MILL & MARGIN ST - BUILDING INSPECTION Q The Commonwealth of Massachusetts
o " I Department of Public Safety
MJSS,IChl6et Ls Sldla Building C0110(780 CkIR)
`"""•} Building Permit Application for any BuiIding other than a One-or Two-Family Dwelling
(This Socliun For Official Use Only)
Building Permit Number: Dale Applied: Building Official:
SECTION 1: LOCATION(Pleaseindicate Block#and Lot k for locations for which a street address is not available)
lr�Ary/.¢-d —C7 al?;;
No.and Street Cih' /TO\%'Il. Zip Code Name of B&lildinl;(if applir,ible)
SECTION 2: PROPOSI?D WORK 'c
Fdilion of NIA Stale Code used If New Construction check here❑or check all that apply in the two rows below
lixislint;Building ❑ Repair❑ Alteration ❑ Addition❑ D%nnulilion ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or amstnrctiun dUCuments being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review rrL�rAired? cs U ❑
Brief Dy"riptiUl}Uf PfUposed WUrk:_� / �'oe/ / A /oo�Wrv���_
:clot drfllg aft r'oo I r�wi}/ 2 �- �JG/7//U /orfs /ti��i,r/ro�•,
--
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 CNIR 3a) ❑
Existing Use Group(s): _ I Proposed 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(scl. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ 1 E: Educational ❑
F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ 11-3 ❑ H-4❑ 1i-5❑
1: Institutional 1-1 ❑ 1-2❑ I-3❑ 14 ❑ Mo Mercantile❑ R: Residential R-10 li 2❑ 1i-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑am1 please describe below:
Special.Use
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SIDE INFORMATION(refer to 760 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Hood Zone❑ Indicate municipal❑ A trench.%kill not be Licensed Disposal Site
required ❑or trench or
Private❑. or indcnlih'Zone:_ or(in site sysorm ❑ permit is cn(losed ❑
Railroad right-of-way: Ilazards to Air Navigation: Al h I i,,I,�r�- ��" r.i_--_„ 1'. -
Not Applicahle❑ Is StnlCtu rr within airport approach area? Is(heir review Complcled.'
I Cannon( to Build rnclusrd ❑ Yrs❑ or No❑ )L'S❑ Nu ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
FditiOlt of Cudc:_ Cse Group(.,). ____ Iv pool Conslruction: __ OIL 011,1111 Lood por IlUor:
Does the bU ild ingconta in an Spit n khor Seslem?:_—.--Special St i pu latiuns'. --__.-_..--------_----
SECTION 9: PROPIT IN OWNER AU'I IIORIZA'IION
N,mic and Address of Pntp,rh Dunn '
---_rc�-4— ,V—Al; -- zi,1�7/1 ,- --f`n.
Name(Print) Nu.and Street City/Town Zip
Property Owner Contact Information:
�.� -T
I it le Telephone No. (business) Telephone No. (cell) c-mail address
If applicable, the property owner hereby*authorizes
Nance Street Address City/Town Slate Zip
to act nn the property owner's behalf, in all matters relative to work authorized by this building permitapplication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less drum 35,1HMr cu.ft.of enclosed space and or not under Construction Control then check here E3 and ski,Svction 10.1
10.1 Registered Professional Responsible for Construction Control
Nine(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Dale
10.2 General Contractor /' /
�pAJ f fig n 4ti rrCO1 �//'r� . c/ c 6.v //LG
Company Name
err( bV f� T� / 9;> 9
Name of
Person Responsible for Co(/as/tt uction 1rr // License No. and Type if Applicable ,r/ /,
�J /J 'tAY�L�/.� /IY —C4 7� /lo'd a/ �0
Street Address City/Town St}� Zip
_j¢y_ /99 ' ��� 293 /�oBG o //oA Ll�Gaf4•`1� (✓z�
Telephone No. business Telephone No, cell a-nail address - —
SECTION II: Wt,I:u;R9( t)NINVSAflt1Nu_�h_t.INANi'I Al1n,r,Vlt M.G.L.c.152.§ 25C6
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
Iten Estimated Costs:(Labor
and Materials) Total Construction Cost(from item 6)=S
1. Building S Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
a. iliechmtic l (HVAC) S Note: Mirthourn fee=$ (contact tunicai}t��dip'
5. Mechanical Other $ iJ
�f2 Enclose chtrk payable ill
3 f__
n. Total Cost $ r — (umtrcl municipality)and rvrile check number hrre— _—___
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering ny nann•below, I hereby altcst hider the pains and penallies of perjury that all of the information contained in this
appliauion is true anfd it)acatnuc , to hest of knowledge,oaf understanding. x
Phase print i d sigi na IVTelephone N Date
S7ect Address Cite/Touts State Z p q
Municipal Inspector to fill out this section upon application approval; ///
No Dal T
v I a
� 1
Professional Roofing Contractors , Inc.
