20 GOODELL ST - BUILDING INSPECTION The Commonwealth of Massachusetts
i Board of Building Regulations and Standards L
Massachusetts State Building Code, 780 CMR, 71h edition
1.
W Building Permit Application To Construct. Repair, Renovate Or Demolish aOne- ur Tuo-Fami(v Duelling
This Section Foy Official Use Only
�1 Building Permit N r. n ,,Datf Applied:
Signature: - I ^`�� �`la G��
5� Building Commission Inspector of Buildings Date'
SECTION 1: SITE INFORMATION
1.1 Property Addreesss� 1.2 Assessors Map & Parcel Numbers
—7 C.-7t.st�sda lA S�
L la Is this an accepted street?yes 6 no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Loi Area tsq fft Frontage tfU
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:
Zone: _ Outside Flood Zone? Munici al ❑ On site disposal system ❑
Public ❑ Private❑ Check if es❑ P �' y'
SECTION 2: PROPERTY OWNERSHIP'
2. Owner of Record:
k j
Qrg - ri hoaJCrS —7aO-o GOQll
Name(Print) Address for Service:
Signatere Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) A I Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
n
/ Od
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ L Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees: $
Su ression)
Check No. Check Amount. Cash Amount
6. Total Project Cost: 0 Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Narnc ol'CSL- Holder
List CSL Type(see below)
Type Description
Address _ U Unrestricted(up to 35.000 Cu. Ft.)
R . Restricted 1&2 Family Dwellin
Signature M Masonry Only
RC Residential Roofing Coverin
Telephone \VS Residential Window and Sidra
SF Residential Solid Fuel Bwnin g A iliance Inotallauon
D Residential Drnwliuun
5.2 � �Registered Home Home Improvement Contractor(HIC) �-7-7 O —7
-
HIC Cum pan Name oW�-IlC Re isuanI Name Registration Number
e n w +ed r z 6 Vim- b 66
Address yp'/ � Z/�/ Ex
9`O '7 (9 'd 7.3 / Expiration Dale
Signature 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 ..........RL 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, L u Gq_5 / oc/q , as Owner or Authorized Agent hereby declare
that the statements and infor ation on t foregoing application are true and accurate, to the best of my knowledge and
behalf. 44 r
F/7
Print Name
( aF?
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 Horne 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115. respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics. 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 SALEM
PUBLIC PROPRERTY
DEPARTMENT
v�nlr.Rl.l-� nRlsc�n t.
VA OK 120\V.ViHING'IONS-I RhET • SAI.I`\I, M,VSSACI.11'SI''I"1'Y 3197C
Tr.l.: 978-745-9595 ♦ FAX: 978-74C-9846
Workers' Compensation Insurance .affidavit: Builders/Contractors/Electricians/Plumbers
ALpitificant Information Please Print Le ibi
Name (Businassr Organiz:niom'Individu:d): __1LnMD1a4A ��fts4nKA[z?A
Address: p Qox I�6�
City/State/Zip: L t444,z4yA r AAA- 01"/6ev Phone #: 9-Y' `le6
kre you an employer?Check the appropriate box: 'rype of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees(full and/or art-time).' have hired the sub-contractors
P 7. ❑ Remodeling
2.®-,I ❑m a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers' con insurance 5. ❑ We are a corporation and its
i P officers have exercised their I0.❑ Electrical repairs or additions
required.]
3.❑ I am a homeowner doing all work g exemption
right of per MGL 11.0 Plumbing repairs or additions
P
myself [No workers' comp. C. 152, §1(4), and we have no 12.kl Roof repairs -
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
'Any applicant that checks box#1 must also till out the section below showing their workers'compensation policy information.
t Ilomcowners 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 their workers'comp.policy information.
/atn tut employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. pp �
Insurance Company Name: L/{tn la-Sd Tt'f.Sormw-- P' L4
Policy #or Self-ins.
��Li��a #:WY0110 ��-Lz(;z 6 1 Expiration Date:
Zo Job Site Address: 61_l Jdt <4_ City/State/Zip:SQ eA
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 NIGL c. 152 can lead to the imposition of criminal penalties of a
tine 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
6 Investigations of the DIA for insurance coverage verification.
/do hereby curt y�t nder the pains and penalties of perjury that the information provided above is true and correct
Date 3 '3I'og
Phone
official use only. Do not write in this area, to he completed by city or town official
City or Town: Permit/License #
Issuing Authority (circle one):
I. Board of Health 2. Building Department 3.Cityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: Phone #:
Information and Instructions
\lassachuse(is General Laws chapter 152 requires all employers to provide workers' compensation for their employees: —�
I'm suant to this statute, an employee is defined as"...every person in the son ice of another under any contract of hire,
express or implied. oral or written."
An engrlOrer is defined as"an individual, partnership, association, corporation or other legal entity, or any two or more
of the t regoing 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 riot 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 till 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 their certificate(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 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.
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 till 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) 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 tilled out each
your. 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 burn leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and tax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
-� r1 DEPARTtiIENT
\1..�, K - l_'C W.%J 11\�,:J�5:3cET0 SAL: M. Sf.\;i.0 :.1 ,1
Cr1:97&.'ii-')i95 0 l kX:WA-74G9846
'on Debris Disposal o sal Affidavit p
(required for all demolition and renovation work)
State Building Code, '30 CbtR section 111.5
In accordance with the sixth edition ofthe S g �
Debris, and the provisions ofMGL c 40, S 54;
Building Permit # _ is issued with the condition that the debris resulting from
' 't as defined b v1GL c
disposal
salfacth
dus work shall be disposed of m a properly licensed waste p Y Y
l 11. S 150A.
The debris will be transported by:
- -F r D J-
gill
Ina ne othaular)
I'he debris will be disposed of in
Wanr of lacliay�
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URivSh (try. ry St1Gy Irk HOLDER. THIS Tl CONFERS
�TE DOES !ROM �JW6ND.CERTIFICATE
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Suite
ALTER THE COVERAGE AFFORDED BY T14E POLICIES GMOW.
Suite 2
Worowter, MA 01604 INSURERS AFFOROMO COVERAGE NAEC Y
Thompwn Coon5buSm I wAw x SSEX INSURANCE CO
15 Box 1 r Sheet I G Rp t�TE STA C FF IP 238
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t.illelon.MA 01460 arc
COVERAGES
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ANY REDUMEMETAT' TEM OR MMITM OF ANY CONTRACT!OR OTHM OOCLOMIf WITH RAT TO WHICH THIS CERTIFICATE NAY BE ISSUED OR
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ACOfW 25 t spB) V ACORD CORPORATION 1BSS
2008-03-06 15:13 15087529303 cameo i
.�/R �c�Nni.er<.eafG nj ��tjnsrz�'1i.wa ma's 4.
Board of Bdilding Regnlntioas and Standards
= ? HOME IMPROVEMENT CONTRACTOR
Registration: 157707,_
. ` Expira£tom.1013112009 Tr# 260905
Type: .Partnership
'HOMPSON CONSTRUCTION
LUCAS ROCHA -
15 JENNIFER ST.
LITTLETON.MA 01460 Administrator
t" (a�LNt7lCJt1101z111�I11 InS a o if
77
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Office 978 4W-0454 Cell 978 490-8142 Address P.O. Box 1465
866 452-7444 Fax 978 486-0458 Littleton, MA 01460
Price Quote Brea down
DATE 3/18/2008 Terms 30 Days
PREPARED BY Dan Lathrop CONTACT Kara Showers LOCATION 20 Goodell St
ESTIMATE# 31811ala Salem,MA 01970
Salesman Dan Lathrop PHONE 617-767-9332 MAILING same
SUBJECT Strip and reroof CELL ADDRESS
Main House FAX
Desch Lion oT Work City Jul M Cost
Removal and disposal of old roofing materials (a8 -
layers)down to wood.thorough inspection of roofirm
loose - -
surface.Tighten up all loe boards. 21- SO 1 $1,531.24
Undertayments,Decking and Edge Metals
Installation of WinterGuard premium waterproofing
undedayment.6 feel at eaves and 3 feet at rakes.All
valleys and low slope roofs covered completely. 8 RL $696M
Installation of Roofers Select undedayment felt (all
areas not covered by Winlwguard). 2 RL $128.63
Installation of drip edge on all rakes and eaves
(white,brown,or mill finish). 33 PC $319-85
Shingles
Installation of starter shingles. 4 BDL $138-09
Hand installation of Certainteed Landmark 30 years
architectural shingles. No nail gums used to ensure -
quality. 21 SO $3,589.85
Installation of cap shingles. 5 BDL $282.31
ventilatlon
Installation of Air Vent ridge vent, end to and, on
ridge. 10 PC $173.12
Other Roofing Accessories
Step Flashing(all wall junctions) 2 PK $162.74
4-Roof Boot 2 EA $51.93
Re-flash,and re4ead chimney 1 EA $281.39
Total Cost 1 $7,365
"Gutters cleaned free of charge. Tarps installed five of charge if contract is signed.
"All loose boards tightened free of charge.
-10 Years Labor Warrantee.
100%clean-up when work is complete.
Any damage incurred during roof installation repaired/replaced at an equal or greater value. ,
-80 Linier foot of boards replaced free of charge If necessary. 1f more is needed the cost is$5.00 per tinier foot installed.
-Three pieces of plywood free. Additional plywood installed$55 per sheet.
Payment 1/3 down, 113 due upon start of work,final 1/3 due upon completion and customer satisfaction in compliance with this
contract. Start dates a a or permissible.
' Start Date
e i aturefro Date
Thom strucjjfin an 9 Color
3 Choice
Omer Signature - D
ustomer Name Print