9 HIGHLAND ST - BUILDING INSPECTION (2) ( -1-w,,L vja)
The Commonwealth of Massachusetts RECEIVED
°. Board of Building Regulations and StalMSAECTIONAL SERVICESCITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair,Rerigvih N&AliAa 9 0 U
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Ap :lied:
47,s
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 loperty Addr ss: 1.2 Assessors Map&Parcel Numbers
(f 'nhh- 6tyld 51.
1.1a Is this ah accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed 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?Check if yes[] Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record!2_
'0 ,Ma � EJO� SQJ-ewe
lame(Print) City,State,ZIP
R �,�hlA� d_ '1s;7g-95-y- rosy ,
No.and Stree Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Er Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ i 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees:
4.Mechanical (FIVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0. ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
05-7 -733
—2_O r z_X License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street (T' / Type Description
S0� �f M ,fit 0 t 9-7 O U Unrestricted(Buildings u to 35,000 cu.ft.
l /� �T R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
ry SF Solid Fuel Burning Appliances
1 Insulation
Tele hone Email address D Demolition
5.2 Registered
�Home
,,Improvement Contractor(HIC) j 0 1 (a 0
` W`V` u-S HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
1[ S N 0 "ice S
No.a d Str et Email address
40, 1+ 01g20 q? -7V1 oYa'f
City/Town,State,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 Issuan a 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
/ l
1,as Owner of the subject property,hereby authorize ( _t�I r—, S ?0YZv
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 he y attest on der the pains and penalties of perjury that all of the information
contained in t ' a plic 'on is ue and accurate to the best of my knowledge and understanding.
`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 found at www.mass.gov/dos
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"
i
• + PGratl
e FC�saz A & A SERVICES, INC.
A&A SERVICES 115 NORTH STREET,SALEM,MA 01970
• • • Telephone:(978)741-0424 Fax:(978)741-2012
Contractor Registration No. 101609
Federal EIN:04-3090162 Construction Supervisor No.CS057733
ROOFING SPECIFICATION SHEET
Boyer(s)Name Date of Contract
Buyerls)Street Address,City,State and Zip Code
9 Nl NL/9ND ST, Srft�LW ✓lZ14 0/`170
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mail Address
08- 9sv-ros&I
The Buyerls)listed above hereby jointly and severally agree to purchase the goods and/or services listed below,in accordance with the prices and terms described on
this Specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet Is a part.
ROOFING SPECIFICATION
Strip Roof of# .3 layers of shingles
' Install 6'of ice and water shield at base of roof where Install 15.b felt paper to roof.
possible. Install 18-24"of ice and water shield in valleys.
UT Flash chimneyvee4wede9{no repointing included). Install 6"perimeter drip edge to rakes and fascia areas.
$= Install vent pipe boots and seal as needed. lash valleys as needed
tstall rollout type ridge vent,6 ' /3C 1i� F lanks/plywood replacement under 32 SO FT included,O,cy-rTs "If more is needed there will be an extra charge of$B6,
per hour for labor plus the cost of materials.
ODumpster/Disposal Included: (Other: 001,c7L. ' v�/O/2Ls 61"C/C
Location: =1 2ft�Nj SIO� ��iVL�LyAi/ '�
Install new roof: Manufacturer �i13 -in/%�2� *J 0 yr Style/type AgaG 6i-/Pz n,�-r�'L__
Included in this proposal are thorough cleanup,building permit,and company/manufacturer warranties.
RUBBER ROOFING SPECIFICATION
t Strip Roof i Not Strip Roof
9 Install 1/2"High Density Fiberboard to existing roof using $ Flash obstacles as needed.
screws and plates.
F Install .060 membrane EPDM(Black)rubber roofing to 4' Install 3x3 aluminum drip edge to perimeter of roof with
fiberboard.s seam tape.
t Flash up sidewall as needed.
Included in this proposal are thorough cleanup, building permit, and company/manufacturer warranties.
SPECIAL INSTRUCTIONS:
B7r�ry�,ns -r 2j;1--1A/SDft- ,L loci s nn!/� /Swt K r r Our/L /Dvvrr_
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/NG7P /-I(.L�41,/VLN7 G0-/LE�II 4noyAla S✓/V9&V -? /*V-4
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3 '- '"
(/ql�N� °l f— S! D//✓Li A1v/� � U�y/TCTH'7VyC� 7D SUiv/�ts,�v1
It is agreed and understood by and between the parties that this Specification Sheet,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,constitutes
the entire understanding between the parties,and there are no verbal understandings changing or modifying any of the terms. This contract may not be changed or its
terms modified or varied in any way unless such changes are in writing and signed by both the Buyerls)and the Contractor. Buyerls)hereby acknowledge that Buyerls)
has read this Specification Sheet.
Contractor Initials: Date: S'II—Iy Buyer's Initials> O°b Dater Vn o
A & A SERVICES, INC.
A&A v�Y 115 NORTH STREET, SALEM, MA 01970
''• Telephone:(978) 741-0424 Pax: (978) 741-2012
Contractor Registration No. 101609
Federal EIN: 04-3090162 Construction Supervisor No.CS057733
CUSTOM REMODELING AND IMPROVEMENT AGREEMENT
Bu er s Name
Date of Contract
/Fill/
By er s Street Atltlress, Cit ,State I tl ZI Code
T awl r-c O/`171J
Da 'me Tele hone Number Evenin Tale hone Number Mobile Telephone Number E-Mail Address
8 9SY(oS� crti�uc 13 z. L
The Buyers)listed some hereby jointly and severally agree to purchase the goods and/or services listed on the accompanying specification sheets,in acconen�Will the prices and terms described on the front antl the reverse of this agreement and any specification sheets(this"Agreement'),and Buyefls)have requested
that such goods or services be installed or provided at Buyer's address listed above.A8A Services,Inc.('Ccmdagor'),hereby agrees to install or cause to be installed
the products or services listed in this Agreement at the Buyerls)address written above,This Agreement represents a Cash Sale of goods and services.The Buyerls)agree to pay in cash the cost of the goods and services purchased as descdbetl herein,regardless of timing or approval of any financing Buyerls)may seek for their
purchase. r' a Purchase Price {330, Est.Staning Date:
Down Payment 3"/(J0i Est.Completion Date: —I S— y
D Cash
Amount Due on Start of Job: ®j Check
t CardA(
Amount Due on_of Completion: ,Credi
No.Y266702.0 ybjSyo O/p
Amount Due on_of Completion: Expiration Date: Oil—17
Balance Due on Upon Completion CVC Code: Z o7
It Is agreed and understood by and between the parties that this Agreement,front and back and any addendum, constitute the entire
understanding between the parties,and there are no verbal understandings changing or modifying any of the terms of this Agreement.Buyerls)
hereby acknowledge that Guyette)has read the front and the reverse of this agreement and has received a completed,signed and dated copy of this
Agreement,including the two attached Notice of Cancellation forms,on the date first written above.Buyerls)also if)acknowledge that they were orally
informed of their right to cancel this transaction;and(if)request that they be contacted via their telephone numbers or email,as listed above,in the event
Contractor believes Buyerls)would be interested in any additional quality products or services of Contractor. DO NOT SIGN THIS CONTRACT IF IT
CONTAINS ANY BLANK SPACES.
A&A Se Bill
I D. Buyerls)
By
Sig ore
// U as S>lignature
Print Name ri�t�N
Signature -
y --
Print Name
You,the Buyerls), may cancel this transaction at any time prior to midnight of the third business day after the date of this
transaction. See the following Notice of Cancellation form for an explanation of this right.
ARBITRATION:The wmraclw and ue norreovener hereby ruwally agree n advance Pal in me evxm either party tlaa a mspme concentrate,conYatl.-Ma pour tray sobnit sum drools to a
private aNleation uM..iO has been agaove]by Ne eeaem,or Pe E radmis¢Omea of Consumer Affairs and Business Regulabonsa d IM mear parry shall be repuimol P subrtit to such
arbiba0cn as proved in FA G L at43A.