James W. Shea,President
P.O.BOX 262 45 DEARBORN STREET
SALEM,MASSACHUSETTS 01970
PHONE (978) 744-6888 FAX (978) 744-8814
professionalroofingQverizon.net
PROPOSAL
April 27, 2011
Mr. John J. Walsh
John J. Walsh Insurance Agency, Inc.
Mill and Margin St.
Salem, MA. 01970
RE: Roof Project
To re-roof main flat roof with the following steps:
1. Set up roof per O.S.H.A. requirements.
2. Remove existing rubber roof and fiberboard insulation under rubber roof.
3. Install wood nailer around perimeter of roof.
4. Install Carlisle russ strip on walls and units.
5. Install Carlisle fully adhered Design"A"roof system.
6. Re-flash all penetrations per Carlisle details.
7. Install bronze 040 aluminum roof edge flashing around perimeter of roof.
8. Clean up and remove all roofing materials.
9. This proposal does not cover, and in no case shall Professional Roofing Contractors, Inc. be
liable for, the removal or damage to HVAC units,conduits, gas lines, water lines and
electrical lines located above, below or in roof system.
i
TOTAL COST...................................._...........$379824.00
ACCEPTANCE OF PROPOSAL D ``
TERMS OF PAYMENT
Optional: Provide Carlisle 15 year labor and 20 year material warranty......$1,200.00
CITY OF sm.&NI, j**vL-kSS.-1CHCSET7S
BI;ILDLYG DEPARTMENT
120 W-+sHLNGTON STREET, 3w FLOOR
TEL (978) 74S.9595
FAX(978) 740-9846
KIJ(BERLEY DRMOLL
MAYOR THo.NAs ST.PtERRB
DIRECTOR OF Pt:BLIC PROPERTY/SUMEILNG CO]LNISSIONER
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 I 11.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit Al 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 b1GL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
44Z
khnvif.l.a
• CITY OF SALEM
PUBLIC 1)ROPRERTY
DEPARTMENT
�i'.M:I Y:IIIIN,nI
1!.'.WA41l Ill.%JI.,( ♦ $111•.N.I`L1\1.\I.I II 4
Ih1. 77t;Ii/i'IJ • f it v79.74-9Ls46
Yorkers' Curnpenaatlon Insurunce lifOdavit: Builders/Cuntraeturs/Electrlcianyplumbers
1,001153111 In unnrflo
� mac/ � it rant Le 'bl
Nilln� 111uuik kyl)r;(anvJrinN Ind,vduall:_JrUC.///6
wldrecr: AOX- 212
11
City,Stage,Zip- � f9r-r7 i /7z C/ I'huneil Q�� ' /7 �Y—Lap d rf
.bray)too all vmployorl Check the appropriate boa
I ua 1 ,un a cmpluyur with �' 4.I 1)M Iltpruiaet(ruqulrrd):entplu)ree(full and/or Part-time).• a hull h filed thu.oh�leamora�unl
4. ❑New construction
2.0 1,I11,a sale prolt r,or partner• listed on the anachcJ sheet : y ❑Relnodelind
