12 LYNN ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'h edition ReOv st ed January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family welling
T s Section For fficial Use Only
Building Permit Number: Date Applied: D. V
Signature:
Building 0711tirissk9ilf Mspector aBuildings Date T
SIYCTION 1: SITE INFORMATION
1.1 Pr'eerty.Ayldress��, 1.2 Assessors Map& Parcel Numbers
I.Is Is this an acceptedstreet?yes no Map Number Parcel Number
1.3 Zoning Information, 1.4 Property Dimensions:
Zoning District Proposed Use y. 'T Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 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 ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Old''o� f Recyrd:L��®`�`4 �� / ?
Name(Print)/�111 I'R Addre s for Service-
Mr-
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
C
n/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ &O, I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 6O 0 Paid in Full ❑Outstanding Balance Due:
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
L'S f4, /oi0o3 /Z / /
R7h(&S A&vvjPOU�—f License Number Expiration Date
Name of CSL?Holder U W
List CSL Type(see below)
ddre Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Si amre / y6 M MasonryOnly
2�07 J1 0 RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Imp ve ent Contra tor(HIC) (e
/h�nicr / ,lcilt�ee�� C'o f ��?2
HIC Com ny Name or HIC Rerceistrant Name Ii` /� Regi tration Number
J c5 A/ �� c 1/TLdAM1. /k4+
Z/L76/
_
re EE piation Date
eleph SECTION 6: WOR ERS' 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 ..........P 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.
Si nature of Owner Date
SECTION 7b: OW ANEW OR AUTHORIZED AGENT DECLARATION
I,—"//V Lf�/�dl'LcA cJt-4�tC J ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
f
_ f tNa /^//�
of r or A e Date ]C .
(Signed under the pain d penalties of perjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I I O.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"may be substituted for"Total Project Cost"
. CITY OF SALEM. ,
r: PUBLIC PROPERTY
DEPARTMENT
ymmF'!t ry owscou
MAYO& t20 WASMNGrON ST"-Er•$ALE2'�. Uf]il:SETIS U197o
TEE-97&74S-959S 0 FAx:978-740-9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code,780 CUR section 111.5
Debris,and the provisions of MGL c 40,3 54'.
is issued with the condition that the debris resulting from
Building Permit# nt this work shall be disposed of in a propalY licensed waste disposal facility as defined by MGL c
111,3150A.
The debris will beetyr�ansported by:
(same of hauler)
The debris will be disposed of in :
/�
(same of facility)
(address of facility)
signature of pe mit applicant
date
.tclxisal7.due
yi+u-tmcnt of Public $al'etc -.... .Board of Building Ru rul ttions ;md St uul:u-ds
Construction Supervisor Specialty License License or registration valid for individul use only
License: CS SL 101003 - 'tbefore-the-expiration date. If found return to:
Restricted.to:. RF,WS :Board of Building Regulations and Standards
One Ashburton Place Rm 1301
STAVROS MOUTSOULAS iBoston
11 A STREET
SgLEM.LEM, M MA 01970
Expiration: 12/14/2011 ! Nof v., without signature
('unuuisvb:ner '
Tt-# 101003'
9 Boar o u> mg egul ion- �ht a�na r s�
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement:Contractor Registration
Registration: 154326
Type: Private Corporation
Expiration: 2/2 712 01 1 Tr# 279846
ALPINE PROPERTY SERVICES`CO, INCa
STARROS MOUTSOULAS
11 WILSON STREET
SALEM, MA 01970
Update Address and return card.Mark reason for change.
Address Renewal Employment Lost Card
DPS-CA1 0 SOM-07/07-PC8490 -
Sl\- Board of Building Reguleh ns and Standards License or registration valid for individul use only ,
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Board of Building Regulations and Standards
Registration 154326 One Ashburton Place Rin 1301
ExpiMtlon 2/2712011 Tr# 279846 Boston,Mo.02108
`pri4ate Corporation
ALPINE PROPERTY�SERVICES'CO,INC.
STARROS MOUI'fi017.Ll�S >°
11 WILSON STREET "'Q'°`"'�- Not valid without signature
SALEM,MA 01970 Administrator -
CITY OF SALEM
3 PUBLIC PROPRERTY
DEPARTMENT
Kp l li P.liI L`, I',RISCL tl I.
),L\riLIK 120 A':ssl HNG IONS i m r.-I ♦ SA I.I[M, it S[i I IS 31970
Tft.:978-7i 9595 ♦ F.ax: 978-73 3-9836
Workers' Compensation Insurance .affidavit: Builders/Contractors/Electricians/Plumbers
kpplicant Information /pt7 ` / )/ p qr/J w J [' �/ /}Please Print Legibly
N:t llll IBllSlnes]r nfgan lZa(lUfli lnJl\'Idllat): ;p✓/(/' Irk "•/�� ^ (���`�• //�rT! ' `'eizo �
Address: A 3 S /J 0 U/�N V r
City/State/Zip:_T7�!'C_(�� .0414' 01 9f 3 Phone #; 7 fC 2(25
:\re you an employer? Check the appropriate box: - -rype of project(required):
I.❑ 1 am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction
employees(full and/or art-time).' have hired the sub-contractors
P 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner-
listed on the attached sheet. i
ship and have no employees. These sub-contractors have 8. ❑ Demolition
working for me in any capacity. Imo.workers' comp. insurance. 9, ❑ Building addition
No workers' cum insurance 5. t;afl�We are a corporation and its
( p� � � - I0.❑ Electrical repairs or additions
required.] officers have exercised their
right of exemption per MGL I L❑ Plumbing repairs or additions
3.❑ I am a homeowner doing all work g P
myself. [No workers' comp. C. 152, §1(4),and we have no 12.NkRoof repairs_
insurance required.] t employees. [No workers' 13. Other
comp..insurance required.]
-Any applicant that checks box HI must 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 their workers'comp.policy information.
1 unt an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: /- /T7�I /P �71/li- _1.Al�PI-/Mn/Ce
6lr
Policy #or Self-ins. Lic. #: C VOO 7.63t90 3 Expiration Date:� /�J
Job Site Address: T_ l L-y/✓1✓ f� City/State/Zip:8/ii�__ A— d 1 70
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
tine up to S 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 S250.00 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.
Ylr ereby certify under the pains and penaltie.ofperjury that the information provided above is true and correct
=1111ic __
Official use only. Do not write in this area, to be completed by city or town official
Citw 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 #:
Information and Instructions -
\la SSa ClnlSetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an emp(gree 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,corporation or other legal entity, or any two or more
of the foregoing engaged in ajoint 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
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the ,,rounds or building ❑ thereto appurtenant pp shall
hall not because of such employment be Deemed to be an em
ployer."
to c"
P Y
MGL chapter 152, §25C(6) also states that"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, MGL chapter 152, §25C(7)states"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 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-contractor(s) name(s),address(es)and phone number(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 may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The 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 tite affidavit for you to fill 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 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 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.
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 Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-NIASSAFE
Revised 5-26-05
Fax # 617-727-7749
www.mass.gov/dia
VL
HIC#154326
EIN#56-2618812
✓� Job#:
OLYMPIC
Roofing—Siding-Painting Office: 978-887-5870
239 Boston Street—Toosfield.MA 01983 Fax: 978-887-5875
Walt Lederhaus
12 Lynn St.
Salem,MA 01970
(978)985-6665
Email: wlederhaus@gmail.com _ July 16,2010
Revised: July 23,2010
Dear Walt, Revised: July 26,2010
The following estimate is for the roof installation for the property located at the above address.The following paragraphs describe the work that
will be performed.
Installation Procedure
X Strip existing roof on the entire house down to the roof deck
a: Install a mill finish vented drip edge on all leading edges
b Install an 8 inch mill finish drip edge on all rakes
A Install ice&water on all valleys
.: Install 6 feet of ice&water shield on all leading edges
Transitional walls are optional and incur an additional cost for the siding repair
a: Install new vent pipe flanges
.a Replace any rotten or damaged decking(we allow 32SF @ no charge,$70.00/sheet thereafter)
A Replace any rotten or damaged ledger board(we allow 2011.at no charge,$4.00/ft.thereafter)
& Install 15 pound felt paper on all areas that is not covered by ice&water shield
& Install new CertainTeed 30-year Landmark Woodscape Architectural shingles
A. Install new ridge vent system
Additional S eci ircadimsJ
A Homeowner to choose color of shingles COLOR: BRc11Fo6d-- �4/��ej�f/OB!/
a. Our dumpsters are sent to a recycling facility;therefore no additional h may be placed in them. The transfer station will charge us
a fee for additional trash which will be passed on to the homeowner.
Transition walls me an option,and if the existing flashing is in good shape,usually do not require replacement
4 We are not responsible for any of the cracks that may arise in any walls or ceilings
d, Please cover all your floors in your attic to protect from dust and debris
a We will remove all of the job related debris
& Permit costs vary from town to town and are not included in this bid
Initial the options you are choosing below:
Cost for Labor&Material for Roof: $5,395.00
Cost for Upgrade to Mill Finish Vented Drip Edge: $ 360.00__&,,--
Cost for Upgrade to Shingle Mate Fiberglass Based Underlayment: $ 195.00
Cost for Labor&Material to Rework Lead on(2)Chimneys: $ N/C
Cost for Labor&Material to Remove Wooden Gutter&Install New Fascia Board: $ 360.00
Cost for CertainTeed Extended Warranty: $ 2�1b50.
Payment Terms: posit$ �3�-�• 1/3 work in progress$ a / pan completion$
Total Amount Agreed Tolle Paid: $ X�/�.od
Remit to:Alpine Property Services Company,Inc,P.O.Box 365, Topsfield,MA 01983
The following schedule will be adhered to unless cirestances beyond Alpine's control arise:
Work Scheduled to Begin: :'BD_-- ` �c'_ Expected Date of Completion: Ei —'--�7 �p
Warranty: Alpine Property Services Company Inc.guarantees all work performed for a period of one year. If any problems occur we will cover
the cost of all labor and material o t the problem and
d meet the customer's satisfaction.
Do not sign this contract if there are any blank spaces.
(add Tonal provisions follow and are inct6d l rein by this reference)
ich Connors, ct M a Lederhaus
AI ' e Property Servi Co any Inc., Homeowner
/a Olympic by(Nam
"® CERTIFICATE OF LIABILITY INSURANCE
'•.6./.a�Yaolo
Roou= (617)471-1220 FASs (617)479-5147 THIS CERTIFICATE IS ISSUED AS A)NATIER OF•INFORMATION
unit Insurance Agent Inc. ONLY AND CONFERS NO RIGHTS UPON; THE,'CERTIFICAT.E
Y Y• HOLDER. THIS CERTIFICATE DOES NOT''AWFEND,'•EXTETiD OR
iDO Victory Rd, ALTER THE COVERAGE AFFORDED BY:THE..POLICIES•BELOW.
I6``� -la say
iortn Quincy MA 02171 INSURERS AFFORDING COVERAGE •NAILS _
+6URC� Inu11Rp=A;First Mercury Ina. •Co_ '
Llpine- Property Services Co-, Inc. INSURER ;8arieysville Insurance,
?-O. Sox 365 INSURER c.Great •American-S_asuranca 139 Boston Street INsuRER D.
_• ,_ __
Cops£ie d NA 01933 INSURER B:
-OVERAGES "..
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDIcATEO.•NOTWTTiLV*DINO .
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEKTIF7Z TE MAY BE ISS,UEb OR'
MAY PERTAIN THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT To ALL THE TERMS,EXCLUSIONS-AMD CONDITIONS OFSUCH
POLICIES.AOeREGAN LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
NSR POLICY NUMBER pOLICY6FFECTIVE NOSY IAI RA ON •••_ .�•DMA
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AADE Ia IOccW ODu861 6/34/2010 6/14/2011S ' :'ExCiudedI Deductible PERSONAL&ADVW URY S' 2,000,000
LIMMAPPUESPER: PRODUCTS-COMKDP CO $ 1'B'0D 000POUCY �O' LOC
AITrOAwaILE UASIU Y ( SINGLEUAOT •. •S' 1,000,.000
ANY AUTO _•
8 ALL OWNED AUTOS 3A0000008111263 1/9/2010 1/9/2011 BODgy WURY'
•S ,
J% SCHEDULED AUTOS (P=Y
8 HIREDALROS GODLY INJURY S ,
j S NON4DWMMAIROS IPa BEdOeYD'
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GARAGE LVBIUN AUTOONLY-fA S
ANYAUTO OTHER THAN •'FA-ACC f
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A DEDUCTIBLE =MD001173 6/14/2010 6/14/2011 -. S
S RETENTION S 10,00( •.S .
WDRRERSCOAPENSATION rrA Q
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DESCRIPNON OFOPFAATIONSILDr:ATN1NS)VENICLESI EXCLUSIONSADDED W ENDORSEMEITISPECULPROMON9
0 CERTIFICATE HOLDER
ER CANCELLATION
SHOULDANYOFTNGAROVED 1118EO IPoITION
DATETNEREOF,TNE ISSUNG INSURER WBIEIDPAVORTOV"L•r� TIE WRITTEN.
NOTICETOTHB CERTIFlCAT6 NOROBR NAMED 70 TNP,I .:. N- . -.- ... ,Cd'308TW1'
IMPOSE NO asuaATIDN OR LWBRNY OP ANY mm DAI1N•THSm pmr.mA61aft OR
REPRfiBTMA
AOnIDRIZED A7TVe . .
ACORD 25(2009101) ®1988-2009 ACORD CORPORATION.101!Wds res Tved.
INS025m0001) The ACORD name and logo are registered marks of ACORD '
AGC)1?D. ;v WiV20110
+l�s:#�'FEl6lfalLLGAiTw °. ..THtB.CERTIFICATE 18 i95 .. .. . ., GP?NFDRALanow -.....
•. ONLY ANO CONFERS NO RIGHTS UPON Y?NE,GEikilFiCiLTE., +. ..
H.J.Knightlntemtrtionel lDSUTiDTCC AgrncIC9,InC: NOLOFR. TT{q CERTIFIGTE DOES NOT AMEJJD"bCTE�N`OOR• ..
500 Victory ttDad-MTuinH 11Ay ALTfR 7wE COVERAGE AFFORDED T{Y 77{E POlI&S xl.aW.
North Quinry,MA D212] MPANIEBNoRDRJLi COVERAGE.
COMFPNT •�'
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COMPAW
PD BOX 365 C
.__..Topsfield,.MA_.01933 .. ._ colaPANY-.- .-.._ . " ..
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