14 MALL ST - BUILDING INSPECTION (4) t
aY The Commonwealth of Massachusetts
ppp 1 Board of Building Regulations and Standards CITY OF
�� , Massachusetts State Building Code, 780 CNIR ced Mar SdMar
iALEM 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Numbest ID pli
LVC'4hag [l y'PYLZi rnsS�I
Building Official(Print Name) Signature Date
SECTION L SITE INFO RINIAT(604---,'�
L I Property Address:Iy1/f{1/ 5/ 1.2 Assessors Map& Parcel Numbers
1.l 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(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water S ply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Di al System:
/y.p Zone: _ Outside Flood Zone?
Public Ca' Private❑ Check if yes❑ Municipal On site disposal system ❑
SECTION2; PROPERTY'OWNERSHIPL '.
2.1 Owner of Record:
nd 1 Fl /N.4i:I—Q &
Name(Print) City,State,ZIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ex ' S /7 r
n,' St1tu 1To c.a `oN .t.tw 4(2c r�/ �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Onl .
Labor and Materials y'
1. Building ! _ 7 S--p 1. Buildthg Permit Fee 5 indicate how fee is determined:
2. Electrical 5 /s—bo ❑ Standard. City(rown Application Fee.
❑'total Project Cost'(Item6)x multiplier. x
3. Plumbing 2. Other Fces: S
1. Mechanical ([fV:\C) 'S List:
5. Mechanical (Fire $
Sri ression) Total All Fees: :S
Check No. Check Amount:__Cash Amount.
6. Total Project Cost: ) /S'?_�
r _ - ----- - � 13 Paul in Full Cl Outstanding Balance
SECTION5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number E. vauon Dute
Name of CSL 1[older
List CSL Type(sae below)
No. and Street 'Type Description
U Unrestricted(Buildings up to 35,000 cu. R.)
R Restricted 1&2 Faintly Dwellin
City/Town, State,ZIP bI �blasonr
RC Roofing Covering
NS Window and Siding
/A— SF Solid Fuel Burning Appliances
1 nsulation
"rcie hone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) 16, t/(, L/ —7
(pq&47 bus./ ��c (A S i- HIC Registration Number .epic;lion Date
I IIC Company Name or HIC egistmnt Name
la.s f /t>ao�/G�
No.and Streit O31�� Email address
M.4 NG 1%2S-k&--
City/Town, State, ZIP 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 uilding permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
ftoact
wner of the subject property,hereby authorize
on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER[ 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 the best of my knowledge and understanding.
Q�^ /
Print Owner's or Authorized:\gcnt's Name(Elec onic ignature) Data
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 Hour Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty find under M.G.L. c. 142A. Other important information on the IIIC Program can be found at
wwtv.m:us.l�uv bca Information on the Construction Supervisor License can be found at www.ntass.covrdL
2. When substantial work is planned, provide the information below:
Total tloor area(sq. 11.) _(including garage, finished basement/attics,decks or porch)
Gros living area(sq. 11.) _ _ Habitable room count
Number of tu"tplaces"_.—_— Number of badrooms --_--
Number of bathrooms Number of halbbaths
I"vpe of heating systcnt - --._ _—_ _—__ — Number of decks/porches
f\pe Ot'Cooling sy;lcut __.--_--_ E:nclosed -- _ —Open
3. "r,rt,il Ptojoct Squ,iro Fomf;lg ,, j ,c "MY he sHlAltutcd cct Gx"I'oral I'tu Cost"
i' CITY OF SiuLEm, 1tL1SSACHUSETTS
v BUILDING DEPARTMENT
3 t-� f• 120 WASHINGTON STREET, 3aa FLOOR
TEL (978)745-9595
F.tiC(978) 74Q-9846
D((j,tgFRt AY RISCOLI.
MAYORDR THODIASST.PIMU
DIRECTOR OF PUBLIC PROPERTY/BUILDLIG CO%L%IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers .
4nnlicant Information Please Print Leeibiv
Vac11C(Busitxs�Organi:atiorvindividual): ��C'7 �•c."� LPNs J
Address: ��S /�2cttiP G✓9oaO �nJ
f
City/Stateizip:J /4Nl1/L¢s7�� /`/f>l o3 PhoneH:
Are you a player?Check the appropriate boat Type of project(required):
1. am a employer with V 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(Nil and/or part-lime).• have hired the subcontractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet 1 7• ❑Remodeling
ship and have no employees These sub-contractors have it. ❑Demolition
workingfor me in an capacity*
workers'comp.Insurance.
Y a h'• 9. ❑Building addition
(No worked comp.insurance 5. ❑ We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homcuwnt:r doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. C. 152,$1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.Q Other
comp.insurance requircd.J
•Any applican that steakoxs b a I must alm illl ow thv=lien bAlow showing their warkm'mmpenudon poary information
'I hvnvuwk- who submit this anldavit indicating'hey atedaing All work and then Mee uutsidecanineton mutt submits new afffdavil indicting such.
