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4 HAZEL ST - BUILDING INSPECTION 12/02/2008 11: 46 9787409846 CITYOF SALEM PAGE 01/02 � the Commonwealth of Massachusetts Board of Building Regulations and Standards town of. kj Massachusetts State Building Code. 780 CMR, 7r"edition ' \�v Building Dept Q Building Permit Application To Co et, Repair. Re ovate Or Demolish a !l�lNYttw pre-or vo-Fmnlly Dtvrllirtg t [s Sect For 0 ial Use nl Building Permit Number a e H.J. Signature: Building Commissioner pcctor of Buildin Daze G� SECTION I• E INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers s 7- 'k." 1.1 a Is[his an accepted street?yes no Map Number parcel Number 1.3 ZoninR Information: 1.4 Property Dimensions. Zoning District Proposed Use Lot Area(sq R) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Rcar Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Disposal Sewage Z Outside Flood Zone? g System: Pu blte❑ Private vate❑ — Municipal O On site disposal system 0 Check if es❑ P po y SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: �+ Name ��//y` fj�/4�CL S 1[4 Lt r O 7 L'� ! ^� Addresv fopr Service: SignaNrE Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Buifding❑ Owner-Occupied Repairs(s) ElAlteration(s) ❑ Addition Li Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units__L other pcci fy: �su+9ElJT- lnJ O6[2}j. Brief Description of Proposed Work': /AT S rst c [, to 4/4g P✓e7 [rnrNT 4 /Al 2 G LZ SECTION 4: ESTIMATED CONSTRUCTION COSTS lie m Estimated Costs:1, Buildin Official Use Only Labor and Materials y + g S SSp, cp I. Building Permit Fee:$ indicate how fee is determined: 2, Elec[rical 5 ❑Standard City/fbwn Application Fee 3. Plumbing $ ❑Total Project Costs(Item 6)x multiplier x 2, Other Fees, S 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ K Su rescion Total All Fees:5 6. Total Project Cost: $ 3�Q`o Check No. Check Amount: Cash Amount: ❑Paid in Full 0 Outstanding Balance Due: 12/02/2008 11: 46 9787409846 CITYOF SALEM PAGE 02/02 SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 160(a -� -, Lense muber Ex irauon Datc G V � � Ngmc of CSL-Hglder O fo O J�p List CSL Type(see below) i tion�u .f 2nFr A r• U Unrestricype ted u w 42 t Cu. Ft. R Restrtcled 1&2 Famil pwellin t t M Mason Onl e2a� RC Residential Roofin Cayening Telephone WS Residential Window and Sidin SF Residential Solid Fuel 9umin A fiance Installation p ResidMtial Demolition 5,2 Registered Home Improvement Contractor(HIC) D d LOD Registration Number HIC Co an Name or HIC Registrant r/ �-72 Ad s 7g Expiration Date Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M-G-1-c. 152-¢ 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application rovide . Failure to p this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... No ........... O SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT f A Aefy/ qr 0CtE /ETA as Owner of the subject property hereby to act on my behalf in all matters authorize relative to work authorized by this building permit application. Si store of Owner Ds lef SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION ,y H E� �Authorized Agent hereby declare that the statementsand information on the foregoing application are true and accurate,to the best of my knowledge and Lbehalf or Authorized AgentDate der the ains and enaltics of r' 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 Mol 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 790 CMR Regulations 110-R6 and 110,R5,respect el When substantial work is planned,provide the information below: finished basement/attics,decks or porch) Total floors area(Sq. Ft.) (including garage, 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 Opcn 3, "Total Project Square rootage"may be substituted for"Total Project Cost" The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers A licant Information Please Print Le ibl Name (Business/Organization/Individual): '0 S /4/ Address: P 6 3c>-x City/State/Zip 6a,'I 5W -Phone #: 762/ Areyou an employer? Check the appropriate box: Type of project(required): 1. I am a employer with 0 4. ❑ I am a general contractor and I 6. ❑ New construction employees art-time)full and/or .• have hired the sub-contractors 2.El I am a sole proprietor or partner-p listed on the attached sheet $ y. ❑ Remodeling 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' comp. insurance 5. ❑ We are a corporation and its 10 ❑ Electrical repairs or additions required.] officers have exercised their right of exem exemption per MGL 11.❑ Plumbing repairs or additions 3.❑ I am a homeowner doing all workP P myself. [No workers' comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13.0 Other comp. insurance required.] *Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information' t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the subcontractors and their worker;'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. 