24 LYNDE ST - BUILDING INSPECTION (4) The Commonwealth of Massachusetts,
Department of Public Safety
/^•)I <•-,�� .Masstchu>rus State Building Code(780 CNIR)Srrenth Edition
City of Salem
Building Permit ApElication for any Building other than a 1- or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Insp r:
SECTION 1: L VCATION (Please indicate Block N and Lot for locations for whic9 a street add es is of ova bl
L. ca 1 S� mI O
No. and Str t Cih• /Town Zip Code N me uildin (At ml
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repa Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer.Review required?; Yes ❑ No ❑
Brief Description of Proposed Work: p 1�••C_'"t eily�./��
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): P
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR.34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5: USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: Hi Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2 ❑ 1-3 ❑ 1-4❑- M: Mercantile❑ — R: Residential R-1❑ R-2❑ R-3❑ R-4 ❑
S: Storage S-I ❑ S-2 ❑ U: Utility❑ 1 Special Use❑and please describe below:
Special Use: _
SECTION b:CONSTRUCTION TYPE(Check as a licable)
IA 100 IIA ❑ 11813 IIIA ❑ 11I60 IV Cl I VA VB ❑
SECTION 7:SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public ClCheck if oulsidr Flood Zone❑ Indicate municipal ❑ A trench will not be Licensed Disposal Site❑
Pricatl•❑ or indenlik. Zone:_ or un site arntem ❑ required Cl or trench or specife:
permit isenclosed ❑
lidilroad right-of-way: Hazards to Air Navigation: >I:\ I listori.( ,nnmi�si�•n Itrci," Pro
\ut \pplicable❑ I.Strl,etllre,c�thm oupnrt approach area' I. their let e c completed.'
rt( nnsem lu liu dd enclosed ❑ Yes ❑ or No❑ Yes❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
fdwm i Cair: �sr Cruuplal: icpa,d Constnich,m: Occupant I��ad per Ploue
I)ncs the brnldm};conleum an Sprinkler tim stem.': Special Stipulations:
SECTION 9: PROPERTY OWF'ER AUt{'HORIZATION
Name and Adde
l ,Pr 1 r N Pro Nerh Owner i C'y1�{ n
IJ 2 �
Name(Print) Nu.and Street City/Town Lip
Property l)•Ncner C� tact lnfu rmation: CSG �9 4?- ,se 3 '/03
�n O�IN �J-=
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address Citv/Town State Zip
to act on the +ro•erty owner's behalf, in all matters relative to work authorized by this buildin ' permitapplication.
SECTION 10:CONSTRUCTION CONTROL (Please.fill out Appendix 2) -,1 . _.
(if lnuilding is less than 35,LW cu.ft.of endovd space and/or nut under(ioroYruetiun Control then check here O and skie Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name:
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COIvII'ENSAT1 N RVSURANCE AFFIDAVIT(M.G.L.c.152. 25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of ' suance of the building permit.
Is a signed Affidavit submitted with this application? Ye o O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item P
ted Costs: (Labor Total Construction Cost(from Item 6)_$
nd Materials)
t. Building b Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical appropriate municipal factor)_$3. Plumbing 4. Mechanical (HVAC) Note: Minimum fee=$ �nicipality)
5. Mechanical (Other) Enclose check payable to C6. Total Cost . (O (contact munici ality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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 knowle and understanding.
WWLAC
I'Ir.^}rinl ani ainame 1 � CT / iir.A _. ` ilcphune \o. Ualc
Glreel Address Ciitt%/Tm%nn te�� Zi iI
Municipal Inspector to fill out this section upon application approval:
Name Date
CITY ®F S.U.Em, NLUSACHUSETTS
Bl•DDLNG DEPAATJIEINT
120 WASHIINGTON STREET, 3w FLOOR
T L (978) 745-959S
FAx(978) 740.984
K1.,tBEA FY DRISCOLL THomu ST.Pt M
MAYOR
DIRECTOR OF PI.BLIC PROPERTY/gl'IIDLVG COSMOSSIOhiER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electr(clrns/Plumbers
A ) licant Information Please Plesse Print Lteibly
Naine (Busirr�w� ^orraairatiori lnhvidufal):
Address: 01-'�3 WS h, N N -r cs7o
City/State/Zip: S w Phone
,\re you an employer?Cheek the appropriate box: Type of project(required):
1 am a employer with 4. 0 1 am a general contractor and 1
itnployces(full and/or pan-time).• have hired the sub-contractors 6. ❑New construction
I.2.El am a sole proprietor or partner- fisted on the attached sheet. : ❑ Remodeling
ship and have no employees Theme sub-contractors have s. 0 Demolition -
working for me in any capacity. trap.insurance• 9. 0 building addition
[No workers' comp. insurance 3. 0 We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself[Not workers'comp. c. 152.§1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. (No workers' 13.0 Other
comp. insurance required.]
