7 LAWRENCE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR S
Revised dMar Mar 20!!
I Building Permit Application To Construct,Repair, Renovate Or Demsh
One-or Two-Family Dwelling
This Section For Official UserOnly
Building.Permit Number: Date Appl'
Building Official(Print Name) Signature Date
SECTION is SITE INFORMATION
1.11 roper 'AQdrg /,� 1.2 Assessors Map&Parcel Numbers
� /`�iLCdr�--F
1.1 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 ft) -Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
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 Cl On site disposal system ❑
Check if yes❑
e�' 7 /SECTION 2: PROPERTY OWNERSAIPt
2.1, Owl-(�i/LL'esr/7 AkyIe cam.
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION.3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Wo 2•0 _
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials `
1.Building $ L1 DD 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard Cny/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (RVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
$6.Total Project Cost: �j 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Expvat
Name of CSL der
> O List CSL Type(see below)
No.and J J�- Q/ Type Description
/�� U Unrestricted(Buildings u to 35,000
/- ?'i R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
l WS Window and Siding
SF Solid Fuel Burning Appliances
/ 1, Insulation.
Telephone Email address H Demolition
5.2 Regis ered a e Improvement Contractor(HIC)
E � �,4 . D
eg�ty���y MC Registration Number Ex�p/iry7ion Dlt�o
HIC Comp e No.an /9'� ,L Email address ^
City/Town,State,Z 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 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACT�O,tXR,APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize !�/ ° O`YJSJ�LLlC-ZGG7z
to act on my behalf,in all matters relative to work authorized by this building permit application.
,�, - 43
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'ORAUTHORIZED AGENT DECLARATION ''
By entering my name below,I hereby a est under the pains and penalties of perjury that all of the information
contain is:n=--
curate to the best of my knowledge and understanding.
5--Z- 13
Print Owners or AutorizeiI Agen s Nam Ele on 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
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/di)s
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Print Form
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
19 www.massgov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business/Organization/Individual):D&H Construction Co.,Inc.
Address:33 Central Street
City/State/Zip:Peabody, MA 01960 Phone #978-532-8188
Are you an employer? Check the appropriate box: Type of project(required):
1.❑ I am a employer with 64 4. ❑ I am a general contractor and I
g ❑
employees(full and/or part-time).* have hired the sub-contractors 6. New construction
2.❑ I•am a sole proprietor or partner- listed on the attached sheet. 7. ❑✓ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ 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 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.❑� Roof repairs
insurance required.] t c. 152, §1(4), and we have no
employees. [No workers' 13.❑ Other
comp. insurance required.]
*Any applicant that checks box#1 most 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.
:Contractors 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 most provide then 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:Continental Indemnity Co.
Policy#or Self-ins. Lic.#:46-829387-01-03 Expiration Date:8/6/2013
Job Site Address:7 Lawrence Street City/State/Zip:Salem, MA 01970
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 civil penalties in 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 IA for insurance coverage Jerification.
I do hereby ce er he ins d enal ' erjury that the information provided above is true and correct
Signature: - Date
Phone#: — 7
AK-
OJrcial 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#:
n
li, R CERTIFICATE ®F LIABILITY INSURANCE DATE
07 as 5 OD cola012
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(les)must be endorsed.If SUBROGATION IS WANED,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 hostler in lieu of such endaraement(s).
PRODUCER CONTACT
NAME:
Applied Risk Irieurance Services, Inc. l HO No,Ext): 877 a34-44a0 f�.No): 877 a34-44a1
10825 Old Mill Rd E-MAIL
Omaha, tom, 68154 ADDRESS:
PRODUCER
CUSTOMER ID A
(877)234-4420 INSURERS)AFFORDING COVERAGE NAIC6
INSURED INSURER A: Continental Indamnity Co. 28258
DGH C®atructian Co., Inc. INSURER B:
d a. D&H canatxucticn Co., z=. INSURER C:
33 Central St INSURER O:
Pesbot�, MA 01960-4339
INSURER E:
CTL 1273 653538 INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES 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 CONTRACTOR OTHER DOCUMENT WITH RESPECT TO
WHICH THIS CERTIFICATE MAYBE 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.
