6 MONROE ST - BUILDING INSPECTION (3) �pl � — � � ZS -GC3Ibo
ECEIvEO
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The Commonwealth of Massac use S ES
} QhD Department of Public SafetyMiVCC
�V'yV Massachusetts State Building Code(7SQL1B 22 A 2t 41
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
(p �n y>xr -2ly\ S,Avr. o m\o
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❑ Repair Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1) ..
Change of Use- ❑ 1 Change of Occupancy ❑ 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 rey ved? Yes ❑ No ❑
Brief Description of Proposed Work: �g� �CTF+r&
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 CMR 34) ❑
Existing Use Group(s): 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(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❑ H: FIi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 43❑ 14❑ IvL• Mercantile❑ R: Residential R-I❑ R-2❑ R-3❑ R-1❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 11B ❑ ILIA ❑ IIIB ❑ IV ❑ I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780.CMR 111.0 for details on each item)
Water Supply: Flood Zane Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: N1'\ I h L i i 0>,n,nusi n Rr.,ic�, I, c"":
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or Nu❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code Use Group(s): Type of Construction: Occupant Load per Floor:
Dues the building contain an Sprinkler Systeim?: Special Stipulations:
4
r
SECTION 9: PROPERTY OWNER AUTFIORIZATION ;
Name and AddressldfJP.ro'°ertyy1 wner
:NI.
Name(Print) ' No.and Street City/Town y/TowT n Zip
Property OwtnereCor�Act 1.�44 833 0�W
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Na� c
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
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 Construction Control (� r
Name(Registrant) q T ephone o. a-mail address �, Registration Number
Street Address City/'Gown State Zip Discipline Expira ion D:[e
10.2 General Contractor
qt
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State
Zip
Tcic hone No. business Telephone No. cell c-mail address
SECTION 11:lb'ORKERS'C MF1FNSA I10N INSURANCP,ABFID,\VI'I M.G.L.c.152§-25C 6
A Workers'Compensation Insurance Affidavit from the NIA 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 Estimated Costs:(Labor
and Nleterials) Total Construction Cost(from Item 6)=$
. 1. Budding $ Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $ _
+. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check to
6."rotal Cost S (contact municipality)
payable
h ��� ality)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 kr owledge and understanding.
Plc prim Yln� n namne - - Title Telephone Date
CC t'K'V"i O
Street Address City/T.W State Zip
Municipal Inspector to fill out this section upon application approval: Z Zl 1
ame Date
C[TY of SALEM, AAsSACHUSF-rrs
'rr BUILDING DEP.I RT\[F—NT
120 WASHINGTON STREET, 3'FLOOR
f' TEL (978) 745-9595
F.Aa(978) 740-98.16
KINtBE RLEY DRISCOLL
VYAYOR Tr ONLJLS ST.PIERM
DIRECTOR OF PUBLIC PROPERTY/BCA.Dr%G CO%WISSIONER
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
V illit L'(0usinas Orgmtization;Individual): � � � � dv� �-s.�-rq�
Address: nJrJc��_e�
City/State/zip: N�!h. fi�o� Phone
Are you un employer?Check the appropriate box: Type of project(required):
1'.�S I am a employer with - 4. ❑ I am a general contractor and 1
—��+ have hired the sub-contractors 6. ❑New construction
employers(full and/or pan-time).
2.0 1 am it sole proprietor or partner- listed on the attached sheet,t 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 worker•' comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 ran a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'
sump. insurance required.] I3.❑ Other
'Any applic:u t dot checks box BI most also fill out the suction below showing their warkeri cumpensatiun policy inllnmation.
t I fomeuwners who whmil this affidavit indicating they arc doing all work and then hire ounid,comracters mat suhmit a new affidavit indicting such.
1C,n1tmmurs that shack this box most attached an odditiunol.haul showing the natne of the sub<onuacton and their warkero'comp.policy information.
i um an employer that is providing Ivorkers'compem.ratlon inturuncefor my emtployees. Belot,is die policy and fob a'ite
information.
Insurance Company Name: sk)�\
Policy 4 or Self-inti. Lic. If: 10�. _ Q Expiration Date:_
Job Site Address: City/statc/zip:_ IM11 \
Attach a copy of the workers'compensatlou pulley declaration page(showing the policy number and expir.tion date}. `
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of s
fine up to S 1,500.00 miller one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to$250.00 a day against dte violator. Be advised that a copy of this statement may be furwardcd to the Office of
Invcstigminns ol'the DIA fur insurance uavemge vcriticatiun.
I do hereby certify rattly the
ppuu�'biisod s m pens/ll es ajper,.ury drat the infuronudoto provided above is true and correct.
S'-•no litre' hth �� )ar"
Phone 1:
Official use idly. Do not write in this area,to be completed by city or larva official
City at Town: Permit/t.lcense N
Issuing Authority(circle one):
I. Board of health 2. Building Deparlumut 3.City4mvii Clerk 4. Flectrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ . __ __ Phone it: -
y„ CITY OF SiU E\,f, ;tiL-1SSACHUSETI'S
BULDLNG DEPdlt1-% NT
120 WASHNGTON STREET, 3' FLOOR
T EL (973) 745-9595
F.A-x(978) 7-W-9M
KtJtBERLEY DILISCOLL
iL�YO I THO�L3S ST.P1ERItt3
DIRECTOR OF PUBLIC PROP ERTY/SUMDLNG CO\DIISSIONER
Construction Debris Disposal Af idavit
(required for all demolition and renovation wo
rk)
In accordance with the sixth edition of the State Building Code, 730 CMR section ( 11.5
Debris, acid the provisions of VIOL c 40, S 54;
Building Permit * is issued with the condition that the debris resulting from
this work shall be l 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by klvfGL c
The debris will be transported by:
y
(name of hauler)
The debris will be disposed of in
(narna of facility)
(addrdVss of titcility)
signature ofpermit applicant
t
• Shea Roofing Co
17 % Foster Street
40V Salem, MA 01970
(978) 74 5-7313
PROPOSAL February 9,2014 .
SUBMIrrED TO: Browne Realty Trust
6 Monroe Street
Salem, Ma.
We hereby submit specifications and as for:
.a I
3o remove all existing roof shingles from top front main roof including
expected third layer.
To install ice and water shield covering complete roof as mentioned
above and along all flashing points prior to re-roofing. ,
" `'°To'install all new metal-drip edge-along all roof edges, both horizontal
and vertical. t
To install standard three tab (GAF Royal Sovereign) roof shingles
covering same area as mentioned above.
To install new roof boarding as necessary at a rate of$4.00 per linear
foot.
To replace all existing roof air vents!,
To install new top trim boards on mansard front roof. rD 134- d}? �-
To clean up and remove all roofing debris from job site.
i
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:
Twenty Two Hundred ---------------------°---------------------------Dollars ($2,200.00)
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 d ,
standard practices.-Any alteration oir deviation from atiove spe'cificationa involving extra costs will be executed
only upon written orders,and will become an extra charge over the estimate. All agreements contingent upon
strikes,*Idents or delays beyond our control. Owner to carry fire,tornado and other necessary insurance.
Our wor8ers are fully covered by Workman's Compensation Insurance.
Acceptance of Proposal—You are authorized to do the work as specked. _rpatil
Authorized Signature:
Signature:
pats61 Acceptance: 7
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