49 LARCHMONT RD - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
s� Building Permit Applicatt To C nstruct, Repair, Renovate Or Demolish a
ne`or Tx' -Family Dwelling
his Se ion For Official Use Only
Building Permit Nuryl5crj Date Applied:
Signature: WT
Buildi g Commissione rpbb3qrlof Buildings Date
SECTION 1: SITE INFORMATION
1.1 Prppe ylAddress: I^ _I_ _ 1.2 Assessors Map& Parcel Numbers
this
n accepted
Yu'street?
y' Ma Number Parcel Number
I.1 a Is this an accepted street. yes no P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(R)
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'
2.1 Olyner'of Record:�/ ( -?_ i rci C f
Name � / Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Spe ifs:
Eirief Description of Propos d Work": f
44
SECAION 4: ESTIAVfl(Dc6N§TRUCTIOr4 COSTS
Estimated Costs:
Item Labor and Materials) Official Use Only
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 $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 7-:;od,- ❑Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
N14 of CSL-Helder List CSL Type(see below)
L Type Description
Address
U Unrestricted(up to 35,000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature 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 7s: 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.
Signature of Owner Date
SECTION 7b: OWN Rt OR AUTHORIZED AGENT DECLARATION
1, LL ,as Owner or Authorized Agent hereby declare
that t tatements and information on a foregoing application are true and accurate,to the best of my knowledge and
beh
Print Namb -� ia,d S ..
Lie?, v
Signature of Owner or Authorized Agent Date
(Signed under the pains 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
(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 I 10.116 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total Floors 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 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"
Bobing, lttiflf�&�
Construcgon Su o ° ° • a
Pervisor License
License: CS 85195
BirtAdaW-:, 1/30/1962
EyWreti6n: IA0/2009 TrN 7639
Restrieti6n 10�
41.
JOHN C OROURKE
180 MAIN ST UNIT 6304'A.
BRIDGEWATER,MA
Commisatoser
71.
Board of Bldiding Regulatio s and Standards
HOME IMPROVEMENT CONTRACTOR
RegistrMion: 139929
Expireti0n: 9/3/2009 Trp 133611
.y. lope: DBA
ON TOPROOFING&CQNSTRUCTi6h
JOHOa'ZSYROURKE .
1.05 ELM ST.
BRIDGEWATER, MA 02324 Administrator
On Top Roofing &Construction
105 Elm St.
Bridgewater, Ma. 02324
(508) 697-8934 (617)%7-3262
Date:9/15/2008
Submitted to: Specifications and Estimate for:
Beth Gerard New Roof at
de-oJ rZ &JD/a to 49 0 Road
tvh7 Saleemm,, M NfA 01970
79! 63/ 9984
Strip off existing roof layers on main house and garage.
Fix any rotted wood, if necessary, at an additional cost.
Apply ice and water shield along eves and valleys.
Felt paper remainder wood exposed.
Add 8" white drip edge around perimeter of roof edges.
Install 30 year wood scape shingles with new pipe flanges and flashing along the chimney.
Cleanup all debris into an onsite dumpster.
Total Cost for Materials and Labor: $7,500
Payments to be made as follows:
$4,000 to start. $3,500 upon completion.
All material is guaranteed to be as specified. All work to he completed in a workmanlike manner according to
standard practices.
Acceptance of Proposal: The above prices, specifications and conditions are satisfactory and hereby accepted.
You are authorized to do the work as specified. Payment will be made as outlined above.
Signature
Signature
CITY OF SALEM
_`; PUBLIC PROPRERTY
DEPARTMENT
:Ien;:K:IiT akisd:w Il.t.
12C W ASHIN .IONS I RUT • SA Ltix4,MASSACI tt:.%I IS 0197C
11a.:978-745-9595 • 1':+x: 978-740-9.146
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Ani licant Information Please Print Leeibly
Name (BusioexsiOr�g �anizatiorvindividual): -bn/ 1-2 eg
Address: 2 rn < t JI
r q /,�
City'Statci%ip: l)� p�
� l'honer'./: � 07 a /�i'
Are you an employer? Check the appropriate box: 'Type of project(required):
1.❑ I an ter a employer with 4. ❑ I am a general contractor and 1 G.p y ❑ New construction
ployces(full and/or part-tine).• have hired the sub-contractors
2. I am a sole proprietor or partner- listed on the attached sheet. : �• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.) otlicers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself. [No workers' droop, c. 152, §1(4),and we have no 12.❑ Roofrepairs
insurance required.] r employees. [No workers' 13.0 Other
comp. insurance required.]
•.Airy,yphcaul that checks box AI must:dsu Iill out the action below showing(heir w•orkaY cumpensulion policy information
'I10MCllwtten who submit this affidavit indic:uing they are doing ant work and(lien him outside contmerom must>utnnit anew affidavit indicating much.
�Contracton that check this box meat ulachdd nn additional mhmt showing th¢name of the subcontractors and their workers'comp.policy information
1 am can employer that i.+•providing)vorkers'coinpensatiaii im.surrmtee for•mty employees. Below,is the policy and job site
information.
Insurance Company Name: . . . .. ......._...__.---__..—_-----
Policy is or Self-ins. Lie. if: —__....... ..-_ _ ._-____ Expiration Date:
Job Site Address: _. Cityistawizip:
Attach it copy of llte workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of:v1GL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the 0111ce of
luvcstigalitns ufthe DIA for insurance coverage verification.
l do hereby cert y mn, the pains ay penalties of p jury that the information provided above .s true nd correct.
Sle:lalllre: Dat f
Plvwc?:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: ._..__ -_ Permit/License 0-____._._
Issuing Aulhurily (circle one):
1. Board of llealth 2. Building Department 3.City/fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
L.Other
Contact Person: _..... ...._-- Phone th
Information and Instructions
\lassadm;etts 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
r 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 :ut 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 shatl 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 time 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 retunmCd 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 time affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be.cure to till in the permittlicense 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
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. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please du not hesitate to give us a call.The Department's address, telephone and fax number:
�" ` The Commonwealth of Massachusetts
Department of Industrial Accidents '
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Revised 5-26-05
www.mass.gov/tiia
CITY OF SALEM
A a PLIBLIC PROPRERTY
DEPARTMENT
d `.ii .I` 121' A \;InM..,INS I L I'T • $.\I I \1. Nhli\I P. aI ;,:I'I -
I I I: 978-'45-'1i95 • 1'.\X: 9�8 .'4 -16'41,
Construction Debris Disposal Affidavit
(re(luired lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 ChiR section 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit tt -. 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:
1/U
(name-of hauler)
The debris will be disposed of in
(name of facility)
(address urlacilily) l
Y mil'/
of permit app cant
/6 3 e
(late -----