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14 INTERVALE RD - BUILDING INSPECTION .� 'The Comnronwealth of Massachusetts i r Board of Building Regulations and Standards Fulz hl(�Vlc'IP.AIJ"Il 4 Massachusetts State Building Code. 780 CMR. 7"' edition I .SIi Building Pennit Application To Construct. Repair. Renovate Or Demolish a Rci to,d.huwma One- or Tit v-Fomih,Duelling l 1001 This Section For Official Use Only Building Permit N tnberr: _ Date Applied: -__ Signature: ii Cununissioner upeaor of Buildings Date SECTION 1: SITE INFORMATION 1.1 Pro erh :Xddress: 1.2 Assessors Map & Parcel Numbers I.Ia Is this an accepted street.• vrs_ no_ Map Number P:ucel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lo(Area(sy f) Frontage(it) 1.5 Building Setbacks (ft) j Front Yard Side Yards Rcar Y:ud ! Required Provided Required Provided Required Poolded i I 1.6 Water Supply: (M.G.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone'! ❑ Public ❑ Private❑ Check if yes❑ Municipal ❑ On site disposal vstein p SECTION 2: PROPERTY OWNERSHIP' 2.a Ownertof ec r' S t'OIno1Gl '� rd4� 6 HOpe. Rye— wo O (_{ S �.vne j& a Name IPrmp Address for Service: o R 9- s 5- Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) Nzw Construction ❑ Existing Building ❑ Owner-Occupied ❑ Rzpairs(s)y® Alteration(s) ❑ r\ddii101 ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specity: _ Brief Description of Proposed Work'::Ir(e_1 P mO SECTION d: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials)_ 1. Building `$ I. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ j ❑Total Project Cost (Item 6) x multiplier \s 3. Plumbin $ 2. iV/\mil g Other Fees: $ List I 4. Mechanical (HVAC) $ � -- 5. Mechanical (Fire S Suppression) Total All Fees: S Check No. Check Amount: Cash :\nuwnC _ b. 'Total Project Cost: $ ' O _ 0 Paid in Full 0 Outstanding Balance Due:__.__ SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSIJ C S s 33d 7- a License Number Fspira[iun Dale Name of C 'L- holder J✓y List CSL ripe (see behm)_poi kd r ss 1 Type Descri t(iun L Lnrestr[c[ed iu to 3�M00 Cu. Ft.) H J R Restricted L@'_ Fanik Dx%elline ue /Sig[ :Nlasunrs my RC Rcsidrntial_Ruohne`'m cru�a._ Tclephone w S ResiJrmi;d CVmdwk ,md Sn-lute SF Residential Sold Fuel 11un[mL \ 1111:InCr Ins(.Jlauou _ D Residential Demolition 5.7 Re •stered Home�J;iprovement (,a�ntractor( IICI J b7S L.`7.. H unipany Na[ie r HIC Registrant Nmnr Registrutio❑ Nun;ber _ r Lie �7 F.ap[rutiun Date Signat re _ Telephone SECTION 6: ORKERS' COMPENSATION INSURANCE AFFIDA.'IT(M.G.L. c. 152. S 25C(6)) Workers Compensation Insurance affidavit must be completed and submitieJ 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 .._....._ C7 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, _ as Owner of(he subject property hereby authorize to act on my behalf. in all matters relative to work authorized by this building permit application. Signature of Owner �- SECTION 7b: OWNER' OR AUTHORIZED AL'I-'N-1' Dt--'CLARATION (, as Ownerer Authorized Agent hereby declare that the statements and information on the foregoing application are true'and accurate, to the best of my knowledge and behalf. Print Name Signature of Owner or Authorized Agent Date (Signed under the 2ains and penalties of perjury) NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor (nut 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 and Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I MR6 and 110.R5. respectively. 2. When substantial work is planned, provide the information below: Total Flours area(Sq. Ft.) (including garage, finished basement/attics, decks or porch( Gross living area [Sq. FL) Habitable room count _ Number of fireplaces Number of bedrooms _ Number of bathrooms Number of half/baths Type of heating system Number of decks/ perches .-- 'Type of cooling system Lnclosed Open -- ---_- 3. "Total Project Square Footage- may be substituted for-Total Project Coat- 4., ANDREWS GENERAL. CONTRACTING INC. 117 HOLDEN ST. SHREWSBLJRY MA.0154.5 508-853-1928 Seven Hills 5\21w9 81 Hope Ave Worcester. Ma. Subject: Contract for new rcxof at 14 Intervail Salem MfLApprox 2700squam feet. . Singles, 600 Square text of rubber seven sky lites,cooping cap driveway side. 1. Roma"existing shingles down to deek. 2. Install new ice and wrier Shield six fM up on roof save,thirty-six inches in valleys,and six Inches sidewalls. v _ 3. Install new fifteen pound nth piper_ x _. 4. Install new meW edgby,& S. Install new 30 year seclsiteenaal shingles. -�- & Install new step flashing.and base flashing as needed. it 7. Deckin;replacensent up sn thirty-two feet ingladed add S3.00 per square foot for mote than allovren e. & All other cmpontry will by charged S50.0q per man-hour,plus note vials. 