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31 JACKSON ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of Board of Building Regulations and Standards kMassachusetts State Building Code, 780 C.MR, T"edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Tito-Fmnil},Dwelling AWOL Thi ction For O tcial Use Only \ BuildMPennitmber: Da Applied: 2 Signa Commis ner/Inspector of i m Date SEC N 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers -?'/ y9c/r < I.1 a Is this an accepted street?yes_ no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq fl) Frontage(FIT 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: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yesO SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: A 2 A1JN PA 12D E/yrGIL�K RJR/ S1L Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(,) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials 1. Building $ I. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5. Mechanical (Fire $ Total All Fees:$ Suppression) Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 0 paid in Full 0 Outstanding Balancee D/ue: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 76-;? License Number Expiration Date N:)me of CSL-Helder 7 List CSL Type(see below) 5 f( t�o%r�, L� s S r� Address / MD2Residenfial Descri Lion cted u to 35,01)D Cu. Ft.) Signature d I&2 Famil Dwellin Only tial Roo Fin Coverin TcJephone tial Window and Siding �ozr 6G �6 ial Solid Fuel Burning Appliance Installation Residential Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC 9�C`�mpan �1e /? Registration Number!l SfXs>l 2ica ! 7 G-l- © 9 Address ,�j����G3 Expiration Date Signature a elephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S/AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 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. Signature of Owner Date / SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION ti ,as Owner or 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. _� ) i (T "5' Print Name - Signature oC ra utho ent e Date indenalties of(Signed and n ' 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 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 110.116 and I I0.115, respectively. Lof n substantial work is planned,provide the information below: rs area(Sq. Ft.) (including garage, finished basement/attics,decks or porch) ng area(Sq. Ft.) Habitable room count f fireplaces Number of bedrooms f bathrooms Number of half/baths eating system Number of decks/porches oling system Enclosed Open . otal Project Square Footage"may be substituted for"Total Project Cost" . The Courntonwealth of Massachusetts . Depardnent oflndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 www.massgov/din Workers' Compensation Insurance Affidavit: Bailders/Contractors/Electricians/Plumbers AOPUcant Information Please Print 'bl Name(Business/organizatigm(Individual): � XE Address: �1. XLAP Y"1 /- t 7 City/State/Zip: <D Phone#: c5 C, �— Are ou an employer?Check the appropriate box: Type of project(required): I.ELI am a with employer . 4. ❑ I am a general contractor and I 6. ❑New constriction employees(full and/or part-time).*; have hired the subcontractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet 7: ❑Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working"for me in any capacity., employees and have workers' y .❑Building addition [No workers'comp.insurance comp.insurance.: required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their I LE]Plumbing repairs or additions myself [No workers'comp. right of exemption per MGL 12.0 Roof repairs insurance required.]t c. 152, §1(4),and we have no 13.❑ Other employees. [No workers' comp.insurance required.] *Any applicant dun checks box#1 must also'fin oatthe section below showing their workers'compensation policy mfamation. - . t Homeowners who submit this affidavit indicating they ate doing an work and then hire outside contractors must submit a new affidavit indicating such. . lContractors that check this box must attached so additionst sheet showing the name of the sati-contractors and state whether or not those entities have .- - employees, tribe sub<onuaetors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurancefor my employees. Below is thepolicy and job site information Insurance Company Name: /l�(GI/Yr��/ ( LI/IGIIXG,Z Z, Policy#or.Self-ins.Lie.#: (��' ' — L�� / F_xpiration Date:_ ?s Job Site Address: Z/ �A' P n i S City/State/Zip: <A P m 614 9 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 civic g attics is 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 tlo hereby certify under the pains es perjury that the information provided above is true and correct Sitmature Date: - // O g Phone Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/Liceuse# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector . 6.Other Phone#: Contact Person: i CITY OF SALEM PUBLIC PROPRERTY ni 1•;Sl:,crr # >.111 \I. - lu: 1r'8 '4;.v;•g I ts:'J78.'4}644. Construction Debris Disposal Affidavit (recµtiied lbr all demolition and renovation work) In accordance %%ith the sixth edition of the State Building Code, 780 CMR section I 1 1.5 Dcbris, and the provisions of MGL c 40, S 54; Building Permit If is issued with the condition that the debris iesullin- from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c I 11, S 150A. The debris will be (transported by: Wane of hauler) The debris will be disposed of in (name of facility) - (address of lucilitv) lat - )t liamlt applicant date I !r rr r� y fiat,£ • ffF`Il �/ 'yirli 1,1, IT'e Xf til toJj,y eD,lry f; In r f' Ilu' Yi ibkPA rh -�7r Im.