - Habitable room count
\'uniticr of lircplaces.._. Number of bedrooms
\unlher of halhrooms Number of half haths
I\pc of heating s)stanl _ _ \unlher of decks, porches
I\pe of Cooli 1_l' i\itelll FacIosed - - _ Open
I
i. "Foial Project Square Footage'ma he iubiottacd 11rt"Dotal Project Cost-
IN$ CITY OF SALEM
; PUBLIC UBLIC PRUPRERTY
DEPARTMENT
i a'.N'I Y-i11N.nI
\111ry
I'cl. /?{.?IS'1$'IJ •1'1.r 'Nt•?IC'HM
Workers' Cumpensadon Insurunce llOduvit: BuildervCuntr2cturi/llectrlclyns/Plumbers
t Mull In unnalio
in a 'I'll
VJITIC I Iln,uy',rl)r;\anlr.11inlrinJlYduuq: I�IcS�^�„LJ-�- �����J/�
Wdro.v: C�110
one If• 1
.\r'. an vnrployer! Check the uppenprlurr box.
I u+t A vm luyur with 0, Q 1 airl a ycnura)c0litr3etot and 1 1 y1>•of prolecl(raqulrrd):
�•❑ map uyvvx(lull and/ur part•liole).• huva hired thu,rub•cunuu fors �' ❑New cunsirucliun
1 ,un a lulu prnpriciltr ar partner• fisted on the anuchad.+huct 1 Rmnodelins
.chip and have no vmpluycw Their aubcontrsators have
uorkiny rile mu inm ucit . o, e' ❑Dtmolition
y cu P y workers'comp.Insutrnce.
I Kn workun'cutup, insurance J. ❑ We art a cm 9• ❑lluildind addition
nyuircJ.j poniinn;utd its
7.Q le 1 :on a hlunuuwnar Juiny all work iy rs have
w�h ivvd their 10•Q Electrical Weirs ur additions
myself.lKo lvnrkors'cutup. D put M(;L I LQ I fumbind rupuirs or additioty c. 1 J2,4!(•1),and 1w hnvu no
insurance rcyuirtd.l t clnployCCN. h'o wntkara' 12.0 Roul'rupuirs
comp, in.vurtncu ruyuiral 1Ia Other
+ny.,,,plw'+II rhW chutat ioa»I mule.Ilw tlll uW 1hy vtrhae Inluw awwMe.hey wwtwt'g"'Peawl,w IWiry waul+Niw�
'lhnww+wryn why+Iyll+il IAir rmravlt inylulin I
'r.Mlrw urr 1AY+hv'et Ihu opt MIN anahte A Wehiyilr ply auine+11 wu fit
ane Ihvw hoe uunies cwm,mww mul.ullwa a note alnJtwa Indlu 'All vlrt.
vrwt AM,huwul Ihy"34te of the IUb.o traeyw ate Ihfr wultM'r°'M 1*+IKy InMwar{Ix
/uln un employer Jhu/!r prole/rin,r rvurbri'rulnpetrnllen lu.rwn�nee jw Ins r/np/uprr.R Bdmr/s the puNcy one/u1 aih
tnNur4lice lr ��� � }
In,urancC C'umpauy .Vaino:�iv'atlL1" XI''1� N
Policy o,It Srlr.ini. Lie.�� I�YY�fiXT'b�31 O . y/ S l 1
1 Eipirwill D;ny.
lob Sift: �--
.\ttach a copy of Ille workers'cumpun+atlur pulley duclaratlen page(rhawf NI rhet policy atutt�pu►an ur date).
I'.ulury w w.ute cuveroye".re
uudcr'"liun:JA lif MGL.c. 152 tau lead to rlu ilnpotitian of criminal pandtia of a
finv up n+SI Jao.nn y d ailut mle•yeu intprisunlncnt, ar lrcll.ls civil punu111u in the lunn era 5TUp WURK URGER and a floe
at up 1. iU1 i1Q,1 Jay ,yuinu the v;nluror. Ile advl.wu thus a copy urthl.v ouiclnunl may be I STOP Cd to the RDLr a
hn„1i�aln au ul ,hu IJIq ;9r annr.u'cC:I,vcra;y l culivatpm.
/Ju/h'rt•by Irrff"A While.. . nine nnJ pros/tieriiiiiiiiiiiiiiiiiiiiiillillillillillillillillillillillillillillilliililI
yN/nry/hue rlrp in/'ur,�ylloe pNriJpr uOov'I i (rue n rr t•orrvrR
`rytl gi.