1 Insurance Company Name: f7/Y ,.5,0 'A� lAf/ k7�'Al',Q l_t 61-(Jq L — q 6 LY�-- policy#ems Lic. #: wcy e�2 j93/ ( t� Expiration Date: ( — Job Site Address: F Z--i9 Z 15-6 S7� t 5,d/E�9 4 City/State/Zip: �5 8 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 cerd and t pains and penalties of perjury that the information provided above is true and correct Signature: 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:Electrical Inspector 5.Plumbing Inspector 6. Other Contact Person: Phone'#: 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 person"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, §25 C(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 - Pleas@zfi: 11 out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necesstiry,`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 fill out in the event the Office of Investigations has to contact you regarding the applicant Please be sure to fill'in the pcnyiiviicense number which will be used as a reference number. In addition, an applicant that must submit m mi multiple pert/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 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 burn leaves etc.)said person is NOT required to complete this affidavit The Office of Investigations would bike 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 fax number: The Commonwealth of Massachusetts i , Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA02111 .. . Tel. # 617427=4900"ext 406 or 1-877=MASSAFE Fax# 617-727-7749 Revised 5-26-05 wwwmass.gov/dia Reg. 12LOM ProWindows Inc. www.prowindows.com P. O.BOX 54063Q,WALTHAM,MAO1454 (781)647-9225 FAX(781)647-9392 LICENSED INSURED ................................................................................................................................. NAME: Marc and Amy Ouellette DATE: 10/28/08 ADDRESS 4 Hazel St. Salem, MA 01790 PHONE# 978 594 5281 WORK CELL 617 501 6703 EMAIL marcgouellettenet.com Furnish and install the following,all to include LowE/Argon filled glass. • 6 HARVEY CLASSIC VTNYI, FULLY WELDED REPLACEMENT WINDOWS, WHITE, DOUBLE HUNG,TILT IN,HALF SCREENS,NITELOCKS. REPLACEMENT INCLUDES REMOVING EXISTING WINDOWS AND HARDWARE. INSTALL NEW WINDOWS LEVEL AND PLUMB. CAULK AND INSULATE ALL CRACKS AND SPACES. CONTRACTOR RESPONSIBLE FOR REMOVING ALL DEBRIS. 6 double hung @$425.00/window $2,550.00 Estimated time to complete is I day ITOTAL INVESTMENT = $2,550.009 /0/ og- —Dr6571_r- -200 cost of Slimline Window is$405 installed. MAKE CHECK PAYABLE TO PROWINDOWS INC. Estimate includes cost of all trash disposal. Painting is responsibility of the homeowner. All workmanship is warranted foi life. Payment terms we 113 up front,and balance due upon completion of contract"less otherwise specified. 10%hoidback of Balance Due for 90%completion. Any and all extras will require separate contracts and are payable prior to start of work. Contractor,to be reimbursed by homeowner,will pull permits if necessary. Work to begin 4-6 weeks following receipt of deposit. Contract is good for 30 days afler contractor signature below. I accept the terms of this contract. date; signutury of contractor. —date:zz_lLla ACORD. CERTIFICATE OF LIABILITY INSURANCE i1/10/2008' PRODUCER (781)344-3200 FAX (781)344-142S THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION Malcolm & Parsons Ins. Agcy. Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 6 Freeman St. ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 527 Stoughton, MA 02072 INSURERS AFFORDING COVERAGE NAIL# INSURED ProWindows Inc. INSURER A: Western World Insurance P.O.Box 540630 INSURER . American International Group Waltham, MA 02454 INSURER C. INSURER D: INSURER E'. COVERAGES THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR DD' rypE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS RM GENERAL LIABILITY NPP1114823 07/23/2009 07/23/2009 EACH OCCURRENCE $ 1,000,00 —RENTEDX COMMERCIAL GENERAL LIABILITY -DAMAGE TO aM0CUM $ 50 00 CLAIMS MADE M OCCUR MED EXP(Any one parson) $ S,00( A PERSONAL BADVINJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN-L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $ 1,000,000 X POLICY PET LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea anddent) ANY AUTO ALL OWNED AUTOS 13001LY INJURY $ (Per person) SCHEDULED AUTOS HIRED AUTOS BODILY INJURY $ (Pera Ident) NON-OWNED AUTOS PROPERTY DAMAGE $ (Per amident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESSRUMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR F—ICLAIMS MADE AGGREGATE $ 8 DEDUCTIBLE $ RETENTION $ $ WORKERSCOMPENSATIONAND WC2931862 06/09/2008 06/09/2009 X I WCSTATU- OTH- EMPLOYERS'LIABILITY EL.EACH ACCIDENT $ 500,000 B ANY PROPRIETOR/PARTNERIEXECUTIVE OFP MI CEREMBER EXCLUDED? E.L.018EASE-EA EMPLOYE $ SOO,OO ffmdewdbeunder E.L.DISEASE-POLICY LIMIT $ 500,000 SPECIAL PROVISIONS belay OTHER DPBC IPTIOp OF OP TION,S/LOCATI NS/VEHI(,LES/ CLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS Tn5ow Tnsta Nation an� s1TdTng Toors CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. Insured's Copy AUTHORIZED REPRESENTATIVE Irvinq Parsons ACORD 25(2001108) ©ACORD CORPORATION 1988 r Board of Building Regulations and Standards """-°^� '• Construction Supervisor License Llcenst�;...CS 66853 Dirthdate 4/27/1966 Expiration. 4/27/2009 Tr# 12658 Restriction: 00 JEFFREYP HER E PO BOX 540630 _ -�— WALTHAM, MA 02154 Commissioner ......_... �lte lOomvroeo9uUe¢C�i �✓�amac�euoe!!a �.�, Board of Building Regulations and Standards HOME IMPROVEMENT CONTRACTOR Registration '123088 lug Expiration ,1214/2008 j�, Tr# 124902 Typ@: Private Corporation T � � PROWINDOWS INC,i` _ JEFFREY FISHERP, 411..WAVERLEY OAKS RD-BLDG WATYgAA, MA 02452 Administrator i i i j iI - ail CITY OF SALEM G PUBLIC PROPRERTY J ' DEPARTMENT P.yay1K V'� KII ' IKKCv 1.:1 -Irl: v7s-'4;.i;a5 f.��:v'sJ4J9841, Construction Debris Disposal Allidavit (required fior all demolition and renovation work) i 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 tt _ - _ is issued with the condition that the debris resulting from ro erl licensed waste disposal Pacilit as defined b MGL c II he disposed of in a Y Y this work shall { properly Y ! 111, S 150A. The debris will be transported by: (came of hauler) I he debris will be disposed of in /7A_ A0.-5. .___. s d �L (name of facility) (address of facilitvl t ' ,igtWtmn of penni[ applicant l late ----- IchlL�: •.,i