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399 JEFFERSON AVE - BUILDING INSPECTION G L nJ The Commonwealth of Massachusetts OF Board of Building Regulations and Standards SALEM �i Massachusetts State Building Code, 780 CMR Revised,tlnr 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Only Building Permit Number: Date pplied: rn m DuildingOtTicial(PrintN:une). Signalure lie < t� SECTION 1:SITElNFORMATION' M 0 I.1 PrN Address: 1.2 Assessors blap&Parcel Numbers r� f� el�er5on ( � l\ I.I a Is this an accepted street?yes no Map Number Parcel Number o rr l \^ 1.3 'Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq Il) Frontage(il) 1.5 Building Setbacks(R) Nam-\J front Yard Side Yams 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 es❑ po y SECTION2: PROPERTY OWNERSHIP!" Owner'of Record: kid �hme(Print) City, tote,ZlP '��9P rl ertoz vg�egl7ff 7`IS Y38C' - No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altendion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other O Specify: Brief Description of Proposed Work-: 0 J�t G t teC f u SECTION 4: ESTIDIATED CONSTRUCTION COSTS Item Estimated Costs: Ofilcial Use Only Labor and Mater' ) I. Building S S ' I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Cost'(item 6)x multiplier x 3. Plumbing $ 2' Qiher Fees: S 4. IN (FIVAC) S List: 27 5.Mechanical (Fire $ Total All Fees:S Suppression) "heck No._Check Amount: Cash Amount: 6.'rotal Project Cost: S '( °( 5 ❑Paid in Full ❑Outstanding Balance Due: M,Pd L_EQ '4 �-� SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Super7JU niricted ense NuE.spiratN: neoFCS Huller 0_ CSL Tbelow)t91rA' ypeDescription u. ;md Street 'U icted Duildin a -to 35,000 uu. Il{A-0( LA (/j�yyR ted 1&2 Famii DwellinLL't y(taw ,State,ZIPM RC CoverinS w andSidinSF uel Duming Appliances r Oj da@-a�✓124, I ionTele hone E tail address D ition �legistered Home Improvement Contractor(HIC) ' 1-� V el, 6 (� ,0 r opwd UK 6/ WC-Registration Number Expiration Date HIC Comp:5 Name or HIC Registrant Name Nu.y1d strict D(, Email address Ci / ovn,S ate ►P Tcle hone SECTION&WORKERS'COMPENSATION INSURANCE AFF!DAVIT(M.G.[L e.ISL§25.C(�}, Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the lsivanpe of the building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a:OWNER AUTHORIZATION.TO BE.COMPLETED.WHEN' OWNER'S AGENT OR CONTRACT61i APPLIES FOR BUILDING.PERMIT I,as Owner of the subject property,hereby authorize t act on my behalf,in all matters relative to work authorized by this building permit application. A M�A-(�,err t Is ` 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 and penalties of perjury that all of the information c�Aw ned in this application is true and accurate to the best of my knowledge and understanding. / CJJ��I�. IA-q11,1mLA�s4,` of/,-1 Pit Owne7'S ur Authorized Agent's Name(Electronic Signature) Date 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. 1 d2A.Other important information on the HIC Program can be found at www mass.cav'oan Information on the Construction Supervisor License can be.found at www.mass.eo%'dns 2. When substantial work is planned,provide the information below: 'total tloor area(sq. R.) '� .(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 1. "Total Project Square Footage'may be substituted for"Total Project Cost" f CERTIFICATE OF LIABILITY INSURANCE ' 4 A �... 3/26/2015 THIS CERTIFICATE IS ISSUED AS 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 the terns and conditions of the policy,certain policies may require an endorsement. A statement on this c artificate does not confer rights to the certificate holder in lieu of such endorsements(s) PRODUCER CONTACT Mr.Jay Howlett Chase&Lunt LLC (A IC.No.E,): (978)462-4434 ONE iwc No.:l (978)465-6204 PO Box 590 E-MAIL ADDRESS: jhowlett@chaseandlunt.com Newbulyport,MA 01950 PRODUCER CUSTOMER ID III,. INSURERS AFFORDING COVERAGE NAIC# INSURED INSURER A: Atlantic Charter Insurance Company VDAC 44326 Joe Baranowski INSURER B: V SR Construction INSURER C 167 Fairmount Avenue INSURER D: Saugus,MA 01906 INSURER E: INSURER F: COVERAGES: CERTIFICATE NUMBER: REVISION NUMBER: THIS ISTO CERTIFY THAT THE POLICIES of INSURANCE LISTED BELOW HAVE BEEN ISSUEDTO THE INSURED NAMED"WE IFORTHE POLIGY 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. WSR TYPEOFINSURANCE ADOL Si POLICY NUMBER POLICYEFRECTNE POLMYE11PRAMON LINKS Lm INSR MD DAM(MMNDNY) DAM(MMIDWYY) Iln Thoa9an ) GENERAL LIABILITY EACH OCCURRENCE S COMMERCIAL GENERAL OAMAGETOOWRENTEDPREMSES tNBILItt ) $ CLAIMS MADE ❑ OCCUR ❑❑ ..=n Exc l�ry mvpmm,) e PERSONAL$AW INJURY $ GENERAL AGGREGATE S GEML AGGREGATE LIMIT APPLIES PER PRODUCTS-COMPIOPAGG $ POLICY ❑PROJECT ❑LOC AUTOMOBILE LIABILITY COMBINED SINGLE LINK $ (Ee Aradem) ANY AUTO BODILY INJURY $ ALL OWNED AUTOS ❑❑ SCHEDULEDAUTOS BODILY INJURY $ lEa Araanq HIREDAUTOS PROPERTY DAMAGE NON�OWNOEDAUTOS GEM�denO NMBRELLA ❑ OCCUR EACH OCCURRENCE $ LLla1LKV E%CESS UA9❑ CINMS MADE ❑❑ AGGREGATE $ DEDUCTIBLE $ 3 RETENTION $ WORKERS COMPENSATION AND WCVOII37OOi 03/18/2015 03/18/2016 X $TATLKoav aTHe+ A EMPLOYERS'LIABILITY LIMITS ANTPROPRIETOU-JU NERIE% CUTNE YIN OFFICERIMEMSER UCLUDED9 Y NIA ❑ Policy Coverage State:MA EACH ACCIDENT $ 1 OO,000 MandatM in NH ifms,dmo0e under SPEGAL PROVISIONS babes DISEASE-POLICY LIMIT $ 500,000 The workers'compensation policy do s not provide coverage for Joseph Barano ski. o1SEASE-EACH EMPLOYEE $ 100,000 OTHER ❑❑ DESCRIPTION OF OPERATIONSILOCATIONSNEHICLES III..ACORD 101.AEditanel Rmwks$ uN,H mom spew is m9ulmd) CERTIFICATE.HOLDER CANCELLATION . SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE Alicia and Mark McNeil EXPIRATION DATE THEREOF,THE ISSUING COMPANY IP LL ENDEAVOR TO MAIL l 12 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT. 16 Richardson son St MA 02143 BUT FAILURE TO DO SO SHALL IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE INSURER,ITS AGENTS OR REPRESENTATIVES. UKIORMED REPRESENTATIVE /T ACORD 25(2009109) Page I of 1 CERTIFICATE HOLDER COPY 019M2009 ACORD CORPORATION All rights reserved. s� The Commonwealth of Massachusetts Department of Industrial Accidents al 1 Congress Street, Suite 100 4 Boston,MA 02114-2017 www.mass.gov/dia Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FILED WITH THE PERMITTING AUTHORITY. Applicant Information (( Please Print Le ibly Name (Business/Organization/Individual): rpit f,/U LAJ l(, Address: 1,1p:) I!a.t f0 'hyVL AA_ - City/State/Zip: D Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1 [-am a employer with_employees(full and/or part-time).- 7. [_1 New construction 2.❑I am a sole proprietor or partnership and have no employees working for me in g. ❑Remodeling any capacity.[No workers'comp.insurance required.] 3.❑I am a homeowner doing all work myself. [No workers'comp.insurance required.]1 9. ❑Demolition 4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10 ❑Building addition ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions proprietors with no employees. 12.❑Plumbing repairs or additions 5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof Tepairs These sub-contractors have employees and have workers'comp.insurance.= 6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14N-1 Other 152,§1(4),and we have no employees.[No workers'comp.insurance required.] -Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. tConhactors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'comp.policy number. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: 17hv/t/♦rrC GU / Policy#or Self-ins.Lie.#: W C- a// -3 70 OZ Expiration Date: Jul/g Job Site Address: 2�� (T—Ifif e/S^__,, prq2 City/State/Zip:_4'p(, M& Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do here b c ify under the pains and penalties ofperjury that the information provided above is true and correct. Siznatur Date: % l Phone Official use only. Do not write in this area,to be completed by city or town official. City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: I Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire, express or implied,oral or written." An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required" Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)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 does 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. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the 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 pemniUlicense 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 town)."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 file for future permits or licenses. 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 dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston,MA 02114-2017 Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia CITY OF SALEM, MASSAaiLISE M t° BLUDING DEPARTMENT 120 WASHINGTON STREET,3RD FLOOR 7tL.(978)745-9595 FAX AX(978)740-9846 MAYOR THOMAS ST.PIERRE DIRECTOR OF Pu.BLICFROFERTY/BUIIDING ODMIvIISSIomR 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 c40, 5 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, S 156A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature of applicant Date Ve ®Ro p QW ALCt7A Construction GAF MffMIAIs S/D/NG, AWF/NSj WINDOWS CORPORATION and Much MORE// Saugus , Ma 01906 781-520-1699 04111115 399 Jefferson Ave Salem Ma 01970 978-745-4389 The following is an estimate for work to be completed at the above address in a timely, clean, and professional manner. Waste removal is included and permit is included as needed. A) Tarp all around the house. Be extra careful of shrubbery as shingles fall. B) Strip off all existing roof shingle off the whole home. (CTp to 2 layers included). C) Replace up to 32 sq ft of rotted wood if needed at no additional cbarge. D) Install new white metal drip edge to the roofperimeter. E) Install ice and water shield to the roof perimeter and all hips and valleys 6ft. Cover the rest of the roof in upgraded syntbetic underl yment. F) Replace all ventp pe boots as needed. G) Reflash chimney. Install shingle to the dormers also ere are s ' akd now. H) Install Owens Corning lifetime Arrhitectural shingle n Black/ or roy color. I) Clean all thegrounds. The total investment amount for the above project is.$9,995.00.-37vill be onsite the entire time the project is going on. This is a 1-2 dayprojectpending weather conditions. Please call me with any questions. rq r, afpvc�s.e v y osep ` aranowski PLEASE ALIKE CHECK PI : JOSEPHBARANOWSKI IS YEAR W NALL LABOR ca0875 3 r �V r� 1 OTice et °'�t°xu�eal!/z.d�v�'[acy _ uasnmer At.a� vn<r�� M`iMPROV c Business Regutahou egistr2hon EM'NTCONTRACTOR x . o \459091 K, C w 'g�d36 Do . yeti � F _ i t ;r - _ , JOSEPH BARANO[A�SKF s��j 1� - 167,FAIRMONTAVE �' -�% E ..._._ SAUG NU _ US,MA 01906 ' t < t Uodenec etay .i Massachusetts -Department of Public Safety t, Board of Building Regulations and Standards I Construction Super,isor - 6 License: CS-087573 JOSEPH E BARANbw 167 FAIRMOUNYA ' Saugus DlA 01909 t Expiration * Commissioner 09/30/2015` �tI I .a LA ' Y