IJ///riu/.r.r ell/y. /!y,Inr wrilp in Ji,r area. ro Ap ruulylerrJ Dy airy ur 1plre a/�hiuL
I.l uin yannibLlcen+el
µ .\uthnnty (circla noel;
I Ih•.uJ rr IfY.111h !. Ilwhhn� Il.p.vtua•ul 1, lll+.'I'ann Clerk J. L'lectricll hnpacrur :. (`luntbi^µ ycerar
6. Uthrr
h1+
'I I n,111\'I I'\r Wll:
—' -__ I'huuc f•
CITY OF S,V1 &Ni, ,%Lkss.kCHL'SETTS
8LMDLNG DEPAtT% LVT
120 W ksmGTON STU". 314 FtOOt
T'EL (978) 745-9595
KI\ISERI EY DIMOLL FAX(978) 74Q984d
,tiL1Y01! THotiW sT.Ptautt
DIAECTOt OP pLaLIC PIIOPERTY/9t LOLN(;CO-NNISSIONEt
Construction Debris Disposal AtIldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MCL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a property licemed waste disposal facility as defined by,MCL c
111, S I50A.
The debris will be transported by:
O a (a)-L a)v m psTe,
(name of hauler)
The debris will be disposed of in
(name of raciljly) '""'---
01dre»of rj,:jj y)
+ yeatute of permit 3pphc4nt
,life
1'
-- - 203 WASHINGTON ST.#256
PRESERVE SALEM,MA01970
carpentry l painting l roofing lgutters PHONE:978.745.8745
SERVICES
Fax:978.745.3476
SALES@PRESERVESERVICES.COM
LM
Rick Lobsitz
11 Forest Ave Date Bid:10/11/2011
Estimator:Sean O'Connor
Salem MA, 01970 Email:sean@prese"ese"ices.com
(978) 741-0148 Mobile:(978)395-7737
ROOFING ESTIMATE
COMMENTS Replace the garage roof and the soffit. If you do the project with the house roofing
project you can save $850.
PRIOR PREPARATION
PERMITTING: All permits will be obtained in accordance with the law as required.
DISPOSAL: A dumpster will be placed in an area designated by the homeowner.
ROOFING PREPARATION
COVERING: Tarp the exterior of the house so as not to damage the siding.
SHINGLE REMOVAL: Remove all layer(s)of old shingles.
NAILING: Re-nail roof decking as necessary.
CARPENTRY*
Replace the soffit with flat pvc of the same size.
UNDERLAYMENT
FELT: Install 15 lb felt on all areas not covered by ice and water shield.
ICE AND WATER SHIELD: Install 3 feet of ice and water shield on eves and valleys. Install as
necessary on other areas.
FLASHING
DRIP EDGE: Install drip edge on all perimeters.
ROOFING MATERIALS
ASPHALT SHINGLES: Install architectural shingles.
z
PRICING
Basic $ 7990
Sales Tax $ 0
Total Price $ 7990 including Labor& Material
Payment Terms: 20%deposit (day of start); 30%progress; 50% end of job McNisa/
` "�y J�J�✓hJ(N`
Sean OX nnor Customer Signature
ADDITIONAL T ABO E TIMATE:
BID 1: Install p o d n t of a stucco; install tyveck; flashing above doors and windows; install
rebutted red ce s I tc m ch the house.
Price $ 350 In u ' g Labor and Material
BID 2: Install mo ng around 9 windows (allowance of$100 each)
Price $ 900 Including Labor and Material
Installation Note:
If you have an older home that has dimensional lumber for roof decking you will need to cover your
attic because shingle debris may fall into the attic and create a mess.
*Above additional prices includes all discounts and coupons discussed prior to estimate. The
above quote is valid for 60 days.
*Warranty: Craftsmanship: Kyron Inc. DBA Preserve Services warrantees all work performed
for a period of 2 years. If any problems occur we will cover the cost of labor and materials. For the
warranty to be valid the invoice that was presented at the time of completion must have been paid in full.
Materials: The duration of the manufacture's warranty is specified in the materials section above.
Licenses:
Home Improvement Contractor(HIC): 123553
Protection: It is required by law that roofing contractors have a home improvement contractor
license. If a contractor is properly registered, you are entitled to limited protection by the
Residential Contractor Guaranty Fund up to $10,000. (The above is a only a summary of
Massachusetts General Law 142A) To check our license or our competitors go to:
http://db.state.ma.us/homeimprovement/licenseelist.asp and license 123553.
Constructor Supervisor(CS): 93403
The construction Supervisors license is under an individual's name, not a company name. To
check Sean O'Connor, owner of the Kyron Inc. DBA Preserve, license go to:
http://db.state.ma.us/dl)s/licenseelist.asp select Construction Supervisor and license 93403.
Insurance:
Worker's Compensation:
Our policy is under Kyron Inc. DBA Preserve Services
Protection: Covers the injury of a worker employed by the contractor doing work at your home.
