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14 LINCOLN RD - BUILDING INSPECTION (2) 25 uc ( p3 The Commonwealth of,Massachusetts"E ' t C$lr f R- 'wS, CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 78 1 v q�p �� ,12. h* � l�e 'se J afar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a �- One-or Two-Family Dwelling �. This Section For Official Use Only ( A led: /✓/rim( Building Permit Number: Date P ` Building Official(Print Name). Signature•. , Date SECTION I:SITE INFOR,NIATION 1.t Property Addres : 1.2 Assessors Nlap&Parcel Numbers fir / .�..�willy �C� �a•LGIr•� MY1 D I�ZD I.I 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 tl)',,.. Frontage(11) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yani Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40,§5J) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ SECTION2: PROPERTY OWNERSHIP' ^� p 2.1)wecor r^ ,(m M l I 0 me(Pool) City,-state,ZIP .iI. Lty)edin 2 1 �i3 T t1//� .6jjje_2G�16M No.and Street Telephone Email Addre SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building Erl Owner-Occupied (7-f Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Nun berof Units_ Other Specify: Brief Des ription of Proposed Work': SECTION is ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials) I. building S 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S •t. MCchaniC01 (11VAC) S List: 5. \fechanic;d (Fire S Total All Fees:S Su ression) I Check No._Check Amount: Cash Amount: 6. Total Project Cost: .S !�D tV— ❑Paid in Full ❑Outstanding Balance Due: Fo c)L4\J�-_ tu , C) U SIGN l � L-tt\ICO�-tJ 2� � fL�rt�2-ram �D C,f� OF Sra1.� SECTION 5: CONSTRUCTION SERVICES 5.1 C nstruction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL'rype(see below) Type - - Description No.:md Street - s U Unrestricted(Buildings up to 35,000 cu.tl. R Restricted 1&2 Family Dwelling Cilyfro%m,Stale,ZIP N Nlasonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation T5.2 one Email address D Demolition Rc istered Home Improvement Contractor(HIC) HIC Registration Number Expiration Date HIC Compemy Name or tilC Registrant Name No, and Street Email address C ity/Town,Torun,State ZIP Tele hone SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.O,L.C. 152.§ 2$C(6)), kers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide ffidavit will result in the denial of the Isivance of the building permit. ed Affidavit Attached? Yes ..........❑ No...........O 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 t9 act on my behalf,in all matters relative to work authorized by this building permit application. ' t Owner's Name(Ele irronic Signature) Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 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 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 I.G.L.c. 142A.Other important information on the HIC Program can be found at www mass.eov:'oca Information on the Construction Supervisor License can be found at wwtv.ntass.scn:'Jns 2. When substantial work is planned,provide the information below: 'total floor 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 `lumber of half/baths Type of healing system Number of decks/porches "Type of cooling system Enclose) Open 3. "I'otal Project Square Footage"may be substiuued far"'Coed Project Cost" MANL _ p-g-Kt.-C To +\. b . t L I1J C©t_N 2fD fLe-rt>2s �o G.r-L� O F SI--rL,EErA SECTION 5: CONSTRUCTION SERVICES 5.1 L nstruction Supervisor License(CSL) 9 �A n ,�-f�- License Number Expiration Uate Name of CSL tioolder L , List CSL Type(see below) WJ I ! 'YL l�T r'/�� "Type :._ Description No.wd Suect - �5i)(w-' ` a� �� U Unrestricted 2 Family su Dwellito ng 00 cu. ll. ('` r'I C.•�U `1 R Restricted I&2 F:unit Dweilin Cityrro+vn,State,ZIP �- M Masonry RC Roofing Covering 1 Window and Sidinx S Solid Fuel Bruning Appliances 1 Insulation •e une mail address D I Demolition 5.2 it istered florae Improvement Controctor( 17 -W� 2 16 I 11C Registration Number Expiration Date tuC C hp: y ame or ti11C Regis nt Name 1�7r7 VVlL1,lVl l� t�Vr &&at flahTla No. ul eet y, 77 Email address Ci /Town State Z Tel ( 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 isivance 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 t9 act on my behalf,i artersrefative to work authorized by this building permit application. t Owner's Name(Elec Signature) Dale 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 contained in this application is true and accurate to the best of my knowledge and understanding. Dave iz- 1"V Print Owner's or Amhurized:\gcnt's N;one(Eleevunic Stgnamre) Dute 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 no 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 ew.v.ncrss.eav:'oca Infommtion on the Construction Supervisor License can be found at w+v+v mass.eov!dns 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch) Gross liying area(sq. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of ballrooms Number of half/baths ` 'type of heating system Number of decks/porches - "rypeof cooling system Enclosed Open .i. "1'oial Project Square Footage"may be substituted fur"'focal Project Cost" {MALL_ pC-:rZ-K LY '[O FV v . Q SWEEPNMAN INC. Estimate# 1448 Chimney & Fireplace Estimate Jeff Olive 14 Lincoln Rd Salem, 01970-4456 Nov 08, 2016 Pellet stove- Installation of new pellet vent where the stove is being moved to. Installation of an outside air kit. Placement of the hearth pad and the stove and connecting the new pellet vent and outside air kit.Test run and tuning of the stove as needed. A permit will be needed for this installation.The customer plans to get the permit himself. Revised proposal. Item Amount MISC. SERVICES - $200.00 PELLET LINER,- Pellet Vent :.Installation of complete pellet vent system with termination cap. $1990.00 Sub Total: $2190 Sales Tax: $0 I Total: $2190 All pricing and proposed work is based on visual inspection. If other conditions are discovered upon commencement of work, it may increase the scope of work and if additional work is mutually agreed upon, may increase the price. All material is guaranteed to be as specified. All work is to be completed in a substantial workman like manner according to specifications submitted, per standard practices. If at any point the customer requests a work stoppage due to unforseen conditions, Sweepnman, Inc. shall be entitled to all costs incurred to that point. Sweepnman, Inc. 108 Main Street, North Reading, MA 01864 978-664-6642 dee.kelly@sweepnman.com www.sweepnman.com The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston,MA 02111 www.mass gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information l n/� Please Print Leeibiv Name (Business/Organization/Individual): Swee- a Address: F)d /} c City/State/Zip: ' Phone#: Are you an employer?Check the appropriate box: Type of project(required): 1. 4. ❑ I am a general contractor and I ® I am a employer yer with 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ I am a sole proprietor or partner- listed on the attached sheet.t ? ❑ Remodeling \ ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers' comp.insurance. 9. ❑ Building addition [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.[No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.® ur er C *Any applicant that checks box H 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 hive outside contractors most submit a new affidavit indicating such. =Contractors that check this box must attached an additional sheet showing the name of the subcontractors and their workers'comp.policy information. I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. / Insurance Company Name: /-r; )/� 2M. /Q l —/fzi:lffla 'P cr wjl%U Policy#or Self-ins.Lic.#: trl J� 3�S .� �3 (/� Expiration Date: Id /(Y'Z()lb Job Site Address: ��� �� V� City/State/Zi �wo 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 DIA for insurance coverage verification. I do hereby card under the pains and penalties ofpedury that the information provided above is true and correct Signature: J?Cos- Date: Phone#: Official use only. Do not write in this area,to be completed by city or town official. City or Town: PermitfLicense# Issuing Authority(circle one): 1. Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: _ Commonwealth of Massachusetts Massachusetts Department of Public Safety Department of Public Safety - j Board of Building P,egulations and Standards License: BU-026558 License: CSSL-100886 Oi! arncs Tacit;sae.,. 0,:ac2fa -Io n .. . _i0:: Su- DAVID A BANCROFT � DAVID A BANCROFT SWEEPMAN INC SWEEPMANINC F 108 MAIN ST BUILDING H -- d Jh.- 108 MAIN ST BUILDING H a NORTH READING MA 01864 NORTH READING rMA, 01864 �ZCK C'/��— Expiration: �^^'� .vim-- =:=piration: Commissioner 0310912018 Commissioner 0 310 912 018 Employer:Sweepnrren Inc Construction Supervisor Specialty Restricted to: \\\\ CSSLSF-Solid Fuel Burning Device Oil Burner Technician Certificate Failure to possess a current edition of the Massachusetts State Building Code is cause for revocation of this license. DPS Licensing information visit:WWW.MASS.GOVIDPS DPS Licensing information visit: WWW.MASS.GOVIDPS Office of Consumer Affairs&Business Rcguleuou License or registration valid for individual use only @HOME IMPROVEMENT CONTRACTOR" `hefoiethe expiration date. If found return to: OffiRegistration: 160389 Type: Office of Consumer Affairs and Business Regulation ` Expiration: 7/16/2018 Pr vate Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 SWEEPNMAN,INC I DAVID BANCROFT 108 MAIN STREET BUILDING H a/ NO.READING,MA 01864 Undersecretar y Not valid without signature