0018 GLENDALE STREET - BPA B-16-1205 -11
The Commonwealth of Massachusetts CITY OF
2 Board of Building Regulations and Standards LEhI
/ Massachusetts State Building Code, 780 CMa916 00 18 A 3$'
Revised,liar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
N This Section For.OfTicial Use Onl
Building Permit Number: Ddle
Date lied: I ZJ.� 1 'A^ U 6
Building OlTiciul(Print Name) . Signatlue
SECTION 1:SITE INFORMATION'
1.1 Property Address: 1.2 Assessors blop& Parcel Numbers
I t3 6 LFs t>N%—f^ (2b h
I.la Is this an acce ted street?yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(IT)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P P y
SECTION 2: PROPERTY OWNERSHIP!'
2.1 Owner'of Record:
v QtiPa�1 xyl\ MA O1G'�c7
slime(Print) City,State,ZIP
10 9-%-4Lk uyp-v ANQC+or�oPcs+•t.�
No.and Sleet Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: QF• QAC4
Brief Description of Proposed Work': M2CQAJ�� Qzj QAGw
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Offi iulUseOnly
Labor and Materials)
1. Building g 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical ❑Total Project Cose(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4.\lechanical (HVAC) S List:
5. Mechanical (Fire S Coral All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 8` 00 ❑Paid in Full ❑Outstanding Balance Due:
V . � , NOT PIctLs7p vP_
SECTION 5: CONSTRUCTION SERVICES
5.1 Construetima Supervisor License(CSL) Cs. �p�L.« IZhj( ,1�
, is I
Lr,� Ct4C - License Number Expiration Date
Nmnc of CSL Holder list CSL Type(see below) y
TYPe Description
No.imd Street
U Unrestricted Buildin s up to 35,000 cu. Il.
R Restricted 1&2F:unity Dwelling
city/Town,State,ZIP M Imasonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) Urb fo
Registration Number Expiration Date
HIC Cunnp:my Name qr HIC Registrant Name
No.and Street Email address
SPvt.Ja#-\ trWc Ey g—Nc
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.ISL$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 Ishuance of the building permit.
Signed Affidavit Attached? Yes ..........C3 No...........❑
SECTION 7u:OWNER AUTHORIZATION TO BE COMPLETED WHEN.'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
I,as Owner of the subject property,hereby authorize �iE >• � �
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
A(0
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.
Print Owner's or Authorized Agent's Name(elcctranlc Signature) Date
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 not have access to the arbitration
program or guaranty fund under b1.G.L.c. I42A.Other important information on the HIC Program can be found at
www nru,eov:oca information on the Construction Supervisor License can be found at www.mas�
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
type of heating system Number of decks/porches
rypeofcoolingsystem Enclosed Open
3. "Total Project Square Footage"may be substituted for"rot:d Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Name: fC
Address: -3C Of 21—�
City/State/Zip:S4l d\ V'-N- 011I': 1fl Phone#: lq��
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with 45 employees(full and/ 5. ❑Retail
or part-time).* 6. ❑RestaurantBar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7, ❑Office and/or Sales(incl.real estate, auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.❑Manufacturing
no employees. [No workers' comp. insurance required]** 11 ❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers' comp.insurance req.] 1213 Other
*Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: T@f -5 11Jo -
Insurer's Address: �6�6V����
City/State/Zip: J
Policy#or Self-ins.Lic.# I V 2�J N�`9]Z Expiration Date: 5/?so�11=
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$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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify, er the pains and penalties ofperjury that the information provided above is true and correct
Si nature: Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 your insurance company's name,address and phone number along with a certificate 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 the number listed below. Self-insured companies should enter their self-insurance license number on the
appropriate line. y
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 permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). 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
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
www.mass.gov/dia
Form Revised 02-23-15
C IYOFSALES MASSAOISEn
BUZAMD AADANr
uo W.roma�vS7a�r,3DA�
]1;t. 745-9995.
