55 GALLOWS HILL RD - BUILDING INSPECTION (3) 322g � �ES � C 19g -7
o The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 1011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied: J Q 1 z—1 13
/l UNA:� /o)dl
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
S L:/42L D
L la Is this an accepted street9 yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
7/-ontAs C-Aingeolz i s'4-te; l M/J • Lr/9 yo
Name(Print) City,State,ZIP
5-S 6—ALLOW3 ,yi// 9` lcf— S41/- 768-3
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) Trl Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
BriefDescript ion of Proposed Work-2: 7-iVSTR44 /ulA/O/rwS ANC it/�iyL
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ a L7 OG d 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total AlkFees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1 ❑Paid it Eult ❑Outstanding Balance Due:
-.i
SECTION 5: CONSTRUCTION SERVICES
* 5.1. Construction Supervisor License(CSL)
�l� oFsKd3s D/ /y
t7�i,IZ.� JE/I/i9y�2` License Number Expi tion ate
Name of CSL Holder
�// List CSL Type(see below)
�� f/OL✓/i IQ� .S/No.and Street Type Description
U Umestricted(Buildings up to 35,000 cu.ft.
/at R Restricted 1&2 FamilyDwelling
City/Town,Slate,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�i SF Solid Fuel Burning Appliances
/P�4e'11A)eAe) [owv I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
AsCSE��9v/� �/ Co�vS /vC/ff7� rr i
y J HIC Registration Nwnber Expirati Daze
HIC Compa Name or HI Regstrant Name
M p n ow- -- Sz �i�/��GN@ IgUL• foal
No.and Street Email address
, �/Lmo Al 1&4 aigsa 9��-say/ao
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 ..........93"' No...........❑
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: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 this application is true and accurate to the best of my knowledge and understanding.
/14!e-il k—/�scz .X A2sE.✓olv/e- >G
'Print Owner's or Authorized Agent's Name(Electronic Signature) "Mu
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 he found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementtattics,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 &U.&NV4 iNLAISSACHUSEM
• BUI DLNG DEPARTMENT
V 120 WASHiNGTON STREET,3"FLOOR
�E TEL (978)745-9595
FAX(978)740-9846
KIJIBERI.BY DRISCOLL
11AYOR 1t1oMAs ST.P[ERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information i A Please Print Le llv
Name(BusithlsriOrgani:ation/Indiividual): 1"�SG6 41, (// L'G �
Address: as //V whir p --
City/State/Zip: SA t -i0-A1 /n,' Phone#:
Are you an employer?Cheek the appropriate box: Type of project(required):
1.L�J 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.Eli am a sole proprietor or partner- listed on the attached sheet t �• ❑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'comp, insurance S. ❑ we are a corporation and its
mquired.j officers have exercised their 10.❑Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 1 LEI Plumbing repairs or additions
myself.(No workers'comp. c, 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers' l3.❑Other
comp.insurance required.]
Any applicant that chccka has sl must also as out the section be Showing their watkm'txrmpenation policy infuonation
I Imrcawrtas who submit this affidavit indicating they are doing all work and then hire outside cvnitaetus twat submit a new affidavit irxlianing such.
;Contractors thin duck this box must attached an additional shot showing the name of the subcomrsctors and their workers•comp.policy infamtntioo,
l am an employer that h providing workers'coaWnsadon lnsnrancefor my employees, Below is the policy and fob site
information. /,
Insurance Company Name:. / ,J UQ
Z d Ve le J SAS `
Policy#urSelf ins Lic.#: Ca n -Q,�1�� 111/1alO -0 -/3 Expiration Date:
Job Site Address: 5JS "LtVW S 11111 d1/J 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
fine up to S 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 S250.00 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.
l do hereby certo under die pains anndd�penalties of perjury that the information ;'true provided above true and correct
Signature: .�e� /A Date, /U�•�///�
Phone#-
Dfr(cial use only. Do not write in this area,to he completed by city or town offtciaf
City or Town: PermidLiceme#
Issuing Authority(circle one):
1.Board of Health L Building Department 3.Cityifown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: —
Phone#:
i —
!
CITY OF SAI.&M XWSACHUSETTS
BuMDLNG DEPARTMENT
` N• 120 W/ASHINGTON STREET, r FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI.NtBERLEY DRISCOLL
jNJAYOR T HomAs ST.PI&RR&
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONSUSSIO.iER
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 MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposcd 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
(name of facility)
(address of facility)
AM
signature of permit applicant
dati
debdsairAx
11\Vl VIJAL
FROM:
ARSENAULT AND SONS CONTRACTING INC.
20 HOWARD ST. PAGE NO. OF PAGES
SO.HAMILTON MA. 01982 DATE'
978-828-1002
PROPOSAL SUBMITTED TO:
THOMAS&DONNA LAMBERT
55 GALLOWS HILL RD. JOB NAME:SAME
SALEM,MA. 01970 ADDRESS:
CfrYISTATEOP:
PHONE:978-5877083
We hereby submit specifications and estimate for.
1)REMOVE 10 EXISTING WINDOWS AND REPLACE WITH ANDERSON 400 SERIES TILT WASH FINISHED WHITE
INT/EXT.INCLUDES NEW INTERIOR TRIM
2)INSTALL 319 RIGID INSULATION FOAM BOARD
3)1NSTALL MASTIC CEDAR DISCOVERY VINYL SHINGLE PEBBLESTONE CLAY
4)COVER ALL FASCIAS RAKE AND MISC EXTERIOR TRIM WITH WHITE ALUMINUM AND VINYL SOFFITS
5)INSTALL 51/2 VINYL CORNERBOARDS
6)INSTALL NEW GUTTERS AND DOWNSPOUTS(WHITE GUTTERS,CLAY DOWNSPOUT PIPES)
We hereby propose to furnish labor and materials—complete in accordance with the above specifications,for the slue of TWENTY
THOUSAND Dollars($20,0oojwith payments to be made as follows:
IsT)$7000 UPON START 2 n$7000 JOB 1/2 COMPLETE 3n $6000 FINAL
All material is guaranteed to he as specified All work to be completed in a workmanlike manner according to standard practices.Any alteration or deviation from above
specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above the estimate.All agreements contingent upon
strikes,accident or delays beyond our control.This proposal subject to acceptance within 30 days and it is voi at the option of"Adersigned.
Authorized Signature �� (N`
ACCEPTANCE OF PROPOSAL
The above prices,specifications and conditions are hereby accepted You are authorized to do the work as specified Paym dt will wdefoulfiabove.
ACCEPTED:
Signature d�1F 7
DATE /( 6 Signature
-0 E-Z CONTRACTORS FORMS FORM NO.PROP 31
u
iffm Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor I & 2 Family e"
License: CSFA-088635 t
ROBERT K ARSENAUL '
20HOWARDST, 'A
S HANHLTON MA 01" -
Expiration
Commissioner 05/14/2014
i ia\ office of Consumer Affairs&BusmEss Regulation
G , ME IMPROVEMENT CONTRACTOR
gistration 144878 Type:p
kxpirahon 11l16/2014. Private Cor orator
rl
ARSENAULT AND SONS CONTRACTING INC.
�l
ROBERT ARSENAULT t
20 HOWARD ST
SOUTH HAMILTON, MA 01982'
Undersecretary
i