148 LORING AVE - BUILDING INSPECTION ,
7 I'he C'ulnmunweallh ot-Massachuscits
Board of Building Regulations and Standards CITY OF
Massachusetts Slate Building Code. 780 C'MR SAL1:\I
'tip,•' Nerised Ilur'U//
Building Permit Application 'ro Construct, Repair, Renovate Or mulish
One-ur Tisw4la ilr Du ellim,,
This Section Fur Official Use On
Building Permit Number: Dot Applied:
d3/
Building OlLcial(Print Name) Sign atureOne
SECTION I:SITE INFOR IATI N
Asseson M p Parcel Numbers
I.to Is this an acre led street?yes no Map Numbvr Parcel Numtnr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Pmposcd Uw Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.J0,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Privale❑ Zone: _ Outside Flood Zone?
Check if—es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 —Ow 1 of Record: � ^A 4-`cGin `IAL 1 t Poti� � M /eF
Nornc(Pnn l city.Stale,ZIP
Iq'6 `ori/\J? AVM Q6�-x7�
No.and Street relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ E.risting Building❑ Osvner•Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed \Vork': �r
T/l) JAt/ /Ji/t�irv5
SECTION 4: ESTIMATED CONSTRUCTION COSTS
I1t1rt Estimated Costs:
(Labor and Materials) Official Use Only
I. Building 5 I. Building permit Fee S Indicate how fee is determined:
2. Electrical S ❑Standard CitylTuwn Application Fee
j 1. Plumbing S
O T Cost'(Item 6)x multiplier
her
. Other
Fees:/r Fees: S J�
J. \Ixh;ulical ill\',\(') S List:
• ?. \techunical tFiro -�J -
Sum+ressionl S Total .\IlFecs: S_
Chcck ('h No. _ eck Amount: Cash \m,nnn:
° Total Project Cost: S yQUd r OO ❑ paid in Full 0 Outstanding BaUlce Due:
SECTIONS: C'ONS'I-RUCTION SF.RVICF.S
$,1 C'mrseructiunSupenisurLicrnsr(C'SLI /a
. - —
f11-e I A1LV a.I S_. I iceusc Nwuhcr I pirnion >alc
n G I oil Ctil. II Pe Isee balull).__._
Li l COL.-'
PC Description
- 1Description---- - ---- -- -N. lnd str, l
` �f.� �/� �{ U t 4lrcstncleJ OhlilJin 9s ti nl 15,11110 cu. Il.l
---�'`IlM 'VIA _CJ ��7,_ . R Nc..stricicdI&II'.Imil Dllcllin
Col-) roam,.`late. I U Masoo
RC R'wlin Cuvcrin f
- A's Window and Sidillit
SF Solid Fucl Ihlrning Appliances
1 Insulation
l'ck hone Email address D Demolition
5.2 Registered Home Ip1provementtContractor(HIC) � A/
(AU r Lcpiru m Dtc
IIIC Cpall)
Nnmc or IIIC'ICe istrt e ,fin _ n�"g�,.,��.�s b>~ k s C� h�-Ir I . o
Ig, f_�(tCAW 11,1:2 M � _ Uc '
No. mld Street Emud address
7�st-G�-a-3
City/Town.State,ZIP 'felt hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ........."p No...........0
RI
SECTION 7a:OWNER AUTHOZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
h as Owner of the subject property,hereby authorize ( Un Ct C
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERI 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.
Print Owner s or:\ulhorirud.\gcnt's Nanlc(Electronic Sigmuurc) Date
NOTES:
I. :\n Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will M)J have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other inlpunant information on the HIC Program can be round at
also it,r.. % of i Information on the Construction Supervisor License can be found at a>s.' nl.l.: �;o\ -II'.
I. \\'hen substantial lurk is planned,pruvidc the infuriation below;
total floor area(sq. fl.l - —_.._I including garage, finished basement ittics,decks or porch)
Gross lis ing area I sq. 11.1 _-__ Habitable room count
Ntuuhcrof ireplaces Numberol'bedruunls
Nunlhcr of hathrooms . . _ . _ . . Number of half hallo ..
I
I\Ile of healing sy sent Numher al'decks, porches
i
I\pe of eoollllg i'Aelll ialilosed 011en
1, "nodal Project Square Foonagc-play he suhstitwed 1or"1' dad Project Cost"
° NWSACHl;SETTS
it c. BUILDING DEPARTMENT
120 WASHLIIGTON STREET, 3'a FLOOR
�. • 1FL (978) 745-9595
F.tie(978) 740.9846
U\IBERLEY DRISCOLL
INLAYO.q THo.%US ST.P1FR"
DIRECTCROF PUBLIC PROPERTY/BCTi.DING COb61ISSIONER
Workers' Cmnpensation Insurance Affidavit: Builders/ContractorslElectrlcians/Plumbers
Applicant information Please Print Legibly
.V;II11C(nunitxs.o UrWaniratiarindivitbmtlh •+emu wy���C ��`��
Address:
Citylstate/Zip: Phone N:
Are�ynu an employer?Check the appropriate box: Type of project(required):
I.� I am a employer with�_ 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the subcontractors
2.❑ I am a sole proprietor ar partner- listed on the attached sheet.I 7• ❑Remodeling
.hip and have no employees These subcontractors have V. ❑ 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.❑ Electrical repairs or additions
J.❑ I am a homeowner doing all work right of exemption per MGL I L❑ 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 13.0 Other
comp,insurance required.)