$t7�ERil1Y J 7449516
MAYOR 7 MASISUMM
DotcFrzasar /atnzMacaaa akU
Construction Debris Disposa/Affidavit
(required forall demolition andrenovation work)
In accordance with the shah edition of the State BuMng Code, 780CIW& Sectim 111.5 oe d&
and the provisions of MGL coo,S 54, BWiding Permit sy is issued wkh the
condition that the debris resulting from this work shall be disposed of Ina properly Ikensed
waste deposit facility as defined by MGL c 111,S 15k
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of fadlity)
(address of facility)
Sign ure of applicant
Date
- 203 WASHINGTON ST.#256
PRESERVE SALEM,MA 01970
SERVICES carpentryIpaintingIroofingIguttets PHONE:978.745.9745
fAx:978.745.3476
HI SALES@PRESERV ESERVICES.CO M
Gerry Ryan
Date Bid:9/23/2016
18 Glendale Rd Estimator:Victor Calumby
Salem,MA 01970 Mobile:(978)594-3590
(978) 744-8258 Email:victor@ preserveservices.com
gerryanna,comcast.net
ROOFING ESTIMATE
COMMENTS
Strip and re-roof main house and rubber roof over right side porch
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.
OTHER: *2layers*
CARPENTRY*
Replace 6' of crownmolding
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 8 inch drip edge on all perimeters.
WALL JUNCTION: Remove the siding, ice and water shield the junction, reflash with step flashing.
VENT PIPES: Install new boot or flange around vent pipes.
CHIMNEY(S): Install new flashing around all chimney(s).
OTHER: *Remove siding on rear wall only
VENTILATION
RIDGE VENT: Install ridge vents.
ROOFING MATERIALS
ASPHALT SHINGLES: Architectural Limited Lifetime shingles either: GAF Timberline HD or
Certainteed Landmark
PRICING
Basic $8,760
Sales Tax
Total Price $8,760 Including Labor and Materials*
Payment Terms: 20%deposit(day of start); 30%progress; 50%end of job McNisa/Amex
fl"
Victor Calumby Customer Signature
Important 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. Acts of god are excluded in the warranty
such as but not limited to ice dams,tornados,and hurricanes.
Licenses:
Home Improvement Contractor Preserve(HIC): 123553
Construction Supervisor Sean O'Connor(CS): 93403
EPA Renovation,Repair and Painting(RRP) Nat-21650-0
Insurances:
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 competitions go to http://mass.gov/dia/ on this page go to"check worker's
compensation proof of coverage"our license is under Kyron zip code 01970.
Liability Insurance
Our policy is under Kyron Inc.DBA Preserve Services and has limit of$4,000,000.
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 provide a certificate from our insurance company.
Massachusetts Department of Public Satety
Board of Building Regulations and Standards
License: CS-093403
Construction Supervisor
m ,
SEAN OCONNOR
26 CHESTNUT ST a
SALEM MA 01970
Expiration:
Commissioner 12I3112017
i
Office off�c r�.oairnrmrrrrea�/� / �uJrir•�ruc/J1
Consumergffairs&Business Re OME IMPROVEMENT guiallon
e 123553
gistratlon; CONTRACTOR
xpiration: 3/6/2017 Type:
PreserveDBA
Painting
Sean O'Connor
203 WASHINGTON ST.#256
SALEM,MA 01970
Undersecretary ',,
203 WASHINGTON 5T.#256
PRESERVE 1970
carpenttylpaintinglroofingIgutters PHONE:978.745 8745
SERVICES FAx:978.795.Wb
SAtES@PRESERVESERVICES.COM
Ll
ToWh Who
m t May Concern,
'i'Sean O Connor give permission to Victor CaiuTnby to use my building licenses to pull building permits.
Sincerely Yours,
Sean O'Connor
lJ 4"-8 7-0F�.eE /31�' Tcz/zS 2 ti�
t•:otary public
SACHU8ERS