31 GROVE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM dMar
Revised Mar 2011
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 App
Building Official(Print Name) Signatur Date
SECTION 1:SITE INFORTJ ION
1 iro�etty���: 1.2 Assessors Map&Parcel Numbers
57 -
I.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: _ 1.4 Property Dimensions:
Propose Zoning District d Use Lot Area(sq ft) Frontage(ft)
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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recot :
C.='1"yi=o SAL<2M C2 19 70
Name(Pritfty City,State,ZIP n
lao WA5HZM1'oA✓ 9786/ 96-r, WHyq5,k0-440-g4GeM CC*1
No.and Street Telephone Email Addres
SECTION 3:DESCRIPTION OF PROPOSED WOR]e(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Descri lion of Proposed Work: (5 M Q & d 5
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
Z. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x inultiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 9 �QQd 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License,(CSL) CSFA-07Oaa- Q//'1O/L/
V&AI CAAoLG oLicense! Number Expiration Date
Name of CSL Holder
3 FoR�sT 57�a��csn004el? NH List CSL Type(see below)
o.and Street Description
N t Type
� � U Unrestricted(Buildings u cu.ft.
Restricted 1&2 Family Dwelling
City/Town,Sta e,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7�/- I Insulation
Telephone Email address D Demolition
5.2 Registered Home
/Improvem'entt Contractor(HIC) / 7�.j6/L, -7_ �1H
t,�—/�R ry M✓...� (:O 7 HIC Registration Number '/ Expiration Date
l
HIC Com y Name or HIC Registrant Name O �Y RRf W/AoG'CO
No.and Sneet O O ��,� /D/•_ � Email ad ss
Ci /Town,State,ZIP Telephone
�O
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 .......... 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 kn wled a and understanding.
CH S l�SchbF�Gos ONE'WH/ J sr/5 4i7'L 3
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 be found at
www.mass.gov/oca Information on the Construction Supervisor License can be foand at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
CONTRACT NO. 0-20
CITY OF SALEM
CONTRACT FOR SERVICES
Over$10,000
This agreement is made and entered into by and between the City of Salem(hereinafter the CITY),
a municipal corporation organized and existing under the laws of the Commonwealth of Massachusetts,and Oneway
Painting& Roofing,44 Springvale Avenue,Lynn,MA 01904(hereinafter the CONTRACTOR).
ARTICLE I. DEFINITION.
This CONTRACT as used herein shall mean these articles,and the"contract documents"which include but are not
limited to the following identified items and all documents,and forms submitted therewith,or attached hereby.
❑ Attachment A: Scope of Services,and/or other bid package materials
❑ Attachment B: Additional Contract Terms and Conditions
❑ Attachment C: Statement of Corporate Authority
ARTICLE II. AMOUNT AND DURATION.
This CONTRACT in an amount not to exceed NINETEEN THOUSAND SEVEN HUNDRED AND TEN
DOLLARS AND ZERO CENTS shall commence upon issuance of the Notice to Proceed and terminate no later
than February 15,2013,unless a written amendment to renew or extend this contract is executed in accordance with
the provision of the CONTRACT.
ARTICLE III. PERFORMANCE.
The Contractor agrees to provide all goods and/or services set forth in the Invitation for Bid,Documents, Scope of
Service,the Contractor's proposal for 0-20 and/or as outlined in ATTACHMENT A-SCOPE OF SERVICES.
ARTICLE IV. TERMINATION.
i. Without Cause. The CITY may terminate this CONTRACT on sixty(60)calendar days' notice, or may
suspend this CONTRACT for up to sixty(60)calendar days upon receipt of notice,when in the best
interests of the City by providing notice to the CONTRACTOR,which shall be in writing and shall be
deemed delivered and received when given in person to the CONTRACTOR,or when received by fax,
express mail,certified mail return receipt requested,regular mail postage prepaid or delivered by any other
appropriate method evidencing actual receipt by the CONTRACTOR.