9. Install new ridge vent. 10. Remove debris. Total---- -----------------S13,C�00-00 Film Wayne Ed Douce — i I I Bb'�oT 6u,1u,ug ReG��eu'in'e� str Conucdon Supervisor License License: CS 53397 ' Expiration: 12/26/2009 Trp 14090 Restriedon: 00 ! WAYNE A ANDREWS 117 HOLDEN ST SHREWSBURY,MA 01545 Comminioner a ! ✓fee �i ammanuieaQ.i ol;�/�¢d;ir�gitde�� . t%c.rd of Building Argnlallons and SNnddrds. HOME IMPROVEMENT CONTRACTOR Registration: 118547 COP)F Expiration: 4/2@009 TiV 128563 Type:. DBA ANDREWS GENERAL CONTRACTING WAYNE ANDREWS, 17 HOLDEN ST d SHREWSBURY MA 01545 �--. nyx�' CITY OF SALEM ' PUBLIC PROPRERTY � s. Y 'I DEPARTMENT 'dt „R I U'.\il11Si,.,'\C}❑iI:1'T 7.\I \1, \L\ii.\� Il it I ,�:I'1"� 9i S".'a Z-98Ili Construction Debris Disposal Affidavit (re(luired lbr all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 7S0 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit It - is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c l 11, S 150A. The debris will be transported by: �tr(!(, ) CC> - (name of hauler) I'lie debris will be disposed of in : ff (name of facility) W1 (address of facilim sienaturcrot.permit applicant ) g-�� -- date ---- dr6i nail'Cac CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT \\ .�,:��� i::all • K1;'. ll. \I1 ..1� !., � � . :I t�: ers \\nrkers' Compensation Insurance :\flidallit: 13uilders/ContructorsiElecl"5i Pript l-ebibl \ 1 tlicant Information Oro ' ; �.tnll tnu,iuc., h_,.mi/;tm.ii htdiudu. — ddl-eSS: j l S ' =15- 15, C'it)' Suite Zip: U r f� Phone 4 5 O9 VS— 3 /`2 9 \re you an employer'! Check the appropriate bus: Type of project(required): I I 1:tin u euployer w ith 3 4. ❑ I and a general contractor and 1 6 ❑ New construction culpluyees (full and'or part-time).' have hired the sub-contractors 7. ❑ Remodeling listed on the attached sheet. • ?.❑ I ,tin a sole proprietor or partner- Ihese sub-contractors have 8. ❑ Demolition ;hip and have no employees workers' comp insurance. y_ ❑ Building addition working for me in any capacity. ❑ We a a corpuretion and its No workers' comp. insurance re 10.0 Electrical repairs or additions required.] otficers have exercised their n •ht of exemption per MGL I I.❑ Plumbing repairs or additions 3.❑ I ys a homeowner doing all work c SI 52, $1(4), and we have no I_-1 J Roof repairs myself. e re worker;cutup. employees. (No workers' insurance required.] - f3.❑ Other cutup. insurance reyuin:d.J \ny applicant that checks box pl must also till out the section below showing their workers'compensation policy infunnation. ' I lomaowers who..,uhmit this afrrdavit indicating they are doing all work and then hire outside contractors must submit a new affidayil indicating such. n �('onuactun that:heck this box must attached an additional sheet>howing the name of the sub-contractors and their workers'comp,policy information. l um an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site inforrnalion. Insurance Company Name: Policy z or Self-tits. Lie. d: Expiration Date: City State/Zip: J,tb tine Address: .\ttach 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 SIGL c. 152 can lead to the imposition of criminal penalties of tine tip ht S 1,5DLLOo and'or one-year imprisonment, is well as civil penalties in the Corm of a STOP WORK ORDER and a fine „n'till Io 1_250f00 a day aPill-st the \iolator, BC ad%i.,ed that a copy of fills statement may he tor%%arded to the Office of Im a,t •cations at the DI:\ for insurance co\crage senlicauon. l do here h}' rem y unr!• rlr uUics of perjnr}•rdm din inJirrmusion provided aho,a is trite and a orrert --ollh iul use stile- no not mite in this area, to he a ompleted by t ity or trnen officiuL Cin or firs,it: ..— Fssuing \ulhorih (circle one): I. Board of Health 2. Building Department }. ('ih/1-own Clerk J. F:Icctricul Inspector S. Plumbing Inspector 6. otherContact Person: Information find` Instructions \Ia„a:Ist,euS (icnr r:iI I .0 ss s:h:gncr I �` requurs .ill cntplo%er, to pros ide ss orkers' compensation for their empim ees. I'ut,u.oit to m[Ills ,[atre, .ut rp/oree I, Jcificd .is ' rs cn per,on in the sees ice of another under .un contra of hire. yvc,s or in I,! cd, oral or ks tit ten. residuum is Jctined .0 *'.tit unhs:dua I. h.urncr,hi p. .[,;iiei,uwn. :orporanon or other Icgal cnntn. or any too or more ,.I the foie ouug cng:rged ut a Lunt cntcipn,e. and including the legal represenranse, ill de:e.u,rJ cmpLs}ce or rht :,,cncr or Irn,tcC of.ut uidn[Dual. parmer,hip. .u„o%tation or other Icgal cnmy, cmplok[nu employees. I lossever the ,�•s ter of :r dsselintg house havne no( more than three .iparuncnts and Milt rc,[des [herrm. or the oc:upant of the Slid.•iang house of.mother who emplol, pernons to du mauucnance. :onstructton or repair Mork on Such dwelling house ,,r �qu [he ,•nouuJs or building .ippuitenant dterew ,hall not hc:ause of,tach cmplu,,mew be dectued it, be an employer.