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16 MASON ST - BUILDING INSPECTION (2) Vl 0 cK- -7 �K c0 i" RECEIVED The Commonwealth 8PASsac usetts Department of Public Safe r� P Q yU Massachusetts State Building 4�5 c PG1R�/ Building Permit Application for any Building other than a One-or Two-Family Dwelling n (T1tis Section For Official Use Only) St Building Permit Number. Date Applied: I Building Official: ' 1 SECTION 1:L CATION(Please indicate Block#and Lot#for locations for which a street address is not available) v l No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2-PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building❑ 1 Repairvi Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) Change of Use ❑ 1 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:. ✓ O SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CINR 34) ❑ Existing Use Group(s): IProposed Use Group(s): 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-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ 1 H: High Hazard H-1 O, H-2❑ H-3 ❑ H4❑ H-5❑ 1: Institutional 1-I❑ 1-2❑ I-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑ S: Storage S•1 ❑ S-2❑ U: Utility❑ Special Use Cl and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IAO ITT ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV ❑ 1 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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ required Cl or trench or specify: Private❑ or indemi(y,Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Ilazards to Air Navigation: FI:\I listnrlr Counmi,jo, ,Re,iaw I'n n:rrc Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: _ Special Stipulations: rn ca t T-0 qTt v�5i3 EJ-7 kkv r� 0 lq z s SECTION 9: PROPERTY OWNER AUTHO IZATION Name and Address of Property Owner / 7application. t l , G ' P ik `$ �(i CS ` .Name(Print) No.and Street City/TownProperty Owner Contact lufonnattbn:ownp /` ©7-?.&a OO-)c�Title TelephoneNo.(business) TelephoneNo. (cell)If a licable,the rope owner hereby author �� 2� t iT) /join' p�Name Street Address City/Town to act on the ro er owner's behalf, in all matters relative to work authorized b this buildin SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) If building is less than 35,000 cu.ft.of enclosed space and or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for ConstrucHon Control ut� �' Name i'tm ele hon nil address Registration Number ��'t - F �aly� lro en ip o i a3 St eel Address City/Town State Zip Discipline Expiration Date 10.2 General ontractor - r 0/t Con ny Name 7 Name gf.Wrson es nsibleio�Construction License No. and T e if Applicable S reet 1d ess City/Town tale ip y�(Y 0 -) 0 Ic�y�-P Telephone No. business Telephone No. cell a-mail address SECTION 11:W'ORFEKS'COMPENSAI[ON INSURANCE AFFIVAVII 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 the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE' Item Estinmted Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Budding $ Building Permit Fee-Total Construction Cost x (Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ d. Mechanical (HVAC) 5 Note:Minimum fee=$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ (contact municipality)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 knowledge and understanding. Please print and sign name Title Telephone No. Date Street Address City/"ruwn State Zip Ia Municipal Inspector to fill out this section upon application approval: 4b'.0 �T Name Date QTYOF SALEM, MASSAmLISEM BUILDING DEPARTMENT 120 WASIENGTONSTREET,3'DRLOOR TkL(978)745-9595 KIWERLEYDRISOOLL FAX(978)740-9846 MAYOR THCMAS ST.PIERRE DIRECTOR OF PUBLIcPROPERTY/BUIIAING omsffssiomR 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 111.5 Debris, and the provisions of MGL c40 S 54• Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in-a properly licensed waste deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of facility) �w 61 (address of facility) Signature of ap licant Date The Commonwealth of Massachusetts Department oflndustrialAceidents 1 Congress Street,Suite 100 Boston,MA 02114-2017 www.massgov/dia Wworkers,Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE FH.ED WITH THE PERWITING AUTHORM. Applicant Information lease Print Le 'bl Name(Business/Organizatio dividu r- o ' Address: �> � p City/State/Zip: one#: 741en employer?Check the appropriate box: Type of project(required): a employer with employees(full and/orpart-time).• 7. ❑New construction . am ovule proprietor or partnership and have no employees working forme in 8. Q Remodeling any capacity.fNo workers'comp.maursnca required] - 3.Q I am a homeowner doing all work myself[No worker rance s'comp.insu required.)I 9: El Demolition 4.�I am a homeowner and will be hiring contractors to conduct my property. conduct all work o I will 10 Building addition. ensure that all contractors either have workers compensation insurance or are sole 1 LE)Electrical repairs or additions proprietors with no employees. 12.Q Plumbing repairs or additions m 5.❑I a a general contractor and I have hired the subcontractors listed on the attached sheet. 13.Q Roof repairs These sub-contractors have employees and have workers'comp." su ncel - 6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other . 152,§1(4),and we have no employees.[No workers'comp.insurance requited.) -Any applicant that checks box#1 must also fill out the section below showing their workers'compensation polity kofotmation. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside connectors must submit a new affidavit indicating such (Contractors that check this box must attached an additional sheet showing the name of the sub-cohbactons and state whether or not those entities have - employm. If the sub-contractors have employes,they must I mW&their workers'wmp.policy number.. I am as employer that is providing workers'compensation insurance far my employees.:Below is the policy and job-site information. Insurance Company Name: . �/ �o / l Policy#or Self-ins.Lice.#: � P Expiration Date: / / Y/( / c Job Site Address:_/�L_ / i U y City�Stete/Zip: U�2�p Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration ate). Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains and penaltie s_ _' or ation provided above is true and correct. ham- Signature:' Date• Phone M Official use only. Do not write in this area,to be completed by city or town ojykial City 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 Massachusetts 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,corporation 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 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 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-contractors)name(s),address(es)and phone number(s)along with thew certificate(s)of insurance. Limited Liability Companies(I.LC)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 thew 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 fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill 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 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 dqg license or permit to burn leaves etc.)said person is NOT required to complete this affidavit. The Department's address,telephone and fax number: - The Commonwealth of Massachusetts Department of Industrial Accidents I Congress Street, Suite 100 Boston,MA 02 1 1 4-20 1 7. Tel. # 617-7274900 ext. 7406 or 1-877-MASSAFE Fax#617-727-7749 Revised 02-23-15 www.mass.gov/dia HBB v'V A.C. CASTLE CONSTRUCTION CO. INC. VC ►� + �� V ;�MFJNBER Telephone(800)505-LEAK(5325) • Fax (978) 777-7750 �'✓�+�L.� �gi Brian LeBlanc, President Please mail accepted proposal to the office located at. 9 Tibbetts Avenue • Danvers, MA 01923 Unrestricted Mass Builders License No.054882 Contractors Registration No. 166565 PROPOSAL SUBli TO PHON ob� DATE STREET . JOB NAME ZgAS � Z CITY,STAT D I CODE JOB LOCATION ,d r- cSL'/1'�i DATE WORK IS SCHEDULED TO BEGIN DATE WORK IS SCHEDULED TO BE COMPLETED JOB PHONE VC VT Og hereby to furnish me net and1la -com I in accordance with specifications below for the sum of: r dollars($ Payment to be follows: 1/3 down, the balance due upon completion. NOTICE: All home improvement contractors and subcontractors engaged in home Authorized improvement contracting unless specifically exempt from registration by Signature: provisions of Chapter 142A of the General laws,must be registered with Agent the Commonwealth of Massachusetts. Inquiries about registration and Note:This proposal may be status should be made to the Office of Consumer Affairs and Business withdrawn by us if not accepted within days. Regulation,Ten Park Plaza,Suite 5170,Boston,MA 02116. WE HEREBY SUBMIT SPECIFICATIONS AND ESTIMATES FOR: A ROOF STRIP We will cover the siding, bushes, and grasses with Blue Tarps in order to protect the property during stripping. We will Strip up to 2 layers of roofing and remove all nails,screws and staples down to the Bare Wood and renail all loose boards. The Ice and Water Shield will then be installed at the bottom of all Edges,under all Step(lashings, under all Roll flashing, around all Chimneys,Skylights,and into all Valleys, in heated areas only. i We will install 30 lb. Synthetic Deck Protector Underlayment to all other areas of the roofdeck. The 8"aluminum Dripedge will then be instal to II oof edges., st Pi peswill be/ y>3red wi luminum Rubber Flanges. The roofingmaterial to be used will be L� b � � *The bottom all roof of edges will have a Pro Starter.course with a glued edge for wind uplift.We will Storm Nail a shingles,using 6 nails per shingle. ., •- zre All the Debris will be cleaned and Dumped by us on a daily basis.We will cleandut all Gutters-Downspouts and Elbows. Magnetic brooms will be used to extract all nails from your property.We will protect your property as best we can,however some foliage matting, breakage,or marring could occur. We cannot accept responsibility for possessions inside of the house,or debris falling into attic areas.Customer should protect personal belongings. EXTRA WORK IN WHICH A COST WILL BE ADD TO E'ABOVE PRICE. Replace Rotted Roofboards 4��er-� Install Aluminum Gutters Relead Chimney(s) Install Aluminum Downspouts Replace Facia Boards Install Skylight(s) 1/0 57 Install Ridgevent �,�1� -Rotted Roof To Wall Flashings Install Roof Louvers OU'i Gutter Repairs NOTES: / P Warranty manufacturer o e free of defects f r years, see manufacturer's warranty for exact warranty performance. All labo erfo mail under is_ ontract shall be of.good quality and free from defects not inherent in the quality required or permitted for a per' "of year . fi' wairaniy excludes remedy for damage or defect caused by abuse, modification, improper or insufficient mair enance, roper opipfation,or normal wear and tear under normal usage.This warranty shall be limited to the work performed by A.0 Castle Constructi o., Inc. and limited to either repair or replacement by A.C.Castle Construction Co., Inc. at its'sole discretion and action. d all claims are waived unless made in writing to A.C. Castle Construction Co., Inc. within 21 days after the occurrence o the event giving rise to such claim.This warranty shall not extend beyond any limits imposed by applicable law. It is our obligation to obtain any and all necessary related permits. PLEASE NOTE:owners who secure their own construction-related permits shall be excluded from access to the Guarantee Fund.