Any applicanl dot chocks box of must also all out the"mium hot**
showing their walkers'compensation policy inanmation.
'I htmauwm"who whn it this AMeavis indicting they am doing all work and then hire ounide contractors mall Submit a new aMdavil;ndiaing cock
:6,nimion,that chalk this box matt anachud an additivad.hraa showing the nalnc of the Subsomtradun and their workers'comp.policy intonnanon.
I um tin eurpluyrr that Is pruvidhrp workers'cumpensarlun insurance j my einp/uyeert slow/s the policy and joh site
informurloon, r-{��
Insurance Company Name:7050_
Policy 4 or Self-ins. Liec..4: / Expiration Date:
Job Site Address: /C` �l` ( O�" clV 4' Cily/Statc%2:ip;<5U✓,-t,_
Hach a copy of the worker'compensation policy declaration p291(showing the policy number and expiration data).
Failure to secure coverage as required under Section 2JA of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500,00 and/ur one-year imprisonmenq as well as civil penalties in the form of STOP WORK ORDER and a lino
of up to S23000 a day against the violamr. Re advised that a copy of this statement may be forwarded to ilia 001ce of
Invrsligatiuns ol•the DIA for ulsurallce coverage verification.
/du Isere •rrrif sat dr thr paint all peaahies ujperjury shut the fu�urumdun provided ab yr it t rand sturrrrR
ii •, Data: e_—4
Phone,f
O//icial u.se tndy. Do aot write fn this area,lobe cumplered by dry ur tawn ojj!t.h L7111.1pector
Citynr 1'usvn: Permiul.lcenseBluingAulhurily (circle une)a1. liourd of 1lealth 2. Ifildim, I)eparisnum .1. Cityifawn Clerk 4. Electriral btipcctur S. Phunbi
b•Other
Cu nisei Perim):_ Phnnc 4:
l
Information and Instructiom,
.\lassachuscus 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,corporatioa 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 1
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 sha0 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)stales"Neither the commonwealth not 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-contractors)name(s),address(es)and phone numbet(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 maybe submitted to the Department of Industrial
Accidents for confumation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he 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. Scif-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 permitilicense 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 bb 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do 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 favestigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
2evi;cd 5-26-05 Fax#617-727-7749
www.mass.gov/dia
CITY OF S,v-E.N[, NLkSSACFiUSETTS
9LLWLNG DEPAR- ENT
120 W.ISNLNGTON STAE$T, Jw FLOOR
rM (978) 735-9595
K1%C3ERilY DRLSCOLL FAX(978) 740-9946
.b(AYOI! D 10swST.PMUS
1)IRECTo it OP PL 8LIC PIIOPERTY/9t:Mn LN(;Co.%M,ISSION EIt
Construction Debris Disposal Afttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code 780 CUR section 1 l I.S
Debris, and the provisions of MGL c 40, S 54;
Building Permit p this work shell be di is issued with the condition that the debris resulting from
sposed of in a 1 11, S I SOA. pro ea
properly licsed waste disposal facility as defined by NIGL c
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
_-- (namof fadj�y)
(.ddrsff oYf��iluy)
�iynanue ofperm t 3PP ant
f
BEAUVAIS
BUrLPER
Finish Carpentry & Remodeling
781-630-2352
10 Sow Av c
sA1 I NLn 01970
Date 1/23/12
TO:jean-luc A lepoutre
149 Loring Ave. Salem Ma. 01970
Cell #978968-8794
Estimate
Rot repair and window installation
• Remove existing siding up to bottom of window
• Remove brick landing
• Remove ply wood to expose sill damage
• Cut out approximately 22' of sill only
• Replace with pressure treated 4x6 sill with sill seal and galvanized sill strap fastened to foundation
• Install two three unit dbl hung Anderson windows, supplied buy homeowner.
• Replace ply wood and wood cedar shingles
• Replace two rotted oak door sills
• Patch in wall in hallway
• Remove all debris from site
• If further damage is found once opened up an additional cost will be discussed and agreed upon prior to
the start of any such work.
Total cost of repairs......All work to be done at a cost plus material basis,and to be performed by Beauvais
Builders,in a timely matter,and to mass state building codes.
Estimated cost 4,000.00
Respectfully sub eed
Daniel Beau ais----- =� —'- Homeowner---