*' \It il. chapter I5', s25C(h) also ,rates that 'c%cry state or local licensing agency %halt withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant ssho has not produced acceptable csidence of compliance with the insurance coverage required." \dditiona I ly, \I(iL chapter 152, j25( 1-[mates '"Neither the conuvonwca l th nor :t fly of its political subdivisions shall enter into any contract for the per Ginn ance of public ssork turn acceptable es iJence of compliance with [he insurance rcquurmentS of this chapter have been presented to the contracting authority." Applicants Please till out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, Supply sub-contractors) name(s)• address(es) and phone numbers)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 dues 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. Sclf-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom Of the affidavit Il)r you to fill out in the event file Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit,license number which will be used as a reference number. In addition,an applicant that must submit multiple permit/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 tow n).•• 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 the for future permits or IiccnSe 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 Jog license or permit to burn leaves cue.) Said person is NOT required to complete this affidavit. Flue I)Rice of Imcsfigations would like tt thank you in advance for your cooperation and should you hase :any questions, plc,t,e do not he'lt re to give its a call. _ I he Ucratnncnt's address. telephone and t'is number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 021 1 1 Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE t 11?e I S.,I,.ttS Fax k 617-727-7749 www.mass.gov/dia (MWDDNYYY r_� TM. ACORDCERTIFICATE OF LIABILITY INSURANCE DATE 812 0 0 8 'PRODUCER., Phone: (508)987-0333 Fax: 508-987-0063 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION OXFORD INSURANCE AGENCY INC ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE P O BOX 370 HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR OXFORD MA 01540 ( O ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. ` I RS AFFORDING COVERAGE NAIC# INSURED INSURER A: EMC Insurance Companies ANDREWS GENERAL CONTRACTING,INC. INSURERS: The Travelers Indemnity Company 117 HOLDEN STREET INSURER C: SHREWSBURY MA 01545 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. INSH ADD' TYPE DF INSURANCE POLICY NUMBER POLICYEFFECTIVE POLICY EXPIRATION LIMITS LTR INSR DATE MMIODIYY DATE Mmila GENERALUABILITY 1B1899308 12108/07 12/08/08 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIABILITY DAMAGE TO REnE.D $ 100,000 PREMISES E. bcarenre) CLAIMS MADE[�] OCCUR MED.EXP(Any one person) $ 5,000 A PERSONAL B ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP ADS. $ 2,000,000 PRO- POLICV JECT LOC AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT ANY AUTO (Ea accident) $ ALL OWNED AUTOS BODILY INJURY SCHEDULED AUTOS - - (Per person):' _S ! $ .. ., HIRED AUTOS _ BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS I UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ $ DEDUCTIBLE $ RETENTION$ $ WORKERS COMPENSATION AND 6KUB7469BO1108 04/02/08 04!02/09 TORYTLIMTa OTHER EMPLOYERS'LIABILITY " B ANY PROPRIETOR/PARTNER/EXECUTIVE E.L.EACH ACCIDENT $ 100,000 OFFICER/MEMBER EXCLUDED] - E.L.DISEASE-EA EMPLOYEE $ 100,000 If yes,describe under - SPECIALPROVISIONSbelm E.L.DISEASE-POLICY LIMIT $ 500,000 OTHER: DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES/EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS I 1 CERTIFICATE HOLDER - CANCELLATION ' '.—` 1 "' `' SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE AUGUSTO SPRINKLERS EXPIRATION DATE THEREOF, THE�ISSUING INSURER WILL ENDEAVORTO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE 1 TAMPA AVENUE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER, WORCESTER,MA 01604 ITS AGENTS OR REPRESENTATIVES. FAX 508-795-3840 AUTHORIZED REPRESENTATIVE /� '��`�',�p� Attention: ��Joseph E.A�tasi ACORD 25(2001/08) Cellificate# 41850 ©ACORD CORPORATION 1988 4 • IMPORTANT If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). If SUBROGATION IS WAIVED, subject to the 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). DISCLAIMER The Certificate of Insurance on the reverse side of this form does not constitute a contract between the issuing insurer(s), authorized representative or producer, and the certificate holder, nor does it affirmatively or negatively amend, extend or alter the coverage afforded by the policies listed thereon. ACORD 25-S(2001108) Certificate#41850