INSR ADDL SUER POLICY EFF POLICY EXP
LTA TYPE OF INSURANCE INSR WVD POLICY NUMBER MM/OD/YYY MMID LIMITS
GENERAL LIABILITY EACH OCCURRENCE S
COMMERCIAL GENERAL LIABILITY ❑ ❑ DAMAGE TO RENTED
CLAIMS PREMISES Ea...m $
MADE OCCUR MED EXP $
PERSONAL S ADV INJURY $
GENERALAGGREGATE $
GEN'LAGGREGATE LIMIT APPLIES PER:
PRODUCTS-COMPIOP AGG, S
POLICY PROJECT LOC $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT
ANYAUTO ❑ ❑ (Ea eccidano $
ALLOWNEDAUTOS BODILY INJURY Pe, $
SCHEDULEDAUTOS BODILY INJURY Pere¢ r $
HIREDAUTOS PROPERTY DAMAGE
Per amdent $
NON-OWNED AUTOS
$
UMBRELLA UAB OCCUR EACH OCCURRENCE $
EXCESS LIAB CLAIMS-MADE ❑ ❑ AGGREGATE
DEDUCTIBLE: , $
RETENTION $ $
WORKERS COMPENSATION WC STATU- OTH.
AND EMPLOYERS'LIABILITY YEN T LIMITSER
ANY PROPRIETOR/PARTNER/ I�
EXCLUDED? FFICENMEMBER i I N/A ❑a6-aa9387-D1-03 08�06�203a �D6/2W3 E.L.EACH ACCIDENT $
(Mandatory in NH) LL���I E.L DISEASE-FA EMPLOYE $ 0
It M.desaibe under
SPECIAL PROVISIONS below E.L.DISEASE-POLICY LIMD $
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLES (Attach Acord 101,Additional Remarks Schedule,if more space Is required)
CERTIFICATE HOLDER CANCELLATION
D&H Clonstruction CID., 3bnc. SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE
EXPIRATION DATE THEREOF,NOTICE WILL BE DELIVERED IN ACCORDANCE WITH
33 Central St THE POLICY PROVISIONS.
Peahocbr, MA 01960-4339 AUTHORIZED REPRESENTATIVE /)
'tta' �� CJ 83118
ACORD 25(20OWM The ACORD name and logo are registered marks of ACORD ® 2009 ACORD CORPORATION. All rights reserved
CONSTRUCTION
33 Central Street Peabody;MA 01960
(978)532-8188 FAX(978)532-7477
www.mydandhconstruction.com
Construction Contmct
This agreement made tliis l:�day of 0-4�Z 2013 by and between Theresa
Pelletier of 7 Lawrence Road, Salem, MA herein referred to as "Owner", and D & H
Construction Company, Inc., of 33 Central Street,Peabody,Massachusetts, 01960,Mass.
Contractor Registration No. 102798, herein referred to as "Contractor". Owner and
Contractor in consideration of the mutual covenants hereinafter set forth agree as follows:
Contractor shall furnish all labor and materials necessary to perform and complete the
work described below upon the following described property,which Owner warrants he
owns,free and clear of liens and encumbrances: - 7 Lawrence Road, Salem,MA.
The work,which shall include all of the labor and materials necessary for the completion
thereof,shall consist ofthe following:
Strip existing asphalt shingle roofing down to base and dispose.
Repair/replace damaged sheathing or roof boards as needed prior to-covering(100 sq. f .
replacement allowance).
Supply and install new premium 30-year Certainteed"Landmark"self-sealing
architectural asphalt/fiberglass roof shingles over a layer of felt paper.
Install ice and water shield membrane to first sbc feet of edge.
Install white eight inch premium aluminum drip edge flashing to perimeters_
Install vent pipe flashing as needed.
Cut 2"opening in existing ridge for ventilation prior to installation of new ridge vent.
Install premium"Cobra"ridge vent and cap.
Re-seal existing chimney flashing and replace lead flashing as needed.
Color of roofing materials to be chosen.
Clean and remove debris. - $6,000.00
Contractor shall perform the work in conformance with such plans and specifications, if
any, as have been provided by the owner or the contractor,which plans and specifications
shall be deemed incorporated into this contract by reference,and will do so in a
workmanlike manner. Contractor is not responsible for performing any work not
specifically referred to in this contract.
Owner shall pay contractor the sum of Six thousand dollars, ($6,000.00), in installments
as follows:
($2,000M), upon signing this contract.
($2,000-00),upon delivery of materials and start
($2,000.00),upon completion ofthe remainder of the work called for under this contract.
In the event any installment is not paid when due,contractor may stop work without
breach until payment is made and for five (5)days thereafter. In the event any installment
is not paid within ten(10)days after it is due,Contractor may,at its option deem.this
-
contract terminated by the owner and may take such action as may be necessary,
including initiating legal proceedings,to enforce its rights hereunder.