�yJl III r3 ��VV��+�/id•11 Sri • ;�F� ; � ate',;R Y� ✓: i.11 ■ ] '�1i ' tftF,w tF�� IM 1 t�3li IJ iI Sri 4r ).' 4V�lr dr A! i ifi{ ACORDw CERTIFICATE OF LIABILITY INSURANCE �taowo�c .THNS CA781S WM-AS A MAUM 0E-R9 OW4ATWN . .NlaisL Oo.meseial Nta.sae.. amixr ONLY AND CONFM NO NNGHTS UPON THE CMT MTE HOLDEL TRS CEJTTMATE D0E8 NOT ANUM, EXTEND OR IWO C0102 SO - SIVd. R400 ALM THE COVERAGE AFC BY 71E 10LlC1FS B130W. iO"'sots $59520 . - VXURERS AFFOROM C0VENOM NARCf Interlock Tadustries* Tac.- 078MMsL AMMUCAT NWE ASSQRA= CO A,Vassachusette•Ooxpo=tion INFAM e Unit #7, 25 Walpole Park South a0u4au C: etamei 0: Wa ley..M, 02083- eo�t C0VERAM THE POUCti's OF DNSURANCEUS7ED BaAw NAVE 8133E MWED TO THE tlam NA m ABOVE FOR THE POLICY mmo B omm.NOTWRriRSFAR ome ANY N tY,TEAM OR CONDnM OF ANY CONTRACT OR OTHER DOCUABd•Y WITH RES`EC1 TO WH CN TOS C6O6iCATl MY BE MM OR JAAYVERTABL1MRSSURARMAFFOROW'HYTHEVOL3esOESCRMEO PIRS51M=,TOALLTHET68AS.rACUJSONS AND MW IMOFMWH .. -_ P. 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ACQRp2fiOR0O1J08F aAt�C�ORATION 1988 DS#4087279 j att>- Della of Public GAt'ct! is- D Re'=ulutiun, Anti}tand:u'ds -'las%atchu' 5 eci,Ity license 1 Buurd ut'to rvisor P �L Construccs S`101286 License'. Restricted to: RF NICK TERLETSKIY yl DOUGLAS STREET CRANSTON,RI 02910 Expiration: 211 1 1 2 01 2 101205 „mmi•+inrr i t f F I L w n estroof.corn Ne /� g lands S. /a / Agreement Between 574- [ ` S �'-ICY/, INTERLOCK INDUSTRIES, INC. �� 7 ` ` � nit 7, 25 Walpole Park South Registered as a Massachusetts Home Improvement Walpole, MA 1Contractor Registration#139640 Registered as a Rhode Island Residential Contractor# 18345 �Q✓ Customer Service: 866.588.ROOF (7663) fdamt l /, y,41J �4 /5 AAA 0 ,OAO('Buyer") Date Job Add�ess 31 SACk S o N 57-- City/Town 5-A« vYl k19 p Zip Code Buyer's Home Zip Code Address G Work PI)one J s ��� Home Phone (V9 75ZO-7/-sd Cell Phone 7i( — W , 4P7`i0,J R " The Buyer is the registered o ner of th and and premises described in the job address above(the"Premises")and hereby contracts with Interlock Industries, Inc. (the"Contractor')and authorizes the Contractor to furnish all necessary materials and labor to install,construct and place the,improvements according to the following specifications,terms and conditions(the"Specifications")at the Premises. (Circle One): SHINGLE SLATE ,, SPECIFICATIONS YES NO ROOFING MATERIAL YES NO OWNER WILL / / ✓ Supply adequate electrical power. Shingle - Color: LE �D IB Low Slope Roofing—Color: ✓ Be responsible for all rot damage and other necessary Flash Skylights - Number roof repairs. (ie) Roof decking, fascia boards, etc. Flash Vents Roof repair work will be undertaken by Interlock Underlayment Industries, Inc. at a cost to be mutually agreed upon in Snow Guards /9 PCs. advance between the parties. OOF REMOVAL LOCATION OF SHIPMENT: Strip existing roof UNC— layers. XeUwAY o ✓( Haul away roof debris and pay refuse fees. START DATE: SAP ✓ Note location for bin COMPLETION DATE: Supply '/3 plywood. (*4S No7r-p 2?gZaw Start and completion dates are subject to change ,r- 715_,e60C1c' To PRo vio47uP To /oo -W, FT oFPAYao 2�r�•�� .u0 E zr1- �3,O' E ' %°"P le 4 44E ova T CE 0 2�t/s .u`E`�VtE P THIS CON RACT INCLUDES: LIFETIME LIMITED WARRANTY,TRANSFERABLE,NON-PRORATED FOR MATERIALS MANUFACTURED BY INTERLOCK ROOFING LTD. LLUS 10-YEAR LIMITED LABOR WARRANTY PROVIDED BY INTERLOCK INDUSTRIES,INC. IFETIME LIMITED MATERIAL WARRANTY FOR IB ROOFING,PROVIDED BY IB ROOFING SYSTEMS po Financing Requested Yes No Sales Price $ 17 96:5) Sales Tax $ 1 CCte PFD Interest Rate: 12.9%to15.9 Sub-Total $ /Z 90o °— �� Down Payment $ 16— Ay Payment not to exceed $ i� Total Balance on Completion $ /Z goo — O.A.C.(onlapproved credit) MAKE ALL CHECKS PAYABLE TO: INTERLOCK INDUSTRIES, INC. IN WITNIESS WHEREOF, the Buyer and Contractor have hereunto signed their names this_7'�day of� 20d� The contractor and the homeowner hereby mutually agree in advance that in the event that the contractor has a dispute concerni�lg this Contract, the Contractor may submit such dispute to a private arbitration service which has been approved by the Office of Consumer Affairs and Business Regulation and the consumer shall be required to submit to such arbitration as provided)in MGL c 142A. DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES INTERLOCK INDU T IES Signed Y // � ,A,Q��it�(Print na L/ Signed c/o Unit , 25 Walpole Park South T / Buyer WaIr ole, MA 02081 Witness HIC. # 139640 Print Name Relationship to homeowner This Agreement is a binding agreement and contract between the parties. This is not a credit transaction and will not be financed by the Contractor. If financing I required, the Buyer hereby authorizes the Contractor to obtain credit information and the Buyer hereby agrees to provide and sign all necessary documents required by any third party financial institution to complete the financing, immediately on request. The Buyer hereby acknowledges receipt of this Agreement. See reverse of Agreement for additional terms and conditions. All surplus material Is the property of the Contractor. MASC CR0707