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110 JEFFERSON AVE - BUILDING INSPECTION (2) G OLf The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: ° Date A lied: to Z 3 Building Official(Print Name) Signature bate SECTION 1:SITE INFORMATION 1.1 Property Address: S 1.2 Assessors Map&Parcel Numbers ���t�R-So-IJ �1`l� 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number 1.3 Zoning Information: IA 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? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP[ z.brpl 10 ko r r of rd: � D 19 -7 0 Name(Pmt`tf City,State,ZIP I I O -CStrn Adc Q?S 74N-9535i No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ I Existing Building Owner-Occupied ❑ Repairs(s) t� Alteration(s) ❑ 1 Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed Work2:_ � n cR— �'ti eel u YJU cI Trim l�4�-tn1 2oOF SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ (�00 — ❑Paid in Full ❑Outstanding Balance Due: END -A-0 Za F) kW\W\O 1,3'D Sj SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) �7cy q `J y I— Q cY j r y 10J A l�Q¢.� License Number Exp Name of CSL Holder Ada t �PrS re Lry S List CSL Type(see below) Noy�dS'jtr�e�et� �(� Q (�., Type Description Y \ " -- � " ' "A ( ` o9 R Restricted 1&22 Fted ammil sDw tip elling 00 cu.ft. City/Town, Z� h& Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances gi W- 4 7 q -7 yZP I Insulation Telephone Email address D Demolition 5.2 Registered Home -Im�provem nt Contractor(HIC) _ L 1 0 - 14 1 O� HI Registration Number Exp do Da HIC Comp y Name HIC Re i t l�'la--, 9 .asIS��-te S� t and m tr t n ! 1 n( q,7 (S-t'� 7 t17 b Email address i /Town,State, rT U l In / 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 ..........X, No...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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. se � l 'n G J Ic ZZ Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. Print Owner's r Authorize Agent's me(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 Information on the Construction Supervisor License can be found at 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,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" q6b ERIC A. TEEL ROOFING - 1 Commercial and Residential • Fully Insured - 79- ROOFING ESTIMATE !f ESTIMATE SUBMITTED TO: r I f JOB NAME JOB# � � f�{ nn1 ✓Plik:rywiy' ai�2(tl ''r� '1,!-/+'1 -' ADDRESS JOB LOCATION / /C. }Iv < i+ CITYISTATE(LIP t DATE li PHONE# FAX# CELL#Vl ? j" -WE HEREBY AGREE TO SUPPLY THE MATERIALS AND LABOR AS SPECIFIED IN THE MARKED BOXES BELOW... NOTE:ONLY THE MARKED BOXES/PERTAIN TO YOUR ESTIMATE. WE AGREE TO: O 1. COMPLETELY STRIP THE ENTIRE ROOF(S) OF THE EXISTING LAYERS OF SHINGLES. O 2. INSTALL A NEW LAYER OF SHINGLES OVER THE EXISTING ONE LAYER OF SHINGLES ON ROOFS. c0 3. INSTALL A NEW RUBBER ROOF(S), USING ALL NEW RUBBER ROOFING MATERIALS ON THE O 4. INSTALL NEW ICE&WATER SHIELD ON ROOF(S), ROOFS EDGE, RAKES,VALLEYS, DORMERS,SKYLIGHTS,CHIMNEYS,&FLAT ROOF AREAS. IIO 5. INSTALL NEW LB.ASPHALT FELT ROOFING PAPER ON THE ENTIRE ROOF OF THE 6. INSTALL NEW A INCH ALUMINUM DRIP EDGE ON THE ENTIRE II ROOF(S). ®. 16. SPECIAL CONDITIONSt?