4 MESSERVY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
° Board of Building Regulations and Standards IEC EFV§6TY OF
Massachusetts State Building Code,780 CMR INSPECTIONAL SekMtf
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or D•e 1
One-or Two-Family Dwelling ""' 1 A C� 53 ,
This Section For Official Use Only
Building-Permit Number: Date pplied: /J
ZQ
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address:
�—V 1.2 Assessors Map&Parcel Numbers
1.labs_this`a`ni+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(it)
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?
Check if yes[] Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: c
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ ecify:
Brief Description of Proposed Work': —+
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
t Check No. Check Amount: Cash Amount:
6:3'otal Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
(�l n<t L -r0 t-t • p
Sir LCA Ls
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /
?, A- the A— -, License Number E p ration Date
Name of CSL Holder
List CSL Type(see below)N
"b N� �No.and Street Type Description
0 Unrestricted(Buildings u to 35,000 cu.ft.)
—\1 R Restricted 1&2 Family Dwelling
City/Town,State, IP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1/ g. �{�
e 1 `% i,_1 - HICMRegistrati_on Number Expiratiim Date
HIC ompany Name or HIC Registrant Name
No. d Street „ Email address
r V
City/Town,State,Z 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 ...........1147 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
to act 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 AUTHOfUZED 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 to the best of my knowledge and understanding.
y' �
\t1," S 4L---- 40
Print Owner's or Authorized Agent's Name lectronic Signa-loue) Date
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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass. ovg /dps
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'
CITY OF S. .&Nl, 1NIASSACHUSETTS
BuUMLNG DEPARTMENT
120 WASHINGTON STREET,320 FLOOR
TEI- (978)745-9595
Fnu(978) 740-9846
KI.NIBERIEY DRISCOLL
MAYOR T Honu,c ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSMRSSIONER
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:
g
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
�iVV l�V
signature of permit applicant
10
date
drn,�,air.aoc
CITY OF SUE, UkSSACHUSETTS
BI:B.DING DEPARTMENT
\ 130 WASHINGTON STREET,3t°FLOOR
TEL (978)745-9595
FAX(978)740.9846
IQ\BERI.BY DRISCOLL
NMAYOR THohw ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COM %MIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricia"Plumbers
Applicant Information ! Please Print Legibly
Name(BusimssiOrganization/Individual): �" AA C, - T��
Address: � _�e. v��
City/State/Zip: Phone M
Are you an employer?Check the appropriate box: Type of project(required):
I.P 1 am a employer with 2_ 4. ❑ i am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-
contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.1 7.remodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs fir additions .
myself.[No workers'comp. c. 152,§1(4),and we have no 12;�Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] 13.❑Other
•Any applicant that checks box 01 must also fill out the section below showing their workers'compensation policy inforenadom
/1 tomeowaen who sulmtit this affidavit indicating they ate doing all work and then hire outside contnchms meat submit a now affidavit indicating such.
:Conuacton that check this bar must anached an additional alteet showing the came of the mbewmactots and their wodms'comp.policy information.
I am an employer that Is providing workers'compensadon insurance jar my employees. Below is the policy and job site
information.
Insurance Company Name:--" Z.n ri
Policy 4 or Self-ins.Lie.#: AA*u— Expiration Date:--
Job Site Address: V City/StauVZip:s
Attach a copy of the workers'compensation poi4 declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 132 can lead to the imposition of criminal penalties of a
fine 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 fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do ltereby certify under are pains nd penalties a p jury that the ioformadon provided above is true and correcR
Signature A Date 10
I1 )
Phone 1/: �—
t7fTiciat use only. Do not write in this area,to be completed by city or town official,
City or Town: PermitR.icense N
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.Cilyffown Cleric 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone ii:
Shea Roofing Co.
W/Z Foster Street
Salem, MA 01970
(978) 745-7313
PROPOSAL September 24,2014
SUBMITTED TO: Donald Hayes
4 Messervey St..
Salem, Ma.
We hereby submit specifications and estimates for:
To remove all existing roof shingles from complete main roof including
all extension roofs.
To install ice and water shield covering all other lower roof edges and,
under 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 and
vertical.
To install architectural (GAF or Certainteed Lifetime) roof shingles
covering complete roof.
To install up to 50 linear feet of roof boarding if necessary.
To install new roof flange on roof vent pipe.
To install new roof vents as necessary.
To re-flash, counter flash and/or reseal all side walls as necessary.
To remove unused vent pipe from main roof.
To re-flash, counter flash and/or reseal chimney flashing as necessary,if
lead flashing is too damaged we will grind out and re-lead chimney at an
additional cost of$275.00.
To clean up and remove all roofing debris from job site.
We propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
Eight Thousand Seven Hundred and Eighty Five-------Dollars (8,785.00)
Payment to be made as follows;
One third to start balance 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 the work as specified.
Authorized Signature:
Signature:
Date of Acceptance:
r,
MassacbusettS -Department of Public Safety'°'�
L,
Board of 30ding Regulatioll
ps ank1;'Standards
Cnnstrilction Supervisor
• License; CS-103580
'WILLUM SHIA
Beverly MA 01913 vj ,
10 i' Expiration.:..
Commissioner 0 311 4120 1 5.`.
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