ii. For Cause. If the CONTRACTOR is determined by the CITY to be in default of any term or condition of
CONTRACT,the CITY may terminate this contract on thirty(30)days notice by providing notice to the
CONTRACTOR,which shall be in writing and shall be deemed delivered and received when given in
person to the CONTRACTOR,or when received by fax,express mail,certified mail return receipt
requested,regular mail postage prepaid or delivered by any other appropriate method evidencing actual
receipt by the CONTRACTOR If the CITY is determined by the CONTRACTOR to be in default of any
term or condition of this CONTRACT the CONTRACTOR may terminate this contract on thirty(30)days
notice by providing notice to the CITY,which shall be in writing and shall be deemed delivered and
received when given in person to the CITY,or when received by fax,express mail,certified mail return
receipt requested,regular mail postage prepaid or delivered by any other appropriate method evidencing
actual receipt by the CITY.
Default. The following shall constitute events of default under this CONTRACT:a)any material
misrepresentation made by the CONTRACTOR to the CITY,b)any failure to perform any of its
ARTICLE XIX. CERTIFICATION.
IN WITNESS WHEREOF,THE CONTRACTOR CERTIFIES, UNDER THE PAINS AND PENALTIES OF
PERJURY.THAT THE CONTRACTOR IS IN COMPLIANCE WITH EACH OF THE FOLLOWING:
a. TAXES. PURSUANT to M.G.L.c.62C,s.49A,the CONTRACTOR has filed all state tax returns and
complied with all laws of the Commonwealth relating to taxes.
b. DEBARMENT. The CONTRACTOR is not currently debarred or suspended by the Commonwealth of
Massachusetts, or any of its entities or subdivisions.
c. AMERICANS WITH DISABILITIES ACT. The CONTRACTOR is aware of the recently enacted
Americans with Disabilities Act which prohibits discrimination based upon disability and shall meet any
relevant standards,and/or conditions set out in the bid/proposal documents,bid/proposal specifications,
and/or ATTACHMENT A-SCOPE OF SERVICES.
ARTICLE XX. FORUM AND CHOICE OF LAW
This CONTRACT and any performance herein shalt be governed by and be construed in accordance with the laws
of Commonwealth. Any and all proceedings or actions relating to subject matter herein shall be brought and
maintained in the courts of the Commonwealth or the federal district court sitting in the Commonwealth, which shall
have exclusive jurisdiction thereof. This paragraph shall not be construed to limit any other legal rights of the
parties.
IN WITNESS WHEREOF the parties have hereto and to three other identical instruments set forth their hands the
day and year first above written.
MAYOR THE CONTRACTOR
e 8
Kbcr y Driscoll CompanyName
cc
Status(Corporation/Non-corporate)
Whitney Haskell Authorized Signature r
Purchasing Agent 0 &� i D� ��➢w
Print Name and Title
APPROV D $TO FORM: C� , a` a d i
Date
��/ Q
Elizabe fi Kennard,Esq. t £� 41 I /
City Solicitor Taxpayer Identification Number
I CERTIFY THAT FUNDS HAVE BEEN ENCUMBERED
IN THE AMOUNT OF$ l C1— --
FOR THIS CO TRACT.
APPROPR / N BER:
.° Approved as Contra
Richard Biscay
Finance Direc r
fff K P
Director of Parks,Recreation&Community Services
DISPOSAL SERVICE INC.
20 RAILROAD STREET
" s REVERE,MA 02151
TELEPHONE(617)567-2524 .
FAX (781)853-0470
TO:
One Way Painting and Roofing, Inc.
44 Springvale Avenue
Lynn, MA 01904
Massaehueetts-Department of?ub sc Safety
Board of BuNing Regulations and Standards
Cantitmtfun Sugerriwr 1 &2 Famii<•
License:CSF _e470522 .
RUVENCAROL,yb _:.:..... ��
3 FDRM S7 . 5
LONMMERRINH'.
Caranissiarer OBN1/2014 -
r
y .
f
BHOME IMPROVEMENT CONTRACTOR
o Registration: 172514 Type: .
Expiration: 7f2@O14 Corporation
YNE WAY PAINTING&ROOEING,INC.