To check our policy or our completions go to http://mass. ove /dia/ on this page go to"check
worker's compensation proof of coverage"our license is under Kyron Inc.
Liability Insurance
Our policy is under Kyron Inc. DBA Preserve Services and has limit of$1,000,000.
Protection: Covers your property in the event of accidental damage up to a dollar limit specified
on the policy. To check our policy we will have to contact our insurance company.
tnt uq Puhh.5;citt?""'< I
,cit.—iizttiuim' , tntl5tmc::n'd�
Swfdin= t-cr L,cUr�
� Board of ti;3n asA ,.
OS 93403.
OD
Re11 Iv
�9ilcte-
3EAI f OCONNOR
26
SALEMSmA 01970
EzPrratlon. i2f 20» .
�--- �� M1IrS��lt 5\nC �a On
� Office 0 onSOVFM N-f C` GTOR
HOME IMPROVEMENT CONTRA Type;
Registration 123553 pgA
MN- ExPiration 31612013
-
Preserve' -"'-
ConnOf 9
Sean O
203 WASHINGTON S7 Undersecretary
SALEM,MA-01970
t
DATE
Av d CERTIFICATE OF LIABILITY INSURANCE 8/15/2�0 in
THtt::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, MEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE%1 CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
RBRE'SENTATNE OR PRODUCER,AND THE CERTIFICATE HOLDER :p
IMPORTANT: 9 the aN71flcate holder Is an ADDITIONAL INSURED,the po0ay(les)must he endorsed. N SUBROGATION IS.WANED,aub)eet to
- the term and aNNBBons of the policy,certain po8elea may rsaWm anembreement. A statamerd on this certificate does not corder rights fo Um
so Iffirals holder in lieu of such s
PRODUCER CONTACT Boynton. TTMg cs
HOyatOII InButanCA AgenCy PIIWm ' (781)449-6786 PAX N,.(7ei)eas-aria
72 River Park Street aLLaIL .
1 " � 0004109
Needham M 02494 INSUREF481 AFFORDING COVERAGE RAICS
am amuaeew34aTcSpelcmaity
Kyron Inc. INeeRsee:Bamford Insurance
- DBA Preserve Services - INseRe(C-
203 Washington Street,S256 INSURER o,
Salem,NA 01970 INSURER E:
COVERAGES CERTV:=&'fE NUM TER-14-18 Union at. condo 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
DEDICATED. NOTWTHSrANDING 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.
E)(CLUSIONS AND CONDITIONS OF SUCH POLICIES UNITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAMS.
TN TYPEOFamURwNCE POLICYNuIelElt POLICY OFF POLICY eIw UNITS
aBlvutuAenJTr EACH OCCURRENCE S 1,000,000
Z Ca1N�11LL GENERAL UASILRY RBALSES� i 50,000
' A CCAeS.MAOE Q OCCIRt 13100002122 5/23/2011 /23/2012 MG)EXP(AP Dort ) f 5,000
PERSONAL 6 AOV DWRY s 1,000,000
GENERAL AGGREGATE S 2,000,000
GENIAGGREGATE UNIT APPLES PER: PRODUCTS AGG S 2,000,000
= POLICY PJECO-RT LOG f
AUTOMOBILE UNNUTY COMBINED SINGLE LIMIT E
(EA acciXIa)
ANY AUTO � BOONYINJURY(Parp j s
ALL OYAgD AUTOS BODILY INJURY(Pe OCWwl) s
SCHEDULED AUTOS PROPERTY DAMAGE
f
HIRED AUiDS fPm�Gara)
NON 31ANED AUTOS _ s
s
1 UNBRBAA LY1e
OCCUR EACH OCCURRENCE S
"Case L111a -MADE AGGREGATE s
p®janam E
fffi'I XTION $ s
is W —OwL ;&rL 11t E VIC STATD- OTH-
AND B�lOY9m'L111BBIR'
�CERM .. p(gUpm•) a NIA EL EACH ACCIDEM s 100,000
p�uy�nd,mONunriMe NMI
60080523N00910 /20/2011 /s0/2012 EL 01SEI15E-FA EMPLO a ].00 000
OESCRP m0FOPHtAT10N5 sebs EL DISEASE POLICY LIMB 13 500,000
OFG9NNONBILGATlONSIVEWA:t"(AR ACORD1N,AQdO�rYmelR60.01.P.tr N yewbnRM.J
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE. EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
N ACCORDANCE WITH THE POLICY PROVISIONS.
AUTHORED REPRESHITATIVE �2
Michael Nasrill/NRM
ACORD 28(20011 - O 1988-2009 ACORD CORPORATION. All rights reserved.
MM026t eJ The ACORE name and logo are registered marks of ACORD