:Cmnaman that chak this box most anwhvd An additionW chat showing the name of the subadntractom and their wurken'comp.policy information.
i um an employer that Is providing workers'compensation Luarance jar my emplayeam Below Is the policy and Jab sAr
irrjorinution.
Insurunce Company Name. �e�r-��S S �J>•.$ L'U
Policy 4 or Self--its.Lic. 4: (.J L SoS-(/(o O Expiration Date:
Job Site Address: IV MA// S City/State/Zip: 5�IIe^
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Fuiluto to sucuru coverage as required under Section35A 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 imprisonmen&as well as civil penalties in the farm of it STOP WORK ORDER and a line
of up to S250.00 a day against the violator. [It advised that a copy of this statement may be furwarded to the Of rice of
Investigations ul'the DIA for insurance coverage verification.
/do hereby cleftlJ' der rho ud renuldes ujpeQury elect the Ltforarudon provided above is/r+e and correct.
// Dar : 3 � i 3
P n i• (O f - — p
It)JJic iul use only. Du cot write in thh urea,to be cuntpleled by city ur town oJJlclaL
CityorTuwn: ___ Permit/I.lconseAl _ I
Issuinit Aulhor4y(circle one):
1. ISoard of Ileallh Z.Building Department 3.City/town Clerk 4. Metrical Inspector S. Plumbing Inspector
6.Other
CunlactPerson: Phone#:
f"
Y
I CITY OF S�u.1rM, 1,L-kSSACHUSE--rS
1 .H
E3UUML1G DEPARTMIUNT
130 WASHLNGTON STREET, 3" FLOOR
T EL (978) 745-9595
KI�IBERr Y DRISCOLL F.LX(978) 740-9346
A+LaYOR - Tmmus ST.PtEMa
DutECTOR OF PLBLIC PROPERTY/3CIIDL1tG 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 l 11.5
Debris, and the provisions of,MGL c 40, S 54;
Building Permit 1# 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 i�IGL c
111, S 150A.
The debris will be transported by:
Ie-"dc I-
(name ul'hau er)
The debris will be disposed of in
(name of Facility) _
(ail(I ress Ot tacility)
rapplicant
i
_ _ a
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-082991
JOHN L DOWNIE-` '-
125 WEDGEWOOD -
MANCHESTER NH; 03I��"
Expiration
Commissioner 01/16/2015
617 7°iomvnzaie«ea/!/ a�✓lfooaac/maella
ter.\ Office of Consumer Affairs&Business Regulation
VHOME IMPROVEMENT CONTRACTOR
_ Registration ,164647 Type:
Expiration 10/30/2013 LLC
BU BEE CONSTRUCTON-LLC'jf'
John Downie
125 Wedgewood Lane�- "" 1-
Manchester,NH 03109 r..
- - - Undersecretary
r
�u�ae Vmn�tixr�.aaz �� V
151 North Ave
Wakefield, MA 01880
Tel (617) 895-8606
Fax (603) 232-5152
Feb. 16, 2013
Estimate for work to be performed at 14 Mall St. ,
Salem, MA:
Vd Floor bathroom remodel
Preliminary work
1 . Make drawing for building dept.
2 . Apply for permit
Demolition work
1 . Protect house floors with tarps
2 . Remove toilet
3 . Remove vanity and top
4 . Remove ceiling board
5 . Remove wall board
6. Remove floor tile
7 . Remove shower
8 . Remove insulation
Page 1
�i
9. Existing window space to remain but replace window
With vinyl copy
10 . Clean up area
11 . Dispose of material
Framing work
1 . Install needed studs
2 . Install ceiling strapping as needed
3 . Install new sub floor
4 . Insulate ceiling and ext . wall
Plumbing work
1 . Install drain for shower
2 . Install new tub by Boots co.
3 . Install new drain for sink
4 . Install new shutoffs for toilet and sink
5 . Install new shower valve and faucet
By Symons (Allure series)
Shower valve must have integral stops
Electrical work
1 . Install new Panasonic fan/light and switch
2 . Install new GFCI outlet
3. Install recess light over shower
4 . Install owner supplied vanity light
Misc. work
1 . Install ',�" blue board and plaster finish
2 . Install tile board in shower
3 . Tile shower walls
4 . Install tile board on main floor
5. Tile bathroom floor
6. Grout
7 . Install door trim
Install bead board around bathroom walls
8 . Paint bathroom two coats
9. Install vanity and top ($800 allowance)
10 . Install toilet ($300 allowance)
11 . Install mirror, towel holder and paper holder, supplied
by owner
12 . Install owner supplied curtain holder
Page 2
Note: all tile is figured at $5 . 00 per sq. ft .
Estimated Cost: $16, 750
Discount $1,000
Total $15,750
General Notes :
1 . Price is subject to change after final drawings and choices
of material
2 . Any added work or changes by homeowner will require a change
order and moneys upfront .
3 . Any unforeseen work will be an additional charge (Example :
termite damage found)
4 . Copy of license and insurance will be issued prior to start
5 . All proper permits will be pulled
6. Payment schedule will be made upon acceptance of contract
7 . Workmanship on new work warranted for a period of 3 years,
(excludes spider cracks in plaster, abuse, paint and existing
conditions)
8 . Excludes landscape damage
9 . Excludes paving damage
10 . Price is good for 30 days
6�q=Qa'
E MM(3,04k 3 C ;, 13
Signature Print Name I 6ate
Sincerely,
John Downie
Page 3
Apr 18 13 08:40a BusyBee Construction 16032325152 p.1
uj-ee- 13 10:qu rRUtl- LT oss Ins Rancrestef OU3-0g1-Duoz I-m ruuuiluVUI r-33I
CERTIFICATE OF LIABILITY INSURANCE F 3/22/200 3"
THIS CERTIFICATE IS 95SUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER- THIS -
CERTIFICATE DOES NOT AFFIRMATNELY 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 foolily(ies)mvst be endorsed- If SUSROGATION IS WAnrED,Subject to
the tarns and conditions of the pvl)cy,certain polic4w may require on enoommeni. A statement on this certificate does not confer rights to the
tertlFicate holder in lieu of such endoetomen s).
PRODUCER Karx Reeves
FIAI/Cross Insurance AiOxE (603)669-3218 F .I6o3)665-03L
1100 Elm Street .kraaveaQcros9agency.cvau
' INSURER AFFOA01 E NAICe
Manchester NH 03101 INSURERA:peerless Indonanity Ins Co 10333
INSURED ixsvRERozPeerlesa Insurance Company 4196
Busy l3ee Construction LLC u,SuAEAG:
125 Wedg0wood Lane wSUR RD:
RERE-
Manc"hest-ax NH 03109 INSURERF- _
COVERAGES CERTIFICATE NUMBER:CL1332 2 81 917 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
INOICATEO. NOTWITHSTANOtNG 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. _
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES,LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS_
q TYPE OF dS01fANCE A D B POLICY POLICYeER MM nn, POLICYFIIP
IY9T12 M LIMITS
GENERAL UABAHY EACH OCCURRENCE i 1,000,000
X COMMERCIALGENF.RALLVGLIT' �ElOp i y IOC,O00
A CVuAeS.MME a]OCCURP30SS137 /Ia/Z019 16/2011 -ED (At,oM RPN S 15,000
PERSONALAADVINJURY S 1,000,000
GENERALAOOREGATE S 2,oD0,000
OWL AGGREGATE LIMIT w LIES PER; PRODUCTS-COUPWA06 a 2,000,000
7X POuGY PRP nwe i
AUTOMOaILELiABILM LIMIT
C
ANYAUTO BDOILYIWVRY(WspeNan) i
��D �MVLED WMLYIHRIRYt�� u S
HIREDAIfOS AAUTOS
9 CEO PROP r
i
UMURELLA LMe OCCUR EACH OCCURRENCE 3
E%CEssms ....-MN)E AGGREOIRE L
DEO RETFNTION8 i
J3 MRKERSCOMFErfSATON 051160 X srwru OTH
ANO EMPLOYERS'LM9UW
ANY PROPRIEIORAy.RTNERA)IECUnVE Y!H overagF A applies Co IfA E.L EACHACLIC'ENi S 500,000
im-t11-1E ER ExClOOEpi II NIA oho Downie is an /3a/2D13 /le/201f
1 IYNRro E.L DISEwsE-EAErAP S 500,000
rtYaA asxnee OF
aC xelvded ot£%O¢r
RIPr10R Of OPERAnOVSEdar Et O1sEnSE-POIJCY UMR S 500 000
DESCRIPTION OF OPERATIONS!LOCAT1011S!VEHICLES(AatchACORO Im,MINNOW Ili9eheed=,Ir MPM%uc.it n:Rm,eA1
ReYer to policy Fox exclusionary endorsements and special provisions.
CERTIFICATE HOLDER CANCELLATION
(603)232-5152 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
----"--- - THE EIPIRATION DATE THEREOF. NOTICE WILL BE DELIVERED IN
- —'---- ACCORDANCE WITH THE POLICY PROVISIONS
AVTHORREOREPRFSENTAnVE ,_ -- - ,, _ / "
Ksri Reavea/XAS .. �• � /
ACORD 26(2010105) 01939-2010 ACORD CORPORATION. Ail rights reserved.