ship aml have no vanpluyeun These subcontractors have
working Ibr Ina in any capacity, workers'comp, insurance g' mmoliriun
I No workers'cutup. insunance 5. 0 We are a corporation and its Q• ❑OuiWind addition
J.0required.) '01cers have esemiatd their 10.0 Electrical«pain or additions
1 :ml a h llrtuuwner duind all work righf Ofc"cmp6011 per bait, I I.0 Plumbing repaid or adJiginns
nysclf. (Ko workers' lump• C. 132, ¢1(4),anJ we have no
nsurance required.)f cmpluyccs. (No workers' 12.91uufrepairs
coml inauraniv requind.1 1)•0 uglier
•.�n>.,phrYa IMI ItIlke bee el mIW alw till uw IM vtsu
'I I„I,W„wnare rha,uymil this alTdeva indiaatin t an is at donne It" r f I con _
e M Ys done ul wu Y and It"half ws M guar sips Wtl au tlw,a s n•a.IRdwir inJlayrina vwt
rmltwnwn IAM aMxe the hr1 now JaaaMe ran addiri.rall 'Al Ill nuns 11tIM mb,"ranare and IMff%%Aw 'cane. *,,NY tnhrmmhn
IIIlY/am toll earployer that tf prov/dlxx rvurk"i rexrpNrfNtex hl fur/rxerlor Iffy emp/ayee.R Bdor/a the pu/lay uxd/ol.rile
rxlYl(rlle,
Insurance Company Name: virl,S �✓LL' GO.
Policy a ur Sulf•ins. Lie.d; B274r2
! Eapiruuun Dane: ! / L
tub Site Address: Lf lS=s-,. 0 //��//
C1ty,JlataLIp+_f mach a copy of Ibs workers'cumpunuNoa pulley duclaralfun page"showing the policy number and e.eplrallua dill
PJllial to sucuro cu\eruye toe required under Setliun 251%ul'.%ICiL c. 152 eau lead to the imposition o/criminal penalties of a
Fine❑p rn.SLJo it day
Iggi ne•year imprisuumcm. Js Nell as civil perlaluu in the I'unn Ofa STOP WORK ORDER snJ a ring
otup rn i?JQ.IM a Jay Jguuut the vLNaux. IIc advL+eJ that a copy of ilia uC swtcmang may be IurwardcJ to the Ullica al
Inr;anyJu,nu tow I)IA for msuracce :rwerJyu Ill ilie allun.
/du/h•n•hy{.rti/y nadir the p,l' f,YtJ pion/tier a/per/nry Ilia/f/�e ix uroxallox/ provided aluee it tract(tied correct
I'IY q. l
I )//$'fiat/Ise an/y. Oa oar n it ilt Ill urea, Ill AI ruuly/rbJ lyy viry ur town a//lciuL
IIfY Vr I,I IYT. '
h.uing .\Wharity (circloone); I'enniul.lecnfaM
I. IL,.+rJ ul IIYJIdt 1. Ilndditt� Ucp,Irtulcul I. Cil).'I'oo11 Clerk 4. llecfrir.rl (nglerfur 3. PluutDiny Irnycer°r
i G. I)11u•r
i
Information and Instructions
ni
pet ion ,n the service of another uu,lef Illy contract of hire.
�I,tbb,tchusatts lieneral Laws:haytet I32 rcywrcs all t employers to provide workers Cfa,npeJllUn t0(Ihelr:Illy JYCCl.
I`ursuattt to uus batute, an rtnOfurrr is JctineJ Js"...every Pe
%press It ,mplicd, fatal or wntten.' oralion far other legal cntiry,or any two or more
urtnerahip,.tssoeialtun.core er far the
No crnptuyrr rr dctincd U••an individual,p to in vas loytes. However the
,t the Iaregfamg engaged m a iwm ent<rynse, and ituluding the legal representatives of a decease)employer.•
,eceever or trubteo cal'.fat individual, ptu Pict" p,assoctatiun or other legal enesidly.a therein.
Y a ' D
owner of a dwelling house having not more than
to three
do maintenance."ent
whtru�ion orlrepuit work faasubll dwellicupant Of ng house
dwalhng huuie of another who employ. Ps
or fan the.,rounds or building appurtenant thereto shall not becausa of such employment be deemed to be in employer•'
�I )L chapter 132. 023C(6) also states that"trsry state or local licansing agency shall common the Issuance or
Ilsaet with the Insurance coverage reglJ
rentwsl of a Ileum at permit to uytrafe•business of to construct buildings la the commonwealth or any
C 11 irates"Neither the commonwealth not any of its political subdivisions shall
typllcant who has not produced acceptable evidence of cutup
Addilifanally, �IGL dwpter l S_, i-3 l
entuiro ct if110
,A of his chapter a pert have been p esantedto the con�ract g aluthorityv mince ufcumpliwtce with the insurance
ray
Applicants ing the boxes that apP1Y to your situation mid if
compensation atlldavit completely�M numbers)along wilts their cartilicate(s)of
Pleaso Till out the workers' comp ns)and p LLP)with no employees other than the
necessary,supply iub•contractor(s)name($),adt)tess(
nsurncc Limited Liability Companies(LLCwofLimitedkers. compensationiaili ituumnce.(if as LLC or LLP does have
members or pullers, are nut required w carryibmim'd to the entpinyeas,a policy is requite 8t advised that thu 31TIChavill'nayAtso be sort 10 l injgn and date the urlldnviL Department
dtidav ndustritt should
artment of
\ecidents for confirmation of insuraneo coverage the low us ii you ate required to obtain u workers'
Ind rmumed to the airy or town that the upplicadon for the permit or licetw f you rrequired, not the 'P
You have tiny questtoms regarding aplet should enter their
Indusrial Accidents• Should y fay quds st'he
number listed below. Sel6insured comp
cutnpensation policy,please call the Dap
self•insuranee license number on tht appropriate line.
City or'rows 0fftclats
You tf till out in the avant the )I11cs of Investigations has to contact you regarding the applicant.
Please he suro that the affidavit is cunpltte and primed legibly. The Department has provided u space at the bottom
cant
of the affiduvit for y
I'I:abe be sort to till in the petmit/licmtse numbti which will men year need only submit ono reference numbor. lntlldavit addition,
curtent
pit far
that mutt submit multiple ysnnio'licattse applications in any g Y be provided to the
Policy ittl'ormation(it neceb,the ufPWuvit that has bean officially stad tinder"Job Site mped or marked tby;tile city oretown tnaytiun in l' Y
town). A tupY
a lictnat far penult not related to any business far comnurchal venture
applicant as proof that a valid affidavit is on file for tLtun permits far licenses. A now a111daviI must be filly out sac
y cur. Where a home owner or citizen is obtaining
t i.e, .1 dug Ilcen..je or permit 16 burn leaves ate.)said person is VOT required to complete this affida utha`a.uty 4uasuous,
I he )i1i:e of Invcaigatiuns wuuld irks to thank you in Jdv:utcc for your cooperation and should y
I+Icabe du nut hesitate to give us a cJll.
lcphuns a
fhc U.p:unncnt's addrat.a, mTh C n�onwealth of Massachusetts
Department of Industrial Accidents
OMCS of lavesdgadons
600 Washington Street
Batton, MA 02111
T'ei. N 617.727E 00 6Cxt 17 702 of 1-877•MASSAFE
x 0
d I,,.u3 www.mass.gov/dia