3 MEADOW ST - BUILDING INSPECTION N — ----- 1'he Commonwealth ot'M:ssachusclts
Board of Building Regulations and Standards CI'1'1' OF
tY u, MassachLISMS State Building Code. 780 CNIR SALEM
ti 12rria'eJ.11ur'Ull
Building Permit Appiication 'ro Construct, Repair, Renovate Or Denwlish a
One-or Two-Famill Uu elliµ�r
f \ this Section For 0lfieial Use Only
�) Building Permit Number: D e Ap is
lhulding 0111cial(Print N;unc) Signa Dale
SECTION I: SITE IN ORMATION
L I Property AJJre{a: r ` 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes no Map Number Parcel Nunrher
1.3 Zoning Information: Li Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§Sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zune? Munici al O On site disposal Check ifa❑ P posal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of R_e\cor�d: ^�
Wulle(Print) City,State,ZIP
Nu.and Street Tele hone
P F.inail Address
SECTION J: 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_ Other ❑ Specify:
Brief Description of Proposed Work-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and \hueriaisi Official Use Only
I. Building S � (6 ^ 1. Building Permit Fee: S Indicate how fee is determined:
'. Fleclrical S ❑Standard CiryiTuwn Application Fee
3, 1'lumhing S
❑ /Total Project C'ostt( P
Item 6)x multiplier _._— x _
. Other Fees: S
a. \Icclrutical ill\,1<'I S List:
tiu+ttcision) S Totd .\II Fees: $ _
1\A ��� Check No. ('heck Amount: _ Cush \monuu:
Total Project Cull: S ❑ Paid in Full 13 Outstanding liahtnce Due:
SECTION 5: CONSTRl/CTION SERVICES
5.1 Construction Supervisor License(CSIJ It
License Nunlhcr fxpirltion I ate
N;une ol'l'Sl. lluldcr
I ist('SI.1)Pk!(sec hclnwl _.
_-.------ 'I\pe Dcxripliun
--
NU. Alld Slrcel
p`�� .[•� (I I InrcunctcJ UhIilJin�s tio to 1$,II00 cu, Il.l
U✓��'�^� l7 t"\�` _... . . Re.+lricled 1C2 Fanlil lAwill"LZ
Cil_si fa"n.Alain _ M1I NLIS011
RC Rix lin Cmerin
.-._._ %%'S Window;utd Siding
SF Solid lvcl l)urning Applianccs
hlsulalion
1'ele hone I!mail address 1) Drnwlitiun
5.2 Registered Home Improvement Contractor(HIC)
1
IIIC'Itegistauion Numher I gsirn un Dom
IIIC C'onlpan Name or I IIC'Registrant Nmnc
YJ j
N and Strcet �q,0,�\ Email address
J >,r:`,, ",a O y 1
City/Town,State,ZfP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 152.1 2SC(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 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
Print Owncr's Name(Electronic Signature) Dale
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 in this application is true and accurate o the best of nl knowledge and understandin ,
• 's M �� onlc Signature) Date
' , � I '� A�enl s Mum hkUr )
I nm Ihs ncr s l r.\uthl nnJ b I g
NOTES:
I. ,%n Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Cuntractor(HIC) Program).will nrt have access to the arbitration
program ur guaranty fund under\I.G.L.c. 142A.Other important information on the HIC Program can be found at
W%1% m.n, % A I Information on the Construction Supervisor License can be found at
2 \%'lien substantial work is planned,provide the information below:
Total flour area(sq. 11 - __.._1 including garage, finished basementattics,decks or porch%
(truss lis ing area I sy. 11.) ....
\umbcruf fireplaces -.. _ Number of hedroums
\'unther oFholhroonts . . _ . _ . \'umber of half hoths _ . . _. .
I')pe of heating i)stem .. . _ Number ot'decks, porches
\Ile of Qoollllg i\itdlll 17I1closed tlpell
i
1. "focal Project Square Foonege-m;p he suhstitutcd for"folal Project Cost"
CITY OF S:u.EM, Al ss.IcHUSETTS
r BUILDING DEPARTMENT
120 WASHIINGTON STREET, 3 a FLOOR
TEL (978) 745-9595
F.'a(978) 7404846
KIJIBE'.RLEY DRISCOLL
NYOR TttoatAs ST.PlERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO-ZlISS10NER
1Vorkers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumbers
Apolleant information Please Print Legibly
.V71710 t0atitxss.Organiyaiianrindividua1): u t \\ 'i t� d\� J�
Address:
City/State/Zip: � Phone Al:
Are you an employer?Check the appropriate box: 'type of project(required):
I1A I am a employer with_'� 4. ❑ I am a general contractor and 1 6. 0 New construction
unpluyces(full and/or part-time).• have hired the sub-contractors
2.❑ lain a sole proprietor or partners listed on the attached sheet,t 7• ❑Remodeling
ship and have no employees These subcontmctors have S. C] 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.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(No workers'Gump, C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t - employees. [No workers' 13.0 Other
cum..insurance nyuircJ.J
•Anv applicant nW chuck,boa Of mutt also n11 ale the section below showing their waken' p
compensation olicy infurmution.
'I hrtteusrtstrs who suhmit this amtLtvii indicating they am doing all work and then hire outside conlmcion,moat adianit a new afrfdavil indicting such:(.,ninon ihel chalk this box must machud an additiurvd sheet shuwing the name of the subaontrsctan and their workers'comp.pulley intennatian.
fain an earpluyer fhatds providing workers'compeatsatlon insurance for my empluyees. Below it rile policy and job site
inf0faradom
�[
Insurance Company Name: + h
Policy 4 or Self-ins. Lie.4: `f LQ)U\Ng')ock?--J V�_ Expiration Date: asa,\
Job Site Address: ^l Moz r}�'1�� - City/State/Zip:Je.. � V
.lttach a copy of the workers' compensation policy declaration poke(showing the policy number an ,expiration date).f
F-Ailuru to secure coverage as required under Section 25A of bIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of Lill to SM.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Of6ca of
I neesli gal ions of the DIA four insurance coverage vcri kcal ion.
I do hereby certify ender'the pales wad penuhles of perjury that file infuralurfar provided above i.r true aard correct
Si�L;Llue:
Date: _
Phone& _
I
i 011icial use only. Du,tor write in this area, to be completed by city ur town o/jiciai
t
City or fawn:
Pcrmirfl,lccnse 4 i
Iss uiagA Lit hurily(circle one): -- -- ---- ---
I. hoard of ilcalih 2. Buildinq Departotcat .I.Cilyawvo Clerk 4, Flectrical inspectur S. Plunlbinq lorpeetor
6.Other
II Cnnlact Person _ Phone;):
[
1
Information and Instructions
>lassachusctts 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 orcompllance 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-contractar(s)nume(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
he 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. Scif-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 the affidavit for you to rill 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 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 dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Off ice 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-MASSAFE
Fax#617-727-7749
2cvi.acd 5-16-05
www.mass.gov/din
CITY OF S.LLEN19 NLkss kcHL'SETI'S
9LILDLNG DEP.1RTlEVT
120 W SHLYGTON STREET, Jw FLOOR
rM (978) 745-9595
KI3 BER1 Y DRMOLL FAX(978) 740.9846
MAYOR 7�to.+w ST.F�ItRt;
DIRECTOR OP PLBLIC PROPERTY/BLILDLYG CO\allssIONER
Construction Debris Disposal AttIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I I I.S
Debris, and the provisions of MOL a 40, S 54;
Building Permit p is issued with the condition that the debria resulting from
1 I I, S I SOA. Properly INS work shall be disposed of in a licensed waste disposal racility as defincd by,VIOL c
The debris will be transportcdd by:
(rums of hauler)
The debris will be disposed of in
(name or racdily) —�. .
IJ dit!l Or rJCIIIIYJ
vtln.Iruro oFP"mJp Jpphcmt
JJIe
Shea Roofing Co.
17 % Foster Street
Salem, MA 01970
(978) 745-7313
PROPOSAL October 13,2011
susmiTTED To: Jane Hackney
3 MeadowboO St.
Salem, Me.
We hereby submit specifications and estimates for:
To remove all existing roof shingles from complete main.
To install ice and water shield along all roof edges and along all flashing
points prior to re-roofing.
To install all new metal drip edge along all roof edges, both horizontal
and vertical.
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 install two new roof vents on rear side of main roof.
To counter flash and/or reseal the chimney flashings as necessary. If lead
flashing is too damaged we will grind it out and re-lead an additional cost
of$350.00.
To point up chimney as necessary.
To remove and board up skylight on main roof 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 furnish material and labor—complete in accordance with above specifications,for the sum of.
Fourteen Thousand Eight Hundred and Eighty Five-------Dollars $14,885.00
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 authorized to do th work as specified.
Authorized Signature: '
Signature:
Date of Acceptance: