34 HOWARD ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY SA EM
Massachusetts State Building Code, 780 CNIR
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For'Off3cial Use Only.
Building Permit Number: : Date Applied-f
TrLZ /
BuildingOfficial(Print Name) V, Sign ture Date
SECTION 1:SITE INFORM TION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
y au,9z0 ST
1.1 a Is this an accepted street?yes_ no Nfap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) 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? Nfunicipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIPj' "
2.1 Owner'of Record:
�/ 0,7 /? g(y/ A A]A / ��� h✓1
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) 4�j, Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
J7—R/"V 9k/1 i2e � .OF uii T.•r� RT7,/io/ cS✓.�/�/ ter
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only,
.
Labor and Materials y`
1. Building s-G I. Building Permit.Fee S Indicate how fee is determined;
�. Electrical S ❑ Standard City/Town Application Fee
❑ 'Pota1 Pro3ect Costs.,(Item 6)x multiplier x
3. Plumbing 5 2. Other Fees: S
4. Mechanical (FIV,\C) 'S List:
5. Mechanical (Fire
Su ression D Total All Fees: S
Check No. Check Amount Cash Amount..
o. "Cutal Pt o,ject Cost: S �"��� 0 Paid in Full ❑ Outstanding Balance Due: ____
SECT[ON 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
j�_
r - License Number Expiration Date
Name of CSL 1-lolder
List CSL Type(see below) AJ O
^�Al /�/I Essex 27- 3
Type Description
No. and Street
U Unrestricted Buildings up to 35,000 cu. ft.)
zw /J/.®1n/ /W-< e2 /,�/3 1Zestricted 1&2 FamilX Dwelling
City/Town, State, ZIP b( Nlasonr
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
'd/ d ,3 d'O£Jjt I Insulation
,rcle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
i Olt/ le �q '�r w4 HIC Registration Number Expiration Date
111C Company Name or IiIC Registrant Name
No. and Street Email address
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 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: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains id penalties of perjury that all of the information
contained in this application is true and accurate to of my knowledge and understanding.
Print Owner's or Authorized Agent's Hume(Ele 'o t 5,(aturc) Date
61 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(HIC) Program), will not have access to the arbitration
fund under M.G.L. c. Id2A. Other important information on the HIC Program can be found at
program or guaranty P
wavay.nmss.,,ov/oca Information on the Construction Supervisor License can be found at yvww.ntass.vlovrclps
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 halbbaths _
Tvpc of heating system --_-__--—__-- Number of dicks/ porches --_-- __
I'ype of cooling system_- Enclosed _ ___--Opcn _
;. •-rural I'roject Squurc Footage" may be sub,titutcrd for fetal Project Cost"
CITY OF S� F-,Nf. -uSACHUSETTS
BL.ILDL\G DEP.1RI M&NT
120 WASHNGTON STREET, 3°FLOOR
TEL. (978) 745-9595
F.�Le(978) 740-9846
KI.NLpERLEY DRISCOLL
�L�YOR TI.10.% s ST.PlERRE
DIRECTOR OF PL:BLIC PROPERTY/BCILDL\'G COSLMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
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 # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
A(l/ 5S7-e
(name of haul )
The debris will be disposed of in
(name of facility)
(a.l e5 )
sign re of permit applicant
_i 3
(late
a
CITY OE Si1LE1d, NWSACHUSETTS
Bl:1LDING DEPARTM�EDiT
120 WAS14LNGTON STREET, 3"FLOOR
-ILL (978) 745-9595
Rut:(973) 740-9844
KI.NfBOLL
MAYOR THciNus ST.PIEm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONWISSIONER
Workers' Cornpensatlon Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
V:11170{0witxy>.Qrganimtiorvindividual):�� ���Jl�Q�'!r"O,✓
Address: l9 3 e s sP e-
�r
City/State/Zip: i✓jg/� � Phone hl:
Are you an employer?Check the appropriate box: 'type of project(required):
1.[�I m a employer with_— 4• 0 1 am a genaval contractor and 1 6
employees(full and/or part-time).* have hired the subwontr icton ❑New construction
2.0 I am a sole proprietor or partner. listed on the attached shoat 1 Z ❑Remodeling
ship and have no employees These sub-contractors have it. ❑ Demolition
working for me in any capacity. workers'comp.Insurance. 9. 0 Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their
I0.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,$44).and we have no 12.0 Roof repairs
insurance required.]i cmployces.(No workers' 11.DOIher
comp.insurance rcquircd.j 11
•Any appitcam that chmks box rt must alau till out the section belowshawina tile"warkam compensation polity intmm2110n
r I f.wneuwnem who submil this aftidavir indicating that,ate Joins all work and rhea him eateida cantraefa,e must nib it a new aMdavil indicadna such
:Cuntrmtors that ulimit this box must mtuhad m nJditlond cheat showing silo name or tho wb�contnoom and that,workers'comp.policy infntrnation.
l um err employer,that is providing)vorkers'comprnratlon htsurance for my emplayen Below Is the pollry and Job soli
btformutlon. �I /
Insurance Company dame: T,4`2? ✓v n ( /�cS✓L�
Policy t<or Sclf%ius. Lic. H: //�/// �— ?_0 �J�T Expiration Date:
Job Site Address: 3 � /7OrLa4lL D 3J— --,;,I�o-,,d amity/Statc/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Suction25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonmcnG as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a Jay against the violator. Its advised that a copy of his statement may be forwarded to the Olfico of
Invustigwiuts of the DIA for insurance coveraga verification.
Ida hereby cart fy under the pubes and penatles of pr r/or file hrfunrrurlon provided above is true cord correct
g',. : l l/�vo l Dare. 4L'/ 7"5 3
Vhmric
IOJJlcial use unfy. Do not ruche in M&urea,to br cuniplered by city ur fawn a lefal
citynrTuwn: ___ _ Perm(t/Lleensefl ________
Issuing Aulliorily(circlo one):
I. Board of ilealth 2. Building Department 3.Cilyffown Clerk 4. Cleetrlcal Inspector 5. Plumbing 6upector
6.Other
Contact Person:_-, . _.. Phone tit:_
1
Massachusetts- Department of Public Safety
I Board of Building Regulations and Standards
% Construction Supervisor License
"Leense:-CS 82584
,DIONEI DASALVA
12 PORTER ST
EVERETT,0A't52149` *`
4,1 * Expiration: 11/18=13
C'ommissinner.` -1 s} Tr#: 8184
�� ,"'?u+ems«v,w./a*�,�-.'�xp>a�+-K-er..r•../�✓�,_'-O'fr�a/��-:r..
'� rpm ✓� IOOi��7�tM[i+�ea.([Ic �,/!?qd6
Otfice of Consumer Affairs&B siness Regulation
HOME IMPROVEMENT CONTRACTOR
Registration a564743
Expiration: � f/6/201.3' Type:
ual
01 EI'DASILVA"i,
.' DIONEI DASILVA� --
129 A WILSON
NAHANT,MA 01908�"�.,
U ndersecretary.
CHC CONSTRUCTION
34 HOWARD ST 12/21/2012
SALEM. MA.
JIM MOYNAHAN
617 838 8377
The following contract is for the roofing instalation of the house located at above address. The following paragraphs
describe the work that is to be done. We believe that a good job requires excellent preparation.
• Strip existing roofing(main house only).
• Inspect deck. Any plywood have to replace cost$ 60.00.
• Install new drip edge 8".
• Install 6 feet ice water.
• Install 30 years warranty shingles.
• Install ridge vent system.
• Install felt paper 15 pond.
• Install new gutter on main house only.
• Dumping all trash.
• PRICE INCLUDED LABOR MATERIAL AND DUMPSTER.
TOTAL$5,600.00.
ROBSON 508 8017388 THANKS...
MAcA1,440N
Av h 01/03/DDYYYY)
® CERTIFICATE OF LIABILITY INSURANCE DA
01/03/2013
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
th(k terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not confer rights to the
certificate holder in lieu of such endorsement(s).
PRODUCER CONTACT TATIANA SALES
NAME:
GLS)BAL HELP CENTER INC PIA/ONy :t: (978)275-0997 ,XC Nq;. (978)275-0589
19 MILL ST SUITE 2 E-MAIL GHCLOWELL@YAHOO.COM
ADDRESS:
LOWELL MA 01852 INSURER(S)AFFORDING COVERAGE NAIC#
INSURER A: NAUTILUS INS
INSURED INSURER B: AIM MUTUAL INS
CARLOS HONORIO DA CU NHA INSURER C
DBA CHC CONSTRUCTION INSURER D:
193 ESSEX ST APT 3 INSURER E
MALDEN MA 02148 INSURER 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 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.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR TYPE OF INSURANCE INSRADD WVD SUER POLICY NUMBER MMIDDYIYEYYY MMIDDYIYEYIPY LIMITS
R
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
DAMAGE TO RENTED X COMMERCIAL GENERAL LIABILITY PREMISES Ea occuoence $ 50,000
CLAIMS-MADE FRIOCCUR MED I(Any one person) S 5,000
A NN278602 10/19/2012 10/19/2013 PERSONAL It ADV INJURY $ 1,000,000
GENERAL AGGREGATE $ 2,000,000
GEN L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOP AGO $ 1,000,000
X POLICY PRO LOC S
AUTOMOBILE LIABILITY COMBINEDSINGLE LIMIT S
Ea accident
ANY AUTO
BODILY INJURY(Per person) $
ALL OWNED SCHEDULED BODILY INJURY(Per accident) S
AUTOS ANN UTOS
HIRED AUTOS AUTOS ED PR PerOa PE cRden DAMAGE $
$
UMBRELLA LIAB OCCUR EACH OCCURRENCE $
EXCESS LIAB I CLAIMS MADEAGGREGATE $
DED RETENTIONS $
WORKERS COMPENSATION X TNRV TATITS OTH-
AND EMPLOYERS'LIABILITY
B ANY OFFICER/MEMBER EXCLUDED'EGUTIVE Y� NIA AWC7028345 10/20/2012 10/20/2013 EL.EACH ACIN CIDENT $ 100,000
(Mandatory in NH) E.L.DISEASE-EA EMPLOYEE $ 100,000
Ups describe under 500,000
DESCRIPTION OF OPERATIONS below E.L.DISEASE-POLICY LIMIT $
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (Attach ACORD 101,Additional Remarks Schedule,if more apace is required)
PAINTING AND CARPENTRY SERVICES.
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN
CITY OF SALEM ACCORgA�CE WITH THE POLICY PROVISIONS.
93 WASHINGTON ST 44
AUTOOE R PR NTATIV
SALEM MA 01970 � I
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