-Any opplicanl that choclts bet tl must also rill tut the secrien below showing their worker'cmnpenratun policy infurrrtatloa
'I Lnrtewrtwss who submit this affidavit indicting they an doing all work and thus hire outside emaaerots mist submit a row affidavit indicating ruck.
:C nnlm,inn that cheek this bon mud a rimhed an a idiriwd rhea showing dw nmme of that suh•ee anMan and their worker'romp.polity iorstrm ndaw
/am an employer that it providfnir workers'compensadon Insurance jar my employees, Below IS rite Polley grad Job alto
information.
Insurinc Company Vame:Z) 'MN) TN&WV•/< vY�
Policy N or Self-ins.. Lie. 1►:_� 40 1 Expiration Date: �
Job Site Address: 11i N City/State/Zip: "Jeo ncy=�
attach a copy of the works&•compensation policy declaration page(showing the polity number and expiration date)`
Failure to secure coverage as required under Section 23A of MGL c. 132 can lead,to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as well an civil penalties in the form of a STOP WORK ORDER and a fine
of up to S230.00 a Jay against the violator. Ile adviicd that a copy of this statement may be rurwurded to the Office of
Inve>ngationa oldie DIA for insurance coverage verification.
f do hereby certify antler rise pains penahlrs of Perjury float tho firfbrma lour provided above i repo ynd correct
�icrreture: Dat
Phone it:
iOfrial use o dy. Do,ear,urine in this area,to be eunrpleted by city or raven a/Jlrial,
City orruwn:
issuing Aulhurily (circle une): j
I. ItwrJ ut Ilralhh 2. RuilJlnU Department 3. Citylfown Clerk J. Electrical Inspector 3. Plumbing Inipeetor
6. Other
Contact Periun: _ _ _ _ _. Phone N:
CITY OF SALEM
Jos?
PUBLIC PROPRERTY
DEPARTMENT
n1rt
\I -.t..N I iC t'<'.t it llM.a4V S1Nk17T O S.\I I'!f, \t.\Si.\t i II
rFl:v78.74.+••li9s 1:.\x:978.74(}9846
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with tire sixth edition of the State Building Code, 730 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
eo; sseAue SvV"c&v31WLk
(name ur hauler)
The debris will be disposed of in
(fame ut aci tty)
taddresx or Facility)
.ignatur mit applicant
date
r 203 WASHINGTON ST.#256
9 PRESERVE SALEM,MA01970 :
carpentryipainting?roofing!gutters PHONE:978.745,8745
S E R .V I C E S
a _ VESFAxER8.74S.COM -
SALES@PRESERVESERVICES.COM
s a.
Laine.Finbury Date Bid:6/18/2008
14 Lynde St Estimator:Sean O'Connor
Salem MA, 01940
(978)°317-5646
lfinbury@ahfboston.com
ROOFING ESTIMATE
COMMENTS For the front main house excluding the flat roof that the fire escape is attached. Exclude
the roof on the rear apartment. Last year was$9250
PRIOR PREPARATION
PERMITTING: All permits will be obtained in accordance with the law as required.
DISPOSAL: A dumpster will be placed in a area designated by the homeowner.
ROOFING PREPARATION
SHINGLE REMOVAL: Remove all layer(s) of old shingles
NAILING: Re-nail roof decking as necessary.
UNDERLAYMENT
FELT: Install 15 lb felt on all areas not covered by ice and water shield.
ICE AND WATER SHIELD: Install 3 feet of ice and water shield on eves and valleys. Install as
necessary on other areas.
FLASHING
DRIP EDGE: Install drip edge on all perimeters.
VENT PIPES: Install new boot or flange around vent pipes.
CHIMNEY(S): Install or rework the flashing around all chimney(s).
ROOFING MATERIALS
ASPHAULT SHINGLES: Install 3 tab shingle 25 year. Black
WING
114asic $ 9699.5
Sale tax $ 0
Total Price $ 9699.5 including Labor&Material
Payment Terms: 33.3%deposit; 33.3%progress; 33.3 completion.
14
� r
Sean O'Connor Customer Signature
*Above additional prices includes all discounts and coupons discussed prior to estimate.p The
above quote is valid for 60 days.
*Warranty: Craftsmanship: Kyron Inc. DBA Preserve Services warrantees all work performed
for a period of 2 years. If any problems occur we will cover the cost of labor and materials. For the
warranty to be valid the invoice that was presented at the time of completion must have been paid in full.
Materials: The duration of the manufacture's warranty is specified in the materials section above.
ACORQ CERTIFICATE OF LIABILITY INSURANCE
10/05/2009
P (781)449-6786 FAX (791)449-4269 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
BOYNTON INSURANCE AGENCY ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER.THIS CERTIFICATE DOES NOT AMEND,EXTEND OR
72 RIVER PARK STREET ALTER THE COVERAGE AFFORDED 13Y THE POLICIES BELOW.
NEEDHAN, NA 02494
INSURERS AFFORDING COVERAGE NAIL III
NODDED Kyron Inc INSURERA Max Specialty
DBA Preserve Services INSURERS: Hartford Insurance
203 Washington Street,8256 INSURER C:
Salem,NA 01970 INSURER D'.
INSURERS
COVERAGES
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 CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POUCIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
INSR AWL
LTD TYPE OF INSURANCE POLICY NUMBER DATE MWO DATE LIMITS
DENERALLIABIDTY MAX01310000309 OS/23/2009 OS/23/2010 EACH OCCURRENCE f 1,000,00w
X COMMDAMAGE TO RENTED
RCUILGENERALLUBILRY PREMISES Eaooaa,elma f 50,00
CLAIMS MADE O OCCUR MED EXP(Any p ppam) S 5,00
A PERSONAL S ADV INJURY f 1,000.0001
GENERAL AGGREGATE f 2.000.0001
GENL AGGREGATE LIMIT APPLES PER: PRODUCTS-COMPWAGG f 2.000,00
X POLICY �CT LOC
AUTOMOBILE UAMUTY COMBINED SINGLE LIMIT
ANY AUTO (Ea 6Q 1) f
ALL OVINED AUTOS BODILY INJURY
SCHEOULEDAUTOS (ParpenuOP)
HIRED AUTOS BODLY INJURY
NONOMEDAUTOS (PAI )
PROPERTY DAMAGE f
(Pa awderX)
GARAGE UAMUTY AUTO ONLY-EA ACCIDENT f
ANY AUTO OTHERTHAN EAACC f
AUTO ONLY: AGG f
E%CESS/UMBRELLA UABBJTY - EACH OCCURRENCE S
OCCUR CIAIMS MADE AGGREGATE f
f
DEDUCTIBLE S
RETENTION f f
W WR BCOMPE1SAnoN o14314392 OS/20/2009 05/20/2010 X -
AND EMPLOYERS'LIABILITY YIN
TORY LIMITS ER
B ANY O PCERIMEMBERPAR MERVE CUTAE ] E.L EACH ACCIDENT f 100,
IMaDdakyffi NIQ �� YES EL.DISEASE-EA EMPLOYEE f 100,00
sPEGIALIONs bewa E.L.DISEASE-POLICY LIMIT f 500,00
OTHER
DEBCDPTION OF OPERATIONS I LOCATIONS/VEIUCLES I EXCLUSIONS MOM BY ENDORSEMENT I SPECIAL PROVISIONS
1,000 Bodily Injury and /or Property Damage Deductible
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 1O DAYS WRITTEN
NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT.BUT FAILURE TO IN)SO SHALL
IMPOSE NO OBLIGATI OR LIABILITY OF ANY LORD UPON THE INSURER,ITS AGENTS OR
Eric Husgen REPRESENT
14 Conant St. AUTHORITPD ATRIE
Marblehead, MA
ACORD 26(2009101) 01 2009 ACORD CORPORATICIN. All eights reserved.
The ACORD name and logo are registered marks of ACORD
_ n
i':` �/.e fcarsixUzzr ma& 1 TIONs '
' BOARD OF BUILDING REGULA
wense: CONSTRUCTION SUPERVfSOP.
S„J-'A03
`
Number. CS � -
ar , ,Expires:. _��[_ .n_ Tr.na:
ASS
- - � Restncted: -
.� SEAN OCONNOR
1
-26 CHESTNUT ST
SALEM, MA Ol5�J G�mmi
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