trio I' � puveM1 Ini 1-/y`-�
Ins"p-7 Dyc: 7! X/t(//l�
aa
TT NOTICE OF CA �� NOTICE OF CANCELLATION
Oale al Transacon OBI I�I You may wnael This transaction,vital any wrafty or Date of Transaction -'l -/ YOU may•anwl the nansactiom vaIn.any dermay or
Fediratioq am,n three business days from Me abuse dale.N you cancel,any WOMp traded ln, obllgafion.Above Mme business data from the above date,Ifyoccancel,anypmpequadMtn,
any payments rude by you under the Contract or Sale,and any negamble Instrument
eculed any pa nts made by you under Ne Conlratl or Sale,and any negotiable ineamem execu.d
by you Fell be returned vb0in 10 days follaying re papt by Pe Seller of your canduclaYw notice, by you will W returned amen 10 days Mlovung receipt b the Seller of
and any security Interest an en9 oN of Pe p esamw wall be cancelled.II you wnwl Y your caucellatiw a Mae
oaks available re Pe SNler n your resldmce,and eubAantial you meal and any royal t the
S fe,at out of me Pansand ys be eancdlad II you cancel,you mual
ly n as geld ver urn as Mlen make evailadg to the Seller at your under ace,and substantially Ines pour f of son as when
preIved.any gelds delivered the Sande
pr Sale or you tray,it S.1 ammgy mithe any goods burned Me
eSeer m1ptlerPlsconbad wServers ofIeeµdsawish,orders
e Pe in d risk It ml the Belly reposing the velum the Sageres.oT Pe gWds al d,Sellers wiP the in d risk 1s N Ne Seller regarding In.ve return M i Salle al the Soup at body
SHIerS
earn upse anddsk.Nyou domaM Pegmdsavailablebra Sellerandy re Seller doesnotf Me them up arthin antln 20Ifyou do make the ppo]ses of To Pe Seller and Me Sellerdoes ridpour
Pam upmed any
aysol tbignerne date l yourfailto val fCe Megoods avoided
tided t theC or dispose of I Me them goods
ma,yfuds of Pe tlateod, yoor u
of make
the goodsumaytttt inmdspose of
Bootle withoutanytourer 1.thetiw.Ilyou fail to mope than Yen —.ab..UsMe BHletor Xyou the pureo Nom any goods to me Sent, a,flailto.rd thangmdemainablue for
memo¢r,orvl
agree to return the goods to the Seller end fail to do ao,then you remain liada for mdormvnce al you agree loretum ll,e goods to Pe S¢II¢rand tail todo sp,than you remain liablelorpedomanw
all subgatlws under the Cono-O,To Fall as transaaon,sea or deliver a signed and dated of all obligations under Me Coneand To cancel this tranendul rest or deliver a signed and dated
mpy Of thecanrellation notiw or any oN¢r Nlitlen notice,or sentlatale ra m,lb ABAS Ia mpy of The canceivere notiw or any aide r symen mand p sentl a Ie legjj�9 �I�O�A�BA Se IC¢
115 Noun Seen,Salem MA 01970.NOT LATER THAN MIDNIGHTOF ca 115 NOM Street,Salem MAm9]O,NOT LATER THAN MIDNIGHT OF f4-/� a
I HEREBY CANCEL THIS TRANSACTION I HEREBY CANCEL THIS TRANSACTION �- !tr
Consumer5 Signature Data Consumer S Signature Date
The Coninion wealth of Massachusetts
n' DepartmentgfLndustrialAccidents
o/ficeoflnuesGyations
h
600 Washington Street, 7' Floor
Boston, Mass. 02111
Workers' Compensation Insurance Affidavit: Building/Plumbing/Electrical Contractors
Applicant information: t e 1�.
NO Please PRINT legibly
name: -l.. `1'/:S �pHel��lSf 7e�1z
address: . �/J r' ! A Y2Q'f/ [
city 60t l-e t," 'L / state:` MA zip: 0119-70 Phone# / / Dy-70-e VOV
work site location(full address): qTI iCf
❑ I am a homeowner performing all work myself. Project"type: ❑New Construction []Remodel
❑ I am a sole proprietor and have no one working in any capacity. ❑ Building Addition
[✓f 1 am an employer providing workers' compensationg for my employees working on this job.
company name: A" -l' 'S'ZIry I(�0-57+ f AAC
address:C I I g5-
1✓O 4 v✓�\ S (� p 7�[ �5 t / '
city: ('Q ( e- ( �. . ll'�,'rl phone#: �-y!�?t 9- /A�7] / -/V `t ;L
insurance co. I -c �✓�OI v o I� t- is Policy# lJ,q S, t4 1 V d 57
❑ I am a sole proprietor, general contractor,or homeowner(circle one)and have hired the contractors listed below who have
the following workers' compensation polices:
company name:
address:
city: phone#:
insurance co. Boller#
comnanr name:
address:
city phone#:
insurance co police#
Attack additional sheet if necessary
Failure to secure coverage as required under Section 25A of MC 152 can lead to the imposition of criminal penalties ofa line up to S1,500.00 and/or
one years'imprisonment as well as civil penalties in the form of it S'rop WORK ORDER and a fine of S100.00 it day against tile. I undenhmd thou a
copy of this statement may be forwarded to the (`lice of Investigations of the DU for coverage verification.
I do hereby/certify Zethpains nnrl p nnities of perjury turnt the information provided above is true mul correct.
signaturN Date b�l ps"
Print name J%-t-f'o� / 70✓2.�./ Phone# 70 -7 7=
T
official use only do not write in this area to be completed by city or town official
city or town: permit/license# ❑Building Department
❑Licensing Board
❑check if immediate response is required ❑Selectmen's Office
❑Health Department
contact person: phone q; ❑Other
(ruvoed Sept 2003)