3ERRY MOSCHOPOULOS -
44 SPRINGVALE -
_YNN,MA 01904
Uederseerersry _
�► CERTIFICATE OF LIABILITY INSURANCE 3/8)13
THIS CERTIFICATE IS ISSUED AS A MATTER OF 05FORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EX3E11D OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(R), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER-
IMPORTANT: tF the certificate herder s an ADDTRONAI-MSIIREO,the policy0es)must he endorsed. )f SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain Policies may nxiai e an endorsement Astat maul on this certificate does not confer rights to the
certificate holder in lieu of such erdorsanen(m).
CONTACT
PRODUCER NAME:
Divirgilio Insurance Agency PHONE (781) 592-5220 FAX Lftr-,O: L7811 59e-5857
270 Broadway �t> L al@divirgilioinsurance.com
P.O. Box 8065 asset+,= sAFroxmNG eovFaAGE NAIC#
Lynn, 1+% 01904 - INbURBt A-Essex
INSURm-- -- nNSrRHt8:ArbeT.la
ONE WAY PAINTING AND ROOFING, nlslRERc:Travelers
44 Springvale Avenue tN msto-ARBFT.T.A PROTECTION INSURANCE C
LYNN, 1-% 01904 IlSURERE:
I IISIIR62 F:
COVERAGES CERTIFICATE NUMBER- REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT.TERM OR COtMFnDM OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAK THE INSURANCE AFFORDED BY THE POLICIES OESM13ED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID
—_--_ Mammy CdLYAAY�YY
-
I PUCW _
UNITS
TYPEOFINSURANCE Yl TY - 5D
A GENERALLIASILRY �3DG5765 7/29/12 7/29/13 EACH OCCURRENCE s 1 ,000,000
DAMAGE TO RENTED S SO,OOO
COMMERCIAL GENERAL LIABIUTY
CLAIMS-MADE lil OCCUR NEO H�Ipry ore PdsrA) 3 1 OOO
PERSONALSADVIWURY S 1,000,000
GENERALAGQREGATE s 2,000,000
GEN'L AGGREGATELIMIT APPLIES PER PRODUCTS-COWIOPAGG S 2 OOO 000
I POLICY PR0. LOC .amf4 E a S
D 11020014061 2/13/13 2/13/1 (E SINGLELIMR
ALI TOMOBILE LIABILITY aarri�Iv s 1 OOO O,_- OO
" BOOILYI URY(Per Pecan) $
ANYAUID
ALLOWNED 5cREDULED SOWLYi URY(Per al I) 3
AUTOS AUTOS PROPERTY DAMAGE s
eramdeN
X HIRED AUTOS X AUTNONOS-DY�RiEU S
DNBR£nA L)Aa OCCUR EACH OCCURRENCE s
EXCESSLIAe CLAIMS- m AGGREGATE 3
DEC RETENTIONS S
C MARKERS COMPENSATION ,7PJUB-SB6 67 2 5-1-1.3 3/18113 3/18/141 1 WC STATU- OTH-
AND EMPLOYERS,DABILnx ANY PROPRIETORIPARTNERlEXECO,,E NIA ELEACHACaDENT s 100,000
OFFICERWEMBHR EXCLUDED? E1.DISEASE-EA EMPLOYE s 100,000
(MaM ta'in NR)
It yes,desameuMer EL DISEASE-POLICY Lang s 500,000
DESCRIPTION OF OPERATIONS G ww 1
I I
DESCRIPTIONOFOPFRATONSl LOrAnONSIVEMCtbq (Aa ACOWtat,Addaional Remn Scbed .Umarespacetslagldrt I
Painting and Roofing
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE
City Of Salem THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
120 Washington St. ACCORDANCE WITH THE POLICY PROVISIONS.
Salem, Ma 01970 AUTRORIZED REPRESENTATIVE
Michael Conlon
9 1988-2010 ACORD CORPORATION. All rights reserved
ACORD 25(2010105) The ACORD name and logo are registered marks of ACORD
Phone: Fax: E-MI: