15 LAURENT RD - BUILDING INSPECTION The Coninionwealth of Massachusetts
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t � Board of 13ullding Reguluuons and Standards �ICVI( II' \I Ill �
Massachusetts Slue Building Code. 780 CNIR. 71' edition I'.S
ll�'rnJ htnudn
t Building Permit :Applirauon To ('onstruct. Repair. Rcnocate <)r I)rnwlish a I
Qnc- or Fu o-Formilh• [)it"Hin,q 'r1r1s
is Sect on For Official Use Only
BuildinL Permit Number: Dale Applied:
I it m onuar,.irmcr ape. oI IiuildingS D:u
SECTION 1: S1TF INFORNIA HON
1.1 Pro erty Address: 1.2 Assessors Mop & Parcel Numbers
I..la la this Lill accepted sn"eel'.' yes ✓ nu__ :\lap Numher Parcel N'umhei
� 7
1.3 Zoning Information: 1.4 Property Dimensions: I
Zonine Distriel Proposed Use Lot Area(sq li) Frontage (n)
1.5 Building Setbacks (ft)
j Frunl Yard Side Yards Rear Yard
Required Provided Reymred Provided Rcvµtired Pruu dcd
� 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'.' ti7unicipal ❑ On site disposal system ❑
Public ❑ Private O Check il'yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name i Print) Address for Service:
Sgenamic Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New CunStrllCtlon ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(N) Alterations) Addniun ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specily: _
Brief Description of Proposed Work: S
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and :Materials)
I. Building 'S 00 I. Building Permit Fee: 5 %/0- ndicate how ice is deter nuned:
- - ❑ Standard Cityfll,wn Application Fee
2. Electrical 000 ❑Total Project Cost' (Item 6) x multiplier x _
_ I
=. Plumbing 5 Q 0 Q 2. Other Fees: 5
i. Mechanical (HV.AC) 5 List:
i. Mechanical (Fire S _
Suppression)
Total All Fees: S /�Q'
CheckNo/24G Check :Amnunt&0. —('ash :Anx:uin --
0. -rotal Project Cost: .S (� _0 0 O _ aid in Full '❑ Outsumdinc, Balance Due._-
. �---
SECTION 5: CONSTRUCTION SERVICES
7�1
tntction Supervisor (CS1.) £
Licence iN'umber F\pir:Wom Data Lint CSL'fcpc lsn helorsl _
'1- c Desert nun
\ddress
�L C Lnreslncted to i to 1i.1111U Cu. ht.l
�� �1- —�lXi-1'^+"'� R Restncwd I.\' Famih D�%clhn_
.ii_I \I \Llwnn Rk
RC Residential al ILiulinc Coscn mt
['rlcphonc \\'S Rc>ldenu.d \\�indo, .old Sidme Q I
3333 Sl- Rrsidenual Sohd Fuel Burning \phh.in.e In.l.dl,1w u��
D Re>idcuu:d Dem"llown
5 2 Registered Home Ini -
r m oveent Contractor IIIIC)
Irfr Company Name or HIC Registrant Name I 12cgatrauun Numher
FA�7 -lugnyIYK `170 - 11�J ^7333 F.aplrahln, Date
Sign❑ Telephone
A_
SECTION 6: WORKE S' 'OMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to pros ide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes ........ No ........... ❑
SECTION 7a: 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: OWNER' OR AUTHORIZED AGENT DECLARATION
1, , as Owner or Authorized Agent heieby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowleclue and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the paitis and penalties of perjury)
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 a hiti:Lion
program or guaranty fund under M.G.L. c. 112A. Other important information on the HIC program and
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations I M.R6 and I I O.R5. respectively.
� _ When substantial work is planned, provide the information below:
foal flours area (Sy. Ft.) (Including garage, finished basement/anICN, decks or porch)
Gross living area ISy. Ft.) Habitable room count
Number of fueplaces Number of bedrooms
Number of bathnxans Number of lialtfh: ih. _ _--
fspe of heating zystem Number of decks/ porchcn __--
Type of cooling system Enclosed Upen
3. "Total Project Square Footage" may be Substituted tot 'Cot:d Project Cost"
CORD CERTIFICATE OF LIABILITY INSURANCE OPIo DATE(MMODNM)
HFMVRPH 11.08 07
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Thomas Gregory Associates Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
60-1 EdVewate'r Drive S235 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Wakefield MA 01880
Phone: 781-914-1000 rax:781-246-2601 INSURERS AFFORDING COVERAGE NAIC0
INSURED —
INSLRERA Arbe13A Protection Ins. (A)
INSURER 8:
BF Murphy Plumbing S Heatin4,
IncH&Brownsolten Kitcben 6 Bath Iac INSI1RERc:
reet
Danvers MA 01923° INSURER°:
INSURER E'
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED,NOTWITHSTANDING
ANY REOUIREMENT,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.
LTR NS TYPE OF INSURANCE POLICY NUMBER DATE(MMfDDrM DATE MMIDD LIMITS
GENERAL LIABILITY EACH OCCURRENCE $1000000
A X COMMERCIALGENERALUASAITY 8500025389 06/01/07 06/01/08 PREMISESEa�e S 4300000
CLAIMS MODE XO OCCUR MED EKP(Any are Perron) S 5000
PERSONAL A ADV INJL.RY $1000000
GENERA AGGREGATE 12OD000O
GENL AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGG $2000000
POLICY JEECT LOc I Emp Hen. 1000000
AUTOMOBILE UW LITY
COMBINED
A ANYAUTO 99770400002 06/01/07 06/01/08 (Es
w ftN)INGLEUMN $ 1,000,000
ALL OWNED AUTOS
BODILY INJURY S
X scTea.LED anos (Per pelsen)
X HIRED AUTOS
BODILY INJURY S
X NON-OWTED AUTOS (Per ecddeM)
PROPERTY DAMAGE S
(Per ecdde )
GARAGE LMBILRY AUTO MY-EA ACCIDENT S
_.._.ANY ANO OTHER THANEA ACC S
AUTO My AGG S
eXCESSAn,BNeLLA LIABILITY EACH OCCURRENCE 11000000
A X I OCCUR ❑cLAIMs MADE 4600025390 06/01/07 06/01/08 AGGREGATE $1OD0000
S
DEDUCTIBLE S
RETENTION 510000 S
WORKERS COMPENSATION AND X TORY WAITS ER
A EMPLOYERS'LIABILITY 9095020606 06/01/07 06/01/08 E.L.EACH ACCIDENT $S06000
ANY PROPRIETOPRARTNERffXECUTIVE
OFFICERIMEMrBER EXCLUDED? El.DISEASE-EA EWLOYEEI S 500000
1I"a.d ms ribo Lnds,
SPECIAL PROVISIONS Salon E.L.DISEASE-POLICY LIMB 1 S$OOOOO
OTHER
DESCMPT10N OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
,- DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAL 10 DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHIALL
IMPOSE NO OBLIGATION OR LIABILITY OF ANY KIND UPON THE BISURER,ITS AGENTS OR
- - REPRESENTATIVES.
AUTHORIZED SENTA
ACORD 25(2001108) ®ACORD CORPORATION 1868
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BR 0 WN 'S KITCHEN & BA TH CENTER
15 Elm Street • Danvers, MA 0I M-2058
Mailing address: 72 Holten Street,,Danvers, MA 01923
Telephone(978) 774-3333 ' Fax (978) 77478709
Home Improvement License#103611 " Mass. Builders License#073175
CONTRACT
This contract,dated below,for materials and/Or labor to be supplied.by Browns mtehen&Bath Center
(Hereinafter,referred to as the contractor),at the sole request and order of. -
NAME:Debra Lou Stevens PHONE:(978)744-1032 DATE: March 5,2008
ADDRESS:'15 Laurent St. Salem, MA 01970
(Hereinafter refened-to as the owner or buyer)to be supplied/performed at premises set forth above;subject to all of the terms and,
conditions set forth on both sides of the Agreement,asfollows:
Brown's Kitchen and Bath Center is happy to furnish you with a quote on your Bathroom project.
Ca en : We will remove walls to the studs. We will also remove the ceiling.
The outside walls will be insulated The walls will have new blueboard and plaster.
The tub walls will have Durock(cement board)and owner supplied Browns installed tile. !p V
There will also be new trim around doors and windows, and around the base of the room.
We will supply and install a vanity size color knobs are included with vanity.
The vanity will have a Corian counter top with integral bowl.
Above the vanity will be a medicine cabinet 9,-4 ri
Flooring: The,floor will 8e prepared for owner supplied and Brown's installed tile.
Plumbing We will disconnect all fixtures.
We will supply and install a 32"X 60"Swanstone shower,base with. 01 a NN I V yam^
The shower will have a Symmons shower valve.Model#S96-2.
we will supply and install a„Kohler 8"Forte lavefaucet, .
We will supply.and install a Wetworth toilet w/seat#K-3423
All work to be connected to existing plumbing.If airy upgrades are needed a quote will be provided.
Shower Door: We will supply and install a shower door; ($800.00 is allocated for the shower door).
Ileatingy. We will move existing heat.
Ventilation: Fan light vented to outside.
Electrical: We will supply and install.a GFI outlet.
We will supply and install a fanlight.
We will install an owner supplied light over vanity':
All electrical will be connected to existing electrical service, if any upgrades are needed a quote will be provided
(Allowancefor electrical is$1800.00 but this will be quoted):
Additional t?ndons:(Prices are not included in quote)Shower seat.$450.00- Heated,floor: $750.00—3Body
spray with diverter&additional plumbing: $800.00.
*Tile quote is based on a straight installation.Intricate patterns-are higher in price for install.Marble like file is a
higher price for install.
"At time of job all knobs,hamlles, TP holders,towel bars etc. must be on site for installation. if not on site during job _
.. ... . ..___..,i._ ...........,,.L.t...nJ indnll these items.
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CITY OF SALEM
nT rpLl/� PROPRERTY
DEPARTMENT
�1'% :i ri1.i'.�
\'I:`,11.I: 120 WASI IINt;'I'ON S'I Ji G1iT ♦ SAI rNI, MASSACI❑.ti1 I
'I'EI.: 978-74i-9S95 ♦ FAs:978-7a0.98a6
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 c 40, S 54;
Building Permit # _. _ 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
I It, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(mine of facility)
— / (address of facility) ,�y7
signature of ppermO applic nt
—� date
drbrisatl:doe
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\L.��.q< I'� U.�.lu��.!,,�tiu<l.r.r ♦ Sul-.t, SL�.:.�� lu .rl : :t'r.;
1: s; 9,8-, 1_'1841,
Yorkers' Compensation insurance Affidatit: Builders/Contractors/Electricians/Plumbers
> flicant Information Please Print Legibly
N aills thus nesa. it all lza arm.I IIdn Iduall l„�7 t��a KlrIC hOM 'F 1b'-'C1-J��
Address: -7a l b49n-, I,—
Cit State/Zi 1 l(Y>� Phone : 4��" 77Y" t ✓
Y � P�^� ° ^ t
.\,r�e/y�ru an employer? Check the appropriate box: Type of project(required):
1.U l aut a employer with 4. ❑ 1 :mt a general contractor and 1 ti ❑ New construction
em plo •ees(full and/or art-time).' have hired the sub-contractors
],El I am a sole proprietor or partner-
I y p listed on the anached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. Insurance. y. ❑ Building addition
JNo workers' comp. insurance 5. ❑ We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
right of exemption per MGL I I.❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work c gl 52, $1(4), and w have no -1,
myself. [No workers' comp. t ❑ Roof repairs
insurance required.) t employees. (No workers 13.❑ Other
comp. Insurance required.)
-Any;tppI cat t that checks box BI must also till out the section below showing their workers'compensation policy information.
r I lomoowners who submit this affidavit indicating They ore doing all work and then hire outside contractors must submit anew affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
l am in employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:_�� ,.y�;
Policy #or Self-ins. Lic. #: CY�'7 Expiration Date:
Job Site Address: Xi �`�� �� t City/State/Zip:.0
.%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 MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S I•ioo.fo and/or one-year imprisonment, as well as civil penalties in the firm of a STOP WORK ORDER and a fine
of up to S250.00 a flay against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Incestivations of the DIA for insurance coverage verific:uion.
1,14) hereby terrify under the and penalties of perjury that the information provided ohove is true and correct.
1i,�na!uro: Date: c _Z v
I'hnne =
tl//itial use aril}. Do not write in this area, it)he aunpleted by city or town official
Cite or Tow n: _-- ----- --_ Permit/License #--_-----
Issuing Authority (circle( ne):
1. Iloard of Health 2. Building Department 3. C'itvi'1'own Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Phone #:__.
Information and Instructions
\Ia Ssachusetis (icncr:ll Laws chapter-1'2 requires all employers to provide workers' contpen.Na I ion for their employees.
Pursuant m this Statute. an rerplgrre is &I'MCd as "._et ery person in the service of another under any contract of hire.
r\prc,s or implied, oral or written."
.\n eiigdorer is defined as ';m individual. p:itr,cr,hip, association. corporation or other legal entity, or any two or more
""'the fore_oing en aged in a joint enterprise, and Including the legal representam es of a dareased employer, or the
rcceiyer or trustee of an individual, partnership, association or other leeal entity, employ ing employees. however the
,,wrier of a dwelling house having: not more than three apartments and who resides therein, or the occupant of the
dwei6ng house of:mother who employs persons to do maintenance. construction or repair work on such dwelling house
,,I ,it the giounds or building APPLUIemmt thereto shall not because of such employment be deemed to be an employer."
\I(1L chapter 152, 325C'(6) also states (fiat "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, SIGL chapter 152, j25C(7) ,rates"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 lace 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-contractor(s) name(s), address(es) and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies fLLC) 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 fur confirmation of insurance coverage. Also be sure to sign and date the affidavit 'rhe 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 till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit,license number which will be used as a reference number. In addition,an applicant
that must submit multiple permitilicense 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 tilled 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.
"file 0t7ice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate ro give us a call
the Departutcnt's address, telephone and tax 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
Reyi,cd 26-05 Fax # 617-727-7749
www.mass.gov/dia