At all times during construction,Owner shall provide and maintain free and unobstructed
access to all areas of the site where the work will be performed and shall provide,at
Owner's sole expense,water and electrical service.
Due to the nature of construction there may be some damage to the landscaping-
Dtunpsters and heavy equipment may be necessary and may cause damage to the
driveway blacktop and lawn.As long as Contractor shall exercise reasonable care,it shall
not be liable for any damage to the above-mentioned landscaping,lawn_,or driveway. _
— NOTE:Hammering to walls,roofing,and around windows may cause dust in attics,
plaster cracks, and things falling.
Contractor shall not be responsible for claims for damages to persons or property
occasioned by Owner or his agents,third parties, acts of God or other causes beyond
contractor's control. Owner shall hold contractor completely harmless from,and shall
indemnify contractor for,all costs,damages, losses, and expenses,including judgments
and attorneys fees,resulting from claims arising from causes enumerated in this
paragraph-
1.All work shall be completed in a workmanlike manner and in compliance with all building codes and
other applicable laws.
2.To the extent required by law all work shall be performed by individuals duly licensed and authorized by
law to perform said.work
I Contractor may at its discretion engage subcontractors to perform work hereunder,provided Contractor
shall fully pay said subcontractor and in all instances remain responsible for the proper completion of this
Contract
4. All change orders shall be in writing and signed by both Owner and Contractor. Contractor shall be
responsible to provide only the work described in this contract and in such change orders as may from time
to time be agreed to between Contractor and Owner. All change orders shall specify in detail any
additional work called for and the price for such labor and materials as shall be necessary to complete such
additional work
5.Contractor warrants it is adequately insured for injury to its employees and any others incurring loss or
injury as a result of the acts of Contractor or its employees and subcontractors.
Contractor snail at us own expense obtain an permits necessary tor me work to be.performed.
Contractor shall not,-however,be responsible for obtaining any variances or other zoning relief.or for the
cost thereof.as may be required to enable the Contractor to obtain a building permit
=�-ctor shall not be liable for removal reeahbr on_or renlacement of alarm systems_satellite
dishes,wall or window air conditioning units or faulty cable,electrical,and telephone connections.
8. Contractor shall not be liable for any delay due to circumstances beyond is connoi including MIKes,
casualty or general unavailability of materials or the discovery of the conditions or defects upon me site or
in the structure(s)thereon not known to the Contractor at the time of execution of this contract and which
may be discovered during the course of the Contractor's completion of the work- In addition,the Owner
acknowledges and agrees that in certain remodeling work the demolition of portions of the pre-existing
structure may reveal additional defects,conditions or the need for additional work which must be repaired,
aitered orca ricd out in order to commence or complete the work called for in this contract In such case,
the Owner agrees that the duration of the work and any scheduled date of completion may vary from that
which has may be set forth herein and Owner agrees execute a change order detailing the cost and scope of
the additional work necessary to repair,correct or alter such additional defects and conditions.
9. Contractor warrants All work for aperiod of 36 months following-completion.This warranty.is void if
payments have not been made to Company Agent or Foreman when due and in the full amount specified.
10. Owner agrees that in the event it becomes necessary for Contractor to collect any payments called for
hereunder or to enforce any provision of this agreement,Owner shall be responsible for the costs of such
collection or enforcement,including reasonable artorney's fees.
You may cancel this agreement if it has been signed by party thereto at a-place
other than an address of the seller,which may be his main office or branch thereof,
provided you notify the seller in writing at-his main office or branch by ordinary
mail posted,by telegram sent or by delivery,not later than midnight of the third.
business day following the signing of this agreement.
Signed this day of 2013.
� f. / 7
Company Representative
Owner Owner
a�me�Ofc SafetyRegulationsandards
lylassachuserts -pep
Board of Building
Construction Suimr�'isor
License: C59 S-068 I
MICHAELMSWIRO s
33 CENTRAL ST% ( IV
PEABOOY MA ff19
` Expiration
6611712014
sJCommissioner _
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CITY OF SM E, , NI.1SS.�CHUSETTS
B1:I mD:G DEPAR .m-
P 130 WASHLNGTON STREET, 3�FLOOR
dj T FL. (978) 745-9595
FAX(978) 740-9846
jCNtBFRt F.Y DRISCOLL
T
MAYOR 1�io>►t�s Sr.P[FRRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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:
M <�ITA-j'6 epP lAc- A;"
—� name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
f
signature o permit app ' ant
2� -/ 3
date
e�ed�irax