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50 FREEDOM HOLW - BUILDING INSPECTION (8) file Commonwealth of Massachusetts CITY Board of Building Regulations and Standards OF SALEM Massachusetts State Building Code, 780 C'MR, 71h edition Revised Jananrw Building Permit Application To Construct, Repair, Renovate Or Demolish a l• 1008 One-or Ttcu-F '! IV Dt•elling This Section Fr 51 cial Use Onl �il J Building Permit Number: to Applied: I, YI/✓{ Signature: Building Co mis ion t Inks$ Date SECT N 1:SITE INFORMATION Lt Property Add�jess: r n�n 1.2 Assessors Map& Parcel Number 07 I.I 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 11) Frontage(it) 1.5 Building Setback$(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provide) 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑ Publ' Private❑ Check if yes13 SECTIXON/ 2: PROPERTY OW ERSHIPI [ w err of Rec kb)c0 .t'l���, �Nume(Print) Address for Service: signature 'telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs($) ❑ AlI I :I on(s) ❑ Addition ❑ Demolition O Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of ProposedWork': Q 2 rrGed SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item (Labor and Materials I. Building S I. Building Permit Fee: S Indicate now Ice is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S 4. Mechanical (IIVAC) S List: 5. Mechanical (Fire $ Total All Fees:S Su ression Check No._Check Amount: Cash Amount:_ v/ 6.Total Project Cost: S - 200 ❑Paid in Full ❑Outstanding Balance Due: et 017(2l �''+'t SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) /© f!s� 1 22 2A (2 _ D2 1- I S 7� �-(/ I.igcnse Number Expiration Date 'Nalneof 'SLI I IoWcr _ n I.ist CSL I')pe UCe below) �® : ddress� G `L fN Description C Il 1!nrestrictcJ(up to 35.000 Cu.Ft. R Restricted 1&2 Family Dwelling Signature M Masonry Only R(-' Residential RoutingC'oserin I c1cph6' WS Residential Window and Siding SF I Residential Solid Fuel Burning Appliance Installation 1) 1 Residential Demolition 5.2 R16red Home ImprovemeP4Contractor(HIC) 6 1 I IC'Cump• Name or t IIC Registrar ran Registration Number 40 aty ;aQ AI -A � 3 / 1/2o f2.Address u Expiration Date Signature Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 151.1 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...4.......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. C� Signature of Owner Date SECTION �7�/b::,O,�W�NERt OR AUTHORIZED AGENT DECLARATION S ��"" (�(/ ,as Owner or Authorized Agent hereby declare that the statements and information-on/the foregoing application are true and accurate,to the best of my knowledge and behalf. 0 %S /r/�� uoV Pont Name Signature of Owner or Aul prize Agent Date®3 (Signed under the pains and •n Ides ofperjury) 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 no have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS, respectively. ?. When substantial work is planned,provide the information below: Total tloors area(Sy. Ft.) (including garage, finished basemenNatties,decks or porch) Gross living area(Sq. Ft.) Ilabitable 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 (inclosed Open 3. "Total Project Square Footage"may he substituted For"Total Project Cost" 40 Higgins Rd JD Flat Roof, Inc Framingham, MA Tel. 617 299 0291 MA CSL # 101150, MA HIC #164691 Home Improvement CONTRACT Date of contract: March 14, 2011 Signed in city of Salem, MA. Jurisdiction: Salem, MA. Signed between the following parties: Contractor: ID Flat Roof, Inc, Address_40 Higgins Road, Framingham, MA 017014310_ Certificate of Liability Insurance: WS085951, dtd: 03/01/2011, exp. 03/01/2012, Insurance company: Northland Insurance Comp Customer: Name_Tatiana Klimovitsky Address_50 Freedom Hollow Drive, 307 I MA 01970 Jobsite address: 50 Freedom Hollow Drive, apt. 307, Salem MA 01970 Job description: Demolition: Removal and disposal of all existing appliances, bathroom fixtures, cabinetry, carpets, kitchen walls(to be removed), door hardware, HVAC grills, bathroom fans, switches/outlets etc. Bathrooms: 2 wall-mounted vanities 1 48"X36" shower cabin-glass doors 1 60"x29.5"tab-folding glass door(42") 1 vanity mirror 1 medicine cabinet with built-in light 1 wall-mounted cabinet with built-in lights and outlets (15"X70"X6") 1 washer/1 dryer(change location of vent and outlets) 1 curtain rod next to washer/dryer 4 shelves next to washer/dryer 2 sets of bathroom accessories - - Flooring Engineered hard wood, glue installation (cork first). 934 sq. ft. Tiling: 2 bathrooms: 1st bath - 63 sq.ft. floor/152 sq.ft. walls 2nd bath -40sq.ft. floor/137 sq.ft. walls Kitchen tile: Floor 174 sq.ft back-splash 38 sq. ft. (glass tile) 40 sq ft rough tile installation under the cabinets Blocking installation under the isle in the kitchen Move the back wall in the kitchen's closet closer to the air duct Ceiling: Plaster, high quality Painting through whole unit. Required prior repair due to existing conditions. jl G ID Flat Roof Inc HigginsRd f Fraa Mmingham, MA Tel. 617 299 0291 MA CSL # 101150, MA HIC #164691 Painting of existing doors(6) Painting of windows frames/silts(5) Painting of balcony door frame Installation of new door hardware(entry door, room doors and closet doors) All painting of existing doors/windows/frames/Jambs required prior repair due to existing condition. Finish carpentry: Installation of Ikea kitchen (moldings/spacers/side panels/lighting included) Installation of 2 heavy mirrors shelving (living room, bathroom, small bedroom) Installation of curtains rods/shades/etc Installation of closets shelving (3 basic closets + 1 walk-in closet). All from Container Store (Elfa) Installation of heavy furniture Installation of new door hardware (1 entry door, 6 room doors, 3 closet doors, 1 balcony door) Installation of new HVAC grills(6) Moldings: Rope lighting crown molding (master bedroom) Baseboard through whole unit Appliances: Oven Speed oven Refrigerator 48" with water dispenser Dishwasher Induction cook top Island hood (new location, required elbow and flex vent extension above the ceiling) Materials to be provided by the contractor include: sheetrock,joint compound, durock, the cement, plywood, paint, glue, primer, caulking, nails, screws, central heat grills. Special Instructions a Total Sale Price: $ a tat Payment-Deposit(40%) $7,680.00 a 2"d Payment—At finish of all rough works (20%) $3,840.00 a 3rd Payment- At completion of installation of finishing materials (fine finish) (20%) $3,840.00 a 4tb Payment—At final completion, when all works are done, confirmed by inspectors and designer(20%) $3,840.00 ��'JJ�� r-moo / q,, �/ Customer Name : Tatiana Klimovitsky /�eLG lip ��(1� Date "/ 43 4t'/7 Customer Signature Contractor Name : ID Flat Roof Inc. ne /e Date /y, O > 10// Contractor Signature CITY OF S'kL&NI, L L-1SSACHUSETTS • BLILDLNG DEPARTIONT t 120 WASHLYGTON STREET, 3"FLOOR TEL (978) 74S-9595 FAX(978) 740-9M KIMBEFI GY DRWOLJL MAYOR I�io.�tAs ST.PiFt:tR DIREcroz OF PL'HLlc PROPERTY/13UMLNG COMMISSIONER 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 It 1.5 Debris,and the provisions of MGL 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: l= �- 2 D 15 2oke,Q (name of hauler) The debris will be disposed of in (name of facility) (address of facility) signature of par tt applicant datC debnvif JAM: CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT .I�I I::K:I Y:)Kls(:t a 1. \1\)oll 12C\ ASHI.M;ION SIX ELI' • SAt b.N,M-WSAC I ItICI.I I\0197.^ 1'1%1.:978.715-9595 r P.tx.978.74C-9S46 Workers' Compensation Insurunce affidavit: Builders/Contracturs/Electricians/Plumbers \DDlicant Information Please Print LeeiblY V it lTle tllucluassl(OrgmirarioNlnJlvuluup: � � 1 �'^" ` ���'^ Address: City,Starci7.ip: P>XM 1'hune ll:� �i � 45 LS -3 \re you an employer! Check the appropriate box: Typo of project(required): 4. ❑ an a.cncra I l contractor and 1 I.❑ I :tin a employer with_ 6. ❑ New construction cm to ecs(full and/ur urt-time).• have hired the sub-contractors y, P Y P 7. ❑ Remodeling �.Lf I :mr a sole proprietor or panne[- listed on the attached sheet. ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition No workers'cum insurance 5. ❑ We are a corporation and its I P• 10.