�L fT I!n +s t tr k ,_ i �r% 4 ft//^ f y t/ f NOTE: WE CANNOT ACCEPT RESPONSIBILITY FOR DEBRIS FALLING INTO ATTIC AREAS.CUSTOMERS SHOULD COVER VALUABLES, GREAT CARE WILL BE USED TO PROTECT THE STRUCTURE BY COVERING EXTERIOR WALLS,OBJECTS,AND FOLIAGE WITH TARPS TO HELP PREVENT ANY DAMAGE DURING THE STRIPPING OF THE ROOF.HOWEVER SOME DAMAGE AND MARRING COULD OCCUR BEYOND OUR CONTROL... - NOTE: (IF)MORE LAYERS OF ROOFING MATERIALS ARE FOUND THAN INDICATED ABOVE,AN EXTRA CHARGE WILL BE ADDED FOR THE LABOR&THE REMOVAL OF DEBRIS OVERHAND ABOVE THE PRICE OF THE ESTIMATE. We propose hereby to f r ish material and labor-complete in accordance with the above specifications for the sum of: 2C�nc Fes, 1.f1 �y�u° �� r=1 /�!i' 1-_ �-- _ Dollars L r Of r with payments to be made as follows: ; r 71 (,tr-P` TJ .Any alteration or deviation from the above specifications involving extra costs Respectfully will be executed only upon written order,and will become an extra charge over submitted and above the estimate.All agreements contingent upon strikes.accidents,or delays beyond our control. Note-this proposal may be withdrawn by us it not accepted within days 2creptattce of Prifibl IThe above prices,specifications and conditions are satisfactory and are hereby Signature accepted.You are authorized to do the work as specified.Payments wilt be made as outlined above. l Date of Acceptance — Signature AC" CERTIFICATE OF LIABILITY INSURANCE °"'�(MMUT"") vk " 10/17/13 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(tes)must be endorsed. N 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 endorsemen s. PRODUCER CONTACT NAME: Circle Business Ins. Agcy, Inc PHONE — FAX N 247 Newbury Street EaINL aoDRe$s: Danvers, MA 01923 INSURER(S)AFFORDING COVERAGE NAIC M INSURERA:SafetV Indemnit INSURED INSURER B:Seneca Insurance Eric Teel INSURERC:Continental Indemnity Company Po Box 46 INSURER D: Rowley, MA 01969 INSURER E: I::BR F: COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICES 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.LMIITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR AWL SUM PO EFF POLICY EXP LTR TYPE OF INSURANCE POUCY NUMBER MnD/Y NMIDIYYYYY UMTS j B GENERALLIABILITY BAG-1009822 12/20/12 12/20/13 EACH OCCURRENCE $ 1,000,000 X COMMERCIAL GENERAL LIAB ILITY DAMAGE TO RENTED $ 100,000 DIAR&MADE OCCUR MEDEXP(Ary Ompersm) 8 5,000 PERSONALBADVINIURY $ 11000,000 GENERAL AGGREGATE $ 2 00O 000 GEN'LAGGREGATE LIMITAPPLIESPER PRODUCTS AGO E 2 OOO OOO 17 POLICY X PR0. LOC $ A AUTOMOBILE LKINUTY 6219821 9/10/13 9/10/14 (CEO W eDit INGL LIMB $ 1 OOO O00 ANYAUTO BODILY INJURY(Per person) $ ALLOWNED X SCHEDULED BODILY INJURY(Per xadenq $ AUTOS ANONUTOS PROPERTY DAMAGE y X HIREDAUTOS X AUTOS-OWNED erawd at E UNBREU.A UAB OCCUR EACH OCCURRENCE $ EXCESS LIAB CLAIMS-MADE AGGREGATE $ DIED RETENTION$ 1 $ L. WORKERS COMPENSATION 46-819686-02-04 11/19/12 11/19/13 WC STATU- X 11 OTH- AND EMPLOYERS!LIABILITY YIN YIN N/A EL.EACHACOD'ENT S 500,000 OFFICERM.EMBER EXCLUDED? (Mandatory In NH) EL.DISEEASE-EIAEMPLOYEM 11 500,000 UYes describe under DE SCRIPTION OF OPERATIONS below EL.DISEASE-POLICY LIMIT $ 500,000 DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (AGach ACORDIM,AddtdonMRmft Stl ,tf o spacebmgti dI CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN Bouchard Brothers LLC ACCORDANCE WITH THE POLICY PROVISIONS. 110 Jefferson S-____-A /C Salem, MA 01970 AUTHORIZED REPRESENTATIVE Michelle Graves/CSR ©1988-2010 ACORD CORPORATION. All rights reserved. ACORD 25(2010105) The AC ORD name and logo are registered marks of ACORD Phone: Fax: E-Mail: . . . � \ ] yoil. ■ h / rct \] . § at \ gig � « t . � . . .