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25 MASON ST - BUILDING INSPECTION � The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEIv� Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolis One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: �lr i Building Official(Print Name) t Signature Date SECTION 1: SITE INFORMITION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers L 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 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 Owner'of Record: Name(Print) — City,State,ZIP ")--5 J"\ t,—s-0 � �` No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify: Brief Description of Proposed Work : r' — ' SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item (Labor and Materials Official Use Only 1. Building $ t' 1. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2.Electrical $ ❑ s Total Project Cost (Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total AII,Fees: $ ^^� Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ 4� �v'1Y 0 paid in Full ❑Outstanding Ralance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) `O,13 "'3 ,�' ' License Number Expiration Date Name of CSL Holder p List CSL Type(see below) \K _ �et No.and Street Type Description Unrestricted(Buildings u to 35,000 cu.ft. \ t, N R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding - ^ SF Solid Fuel Burning Appliances I I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) "" HIC Registratio—QNn umber Expiration Date HIC Company Name or HIC egistrant Name N d S .� � _may-J�.',1 Email address City/Town,State, 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 the building permit. Signed Affidavit Attached? Yes .......... ❑ No ...........❑ SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT (� I,as Owner of the subject property,hereby authorize Syc" �, -.!� I �)NA" to act on my behalf,in all matters relative to work authorized by this building permit'aliplication. Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNEW 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 iinA'this application is true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) ! Date NOTES: I. 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 can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at mL% .mass.eov/dos 2. When substantial work is planned,provide the information below: Total floor 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" Shea Roofing Co. 17 % Foster Street Salem, MA 01970 (978) 745-7313 PROPOSAL May 16,2012 susmirrED TO: John Healy 25 Mason Street Salem, Ma. We hereby submit specifications and estimates for. To remove all existing roof shingles from complete top main roof. To install ice and water shield along all lower roof edges, up all valleys and along all flashing points prior to re-roofing. To install asphalt saturated felt paper covering all roof boarding prior to re-roofing. To install all new metal drip edge along all roof edges, both horizontal ve rtical. ertical. To install architectural (GAF Timberline Lifetime High Definition) roof shingles covering complete main roof. To install up to 100 linear feet of roof boarding if necessary. To install new roof flanges on roof vent pipes. To grind out and completely re-lead chimney. To install new roof air vents. To remove then board up roof hatch prior to re-roofing To clean up and remove all roofing debris from job site. The new roof is guaranteed for five years against any problems created by faulty workmanship. We propose hereby to fumiyh material and labor—complete in accordance with above specifications,for the sum of. Four Thousand Eight Hundred and Eighty Five----------Dollars ($4,885.00) Payment to be made as follows; Upon completion All material is guaranteed to be specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifications Involving extra costs will be executed only upon written orders,and will become an extra charge over the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Owner to carry fire,tornado and other necessary insurance. Our workers are fully covered by Workman's compensation Insurance. Acceptance of Proposal—You are utho'zed to o the work speciii d. Authorized Signature: A� - Signature: / .— Date of Acceptance: 3 ��-- CITY OF & .Em. IIASSACHL'SEM BUILDING DEPARTMENT 120 WASHINGTON STREET, Sao FLOOR TEL. (978) 745-9595 FAX(978)740-9846 KIMBERI.EY DRISCOLI MAYOR THOMAS ST.P[ERRB DmECCOR OF puBLiC PROPERTY/BUILDING comwSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibly Maple(Busim-ssiOrranixatioNlndividual): v, C�='e,. sy c, � Address: City/State/Zip: ��-A z Phone ##:_ Are you an employer?Cheek the appropriate box: Type of project(required): I fi. �6 1 am a employer with, '8� 4. 111 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7• ❑ Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity, workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance S. ❑ We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp. C. 152,§1(4),and we have no 12)NzRoof repairs insurance required.)t employees.[No workers' 13.0 Other comp. insurance required.] Any applicant that checks box g I must also all out the section below showing their workers'compensuion policy information. t Ifomeowners who submit this affidavit indicating they am doing all work and then hire outside eom rum,must submit a raw affidavit indicating sum -Cumrnnon that cheek this box must attached an additional had showing the mane of the subKoahactom and their workers'cmnp.policy infomatim. /am an employer that tr providing workers'compensadon hnsurance jar my employee& Below is the policy and fob site information Insurance Company Name: 111� wc�� i Policy#or Self-ins.Lic.#: �^�L 4Se1 L�`r�.E,r,"\ Expiration Date: Job Site Address: r � /tit < /J ^ .� \ City/State/Zip- Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to scum coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine 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. Ida hereby certify under the ins and pens es of perjury that the information provided above is true and correcL Sig anve: Phone#: OJf eial use only. Donor write in this areas to be completed by city or town official, City or Town: PermitfLicense# Issuing Authority(circle one): I. Board of Ilealth 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: [ i CITY OF SM .M. TN'LASSACHUSETTS • BUILDING DEPARTNMNT i 120 WASHLNGTON STREET, Ya FLOOR \ ' 'ILL. (978) 745-9595 FAX(978) 740-9846 KINIBERLF-Y DRISCOLL MAYOR THOAfAS ST.PtERRB DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%IISSIO,iER 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 c 40, 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 disposal 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 : Nor��S,\cN4 Cam , L�: (name of facility) address of facility) signature of permit applicant Slab I -)o date dcbrisalydoc ACORD,M CERTIFICATE OF LIABILITY INSURANCE osiz3/20121 PRODUCER (978)777-6344 FAX (978)777-9804 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION John J Doyle Insurance Inc ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 85 Constitution Lane ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. Danvers, MA 01923 , INSURERS AFFORDING COVERAGE NAIC# INSURED William 7 Shea INSURER A: Insurance Innovators Agency 30 Echo Ave INSURERS: Granite State Beverly, MA 01915 NSURER C: RE D: INSURENSURR E: 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 POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. IN5R DD'N TYPE OF INSURANCE POLICY NUMBER POLICY EFFECTIVE POLICY EXPIRATION LIMITS GENERAL LIABILITY L143000292 07/03/2011 07/03/2012 EACH OCCURRENCE $ 1,000,00 COMMERCIAL GENERAL LIABILITY DAMAGE TO RENTED $ 100,000 CLAIMS MADE ❑ OCCUR MED EXP(Any one person) $ 5,QQQ A PERSONAL&ADV INJURY $ 1,000,000 GENERAL AGGREGATE $ 2,000,000 GEN'L AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMP/OP AGO $ 1,000,00 POLICY PRO LOC JECT AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $ (Ea accident) ANY AUTO ALL OWNED AUTOS BODILY INJURY $ SCHEDULED AUTOS (Per person) HIRED AUTOS BODILY INJURY $ NON-OWNED AUTOS (Per accident) PROPERTY DAMAGE $ (Per accident) GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $ ANY AUTO OTHER THAN EA ACC $ AUTO ONLY: AGG $ EXCESS/UMBRELLA LIABILITY EACH OCCURRENCE $ OCCUR CLAIMS MADE AGGREGATE $ DEDUCTIBLE $ RETENTION $ $ WORMERS COMPENSATION AND WC009942512 0$/29/2011 0$/29/2012 1 WC STATU- 01 EMPLOYERS'LIABILITY E.L.EACH ACCIDENT $ 100,000 B ANY PROPRIETORIPARTNERJEXECUTIVE OFFICER/MEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYEE $ 100,000 S yes,de PRO ISIO E.L.DISEASE-POLICY LIMIT $ S00,000 SPECIAL PROVISIONS below OTHER DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT SPECIAL PROVISIONS CERTIFICATE HOLDER CANCELLATION SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT, City of Salem BUT FAILURE TO MAIL SUCH NOTICE SHALL IMPOSE NO OBLIGATION OR LIABILITY Washington Street OF AN IND UPON THE INS=I ITS AGENTS OR REPRESENTATIVES. Salem, MA 01970 AUTHOR REPRESENlAT ' ACORD 25(2001/08) FAX: . (978)Z32-2900 ©ACORD CORPORATION 1988