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24 GOODELL ST - BUILDING INSPECTION 4 /_ 'oa The Commonwealth of Massachusetts m '1, Board of Building Regulations and Standards CITY OF ` YV /.$ Massachusetts State Building Code, 780 CMR SALEM 5.C' Revised Mar 201/ 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 Applied: VDeBuilding Official(Print Name) Si nature SECTION 1: SITE INFORMATION I.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.la 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 Rt Frontage(fi) 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 Z.onO Municipal ❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.^11 Owner'of Record: r'_ �,�.sc-,.g..�.n.t _Sab92 9a.r,--4,i .S�Ysr*^� rr..c- G\5-46 Name(Print) City,Stale,ZIP a 1 Gr 1 ,,�SL sk '16k- ay S-N'ac, No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work: .ckr,\-) c� .o JX,. .,., c� �-' a G A sk 3 S-\ SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ U0(1 q/ 1. Building Permit Fee: $ fee is determined: 2. Electrical $ ❑ Standard City/fow pplica[ion Fee ❑Total Project C t3(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: / 4. Mechanical (FIVAC) $ List: Lt�/ 5. Mechanical (Fire $ Su ression Total All Fees: $ . Check No. Check Amount:__Cash Amount: 6. Total Project Cost: S ❑ Paid in Full ❑Outstanding Balance Due: Cpll-, r`b l � l-2y� , ► �2a 5t12 Fog F•v . SECTION 5: CONSTRUCTION SERVICES e 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) 3 9 & R Q No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) -\ \n 'o %,A Imo.--C- R Restricted 1&2 Family Dwelling City/town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation 'telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) �e r\ , r J\C�^-^ 5��`°�� HIC Registration Number Expiration Dale HIC Company Name or HIC istrant Name No.and Street Email address P.or r.c.� C\4 b Cit /Town, fate,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 ..........✓9 No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, as Owner of the subject property,hereby authorize a 3k s Cy� - to act on my behalf, matters relati a to work ant orized by this building permit application. Print Owners Name(Electronic Signaturm) Date SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information cont�ainedd in this appli tion is true and accurate to the best of my knowledge and understanding. iS'+Z % Print Owner's or Authorized Agent's Name(Electronic Signature) 'r— 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(FIIC) 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 be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 2. When substantial work.is planned,provide the information below: Total floor 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" Massachusetts - Department of Public Safety - Board of Building Regulations and Standards ( in ii uiiir 1u pi�n ,r a c y ...,. License: CS 104381 � ARTHUR R CARLjONE ' 3 PINEWOOD ROAD'y - PEABODY;MA M960 ' Expiration Commissioner 12/11/2015 Office of Consumer Affairs&Rusiuess Regina[on e� , Wejg1Ietratlp MEIMROVEMENTCONTRACTOR ' n 159367Type: piration 4/24/2016 DBA :I ACTION SIDEING ARTHUR CARBONE , ' .'. V ; 3 PINEWOOD RD. PEABODY, MA 01960 � �- Undersecretary - ° CITY OF &U-EM, tiIa-�SSACHUSETTS r BUILDING DEPARTME.\T 120 WASHLNGTON STREET, 3aa FLOOR TEL (978) 745-9595 FAA(978) 740-9846 KIMBERL.EY DRISCOLL VLAYOR THOAIAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLAISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information pPlease Print Le ihly N;IIne tourines,.Organizatiom'Indivi(luml): Address: '3 P,.e ,- )C v-IA (2 o City/State/Zip:p�QC&znc�4 rye Phone #: G 14-9,j5-*9&3`r Are you un employer!Check the appropriate box: Type of project(required): 1.21 am a employer with 1 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 mn a sole proprietor or partner- listed on the attached sheet.t Z ❑ Remodeling ,hip and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'camp. insurance. 9. ❑ pudding addition [No workers'comp. insurance 5. ❑ We are a corporation mid its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.[No workers' sump. C. 152,41(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' j3.❑ Other sump. insurance required.] •Any upplic:mt sat checks box#1 must also fill out the union below showiita their workcn'compensation pulicy intbrmation. '11,meowneo who submit this afllciivit indicating ihcy arc doing ail work and then hire ounida contmcion most suhmit anew affidavit indicating such. $],melon that chock this box must anach d an additiunal shoot showing the name of the sub-c'omncton and thelt workcn'camp.put icy information. No- 1 mu as enipluyer that is pruviding workers'compensation insurance for my employees. 8e1ow is the policy cord Jab rile infornnatian. Insurance Company Name: tl.to soy c, Policy 1l or Self-ins. Lic. 4: 1 Expiration Date: Job Site Address: -I GC*8 ,5-k City/State/Zip:, rJs, Y\,c., nAg-,46 Attach a copy of the worliers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ot'%IGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby certify gander Ill' pull's and penalties of periury that tine/nfOnnution provided above is true and correeL S' n I re• rY° Date. 5 phone 1' OJJicial use only. Do nor write in Ibis•area,to be completed by city ar town offiviuL City or Town: Issuing Authurily(circle one): 1. Board of Ifeallh 2. Buildim; Departulent 3.Cllyfruivn Clerk 4. Electrical laspector 5. Plumbing Inspector 6. Other Contact Person: __. __ Phone H: CITY OF S: zm, ;tiL15S:1CHUSETTS ©CILDL\G DEP.IRTMHNT ;•, .Y� 1 A CV.ISHLNGTON STUET, 3%0 FLOOR �. `` T EL (978) 745-9593 KIMBERLEY DRISCOLL F.Lv(978) 7404944 &UY0 t THo.%tAsST.PIEAR$ D(.7ECTOR OF PUBLIC PROPERTY/81:tLOLNG CON a((55IONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) 1n accordance with the sixth edition of the State Building Code, 730 CM section 111.5 Debris, and the provisions of tb[GL c 40, S 54; Building permit >*this work shall be is issued with the condition that the debris resulting from 111, S ISOA. disposed of in a properly licensed waste disposal facility as defined by ttv1GL c The debris will be transported by: y (name ut hauler The debris will be disposed ot'in (mmic oe f'acdity))) (1dUre5s or'racility) signature(Wperr'nit applicant Marc '-- GUIMARAES CONSTRUCTION 21 BALCOMB STREET SALEM MA 01970 FONE: 978-836-7279 To: Carleen Sobezenski QUOTE: 01 24 Goodell St DATE: Friday, May 1, 2014 t Salem MA 01970 p 781-249-1120 Quantity Description Amount A • Roof Scrape old roof Install 6 inch drip edge Install Ice water � w Install black paper number r,$t Install 30 year roof—shingles Repair facing board and sofit where needed. Remove old gutter to repair facing and put old gutter back "fir � sl`5... t x ry yy a X , d 1 y q, Total Price labor, permit,disposal and material. $9,000.00 Three days cancellation, under MGL c 93§48, MGL c 140D§ 10 or MGL c 255D §14. All work is warranted under MGL c. 142A All permits shall be the obligation of the contractor. The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerning this contract,the contractor may submit such dispute to a private arbitration services which has been approved by the office of Con- sumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided in MGL c 142A. Quotation,prepared by: Rodrigo Guimaraes GUIMARAES Si nature of Rodrigo: CONSTRUCTION 21 BALCOMB STREET Down payment due at signing for material purchase:$4,000.00 SALEM MA 01970 FONE: 978-836-7279 2nd payment due in 30 days after amount of: 5 0.00 To accept this quotation, sign here and return: Complete Name of person signing this quote: Dater (Y /