❑ Electrical repairs or additions required.] officers have exercised their 3.❑ 1 an,a homeowner doing all work right of exemption per NIGL I I.❑ Plumbing repairs or additions myself.tNo workers'comp. c. 152,q 1(4),and we have no 12.❑ Roofrepairs insurance required.] t employees. LNo workers' 13.❑ Other comp. insurance required.] -:guy;yphcaul d at checks box OI must:IIsa Jill WI Iha fiction 6dow,howlna Itself wockusY cumpcnsluiou policy infurtnaliun ' I lomcuwram whu submit this aPodavil indicating the)are doing all work and Ihen him outside cottraeton must suhmil a new alridavil indicatatinu.och. d'omrxarn That chuck this box most attached.m addilioaal ahem showing the name of the sub:ontractoa and their wurken'comp.policy information. /am tin roplu3•er that Lv pruvfd/nx,vurkers'c•uarprn.vntinn iusurnnc¢jar aty employees. Below is the policy and Job vile lmjurvnrctiun. Insurancc Company Name; llulicy a or Self-ins. Lic.ti: (JS©O� 's 3,57 _ ... .__ Expiration Date: Job Site Addn:ss: 50� ��--B�h t^( x.d^n' 7 City;Slate/'Lip: r 'µ zor-q7o. Attach it copy of llte workers'compensation policy declaralion page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of.vIGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51.5w.00 and/or une-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up m,5250.00 a day against the violator. He advised that a copy of this slatcmcnt may be turwarded to the Office of III\"inthal1011f ul the DIA for insurance coverage (critic.uiun. l /a hereby certify under the pain'and petraltiev ujperjary that the injurmulion provided above is true end correcr. Cis•:cnitre " Dan;' FFfjse ly. Do not Ivrite in this area,to be completed by city ur town o/ficia/.: Permit/License 0._rily (circle nuc): c:dth 2. Building Dcliarnucot 3.Cii.w Total Clerk 4. Electrical Inspector 5. Plumbing Inspector .__. Contucl Vvrnou: __ _ Phone:Y: Information and Instructions Massachusetts;Gcneral Laws chapter 152 requires all employers to provide workers' compensation tot their a nployeel. Pursuant to this statute, an emplgree is defined as"...every person in the service of another under any contract of hire, cypress or implied, oral or written." - An employer is defined as"an individual, partnership,association,corporation or tither legal endry,or any two or more of the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the receiver or trustee of.us Individual,patmership,association or odor 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." NIGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or renewal of It 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 nuniber(s)along with their certificale(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 sigh and date the affidavit. The affidavit should he rcummed 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 Official 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 penniulicerse applications in any given year,need only submit one affidavit indicating current policy information(if necessary) :old 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 dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. I he 0i f Ice tit Investigations would Rice to thank you in advance for your cooperation and should you have any questions, please du not hesitate to give us a call. The D.partmcnt's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Ofitee of Investigations 600 Washington Street Boston, MA 02111 Tel. N 617-7274900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 Itcci.cd 5-16415 www.mass.gov/dia ` YLtssachusctts- Dcpartmcnl of Public Safctj 1 Board of Buildin!L Re!Lulations and Standards Construction Supervisor License License: CS 101150 Restricted to: 00 DENIS TCHERNOV 22 POTOMAC ST 02132 WEST ROXBURY. MA Expiration: ty22/2012 Tr#: 101150 P� �I�e YLJO?ivi:a>tu/P,[2[t� 0�✓67.Oddac�tl{{�� a �\ Office of Consumer Affairs&Bus n¢ss RegulNd�..,, I, ROMEIMPROVEMENT CONTRACTOR Reglatretlonl 1P5546- Explrill&ri, �3/1/2012 Tr# 2936& Type,"_' t?nve Corrojgtion ID FLAT ROOF INC:;1� DENIS TCHERNC}�� 22 POTOMAC STI I WESTROXBURY, MA02132'' Undersecretary