6 MONROE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: I D App ' d: Building Official:
SECTION 1:LOCATION(Pleas ' dicate BI #and Lot#for 19cAians for which a street address is not available)
1'�o-,� S<A O 'J
No.and Street iKy/Town ip Code Name of Building(if applicable)
/SECP6N 2 PROPOSED WORK
Edition of MA State Co used 71zI ew Construction check here❑or check all that apply in the two rows below
Existing Building❑ Re AI a ' n ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of O ancy ❑ Other ❑ Specify:
Are building plans and/or cons 'on documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review require��Yes ❑ No ❑
Brief Description of Proposed Work:
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 ❑ A11❑ A-5❑ B: Business ❑ E: Educational ❑
F. Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ I-4❑ 1 M: Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R-4❑
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 ❑ IIB ❑ lIIA ❑ IIIB ❑ TV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit Debris Removal•Licensed Disposal Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be p
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
1`
r �Cc� Co�coW .N\ �cc _ 01
Name(Print) No.and Street City/Town Zip
Property Ovkner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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)
It 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
t iW S��, ,^ Sro -a-vaD 1 01
Name(Regr�trant) Telephone No. e-mail address Registration Number
Street Address Cr� State Zip Discipline Expiration Date
10.2 General Contractor
t \ _
Company Name
Name of Person Responsible for Construction (� License No. and Type if Applicable _
NN
Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:WORKERS'COWENSATION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
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 O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$
1.Building $ - - Building Permit Fee=Total Construction Cost x (Insert here
2 Electrical $ appropriate municipal factor)_$
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)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 b Iof my knowledge and understanding.
Plrint and sign name- - � � Title Telephones- e N Date
Street Address d1S` City/ wn State Zip
Municipal Inspector to fill out this section upon application approval: b
Name Date
Shea Roofing Co.
17 % Foster Street
Salem, MA 01970
(978) 745-7313
PROPOSAL May 31,2012
SUBMITTED TO: Browne Realty Trust
6 Munroe Street
Salem, Ma.
We hereby submit specifications and estimates for:
To remove all existing roof shingles from top main roof and all mansard
roofs except front main and mansard roof.
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.
To install standard three tab (GAF Royal Sovereign) roof shingles
covering complete main roof.
To install up to 100 linear feet of roof boarding if necessary.
To re-flash and re-shingle sidewalls of all mansard windows.
To counter flash, re-flash and/or reseal all side walls as necessary.
To install new roof flanges on roof vent pipes.
To grind out and completely re-lead all three chimneys.
To replace all existing roof air vents.
To install new bathroom roof vents.
To remove and board up both skylights on main roof prior to re-roofing.
To install new top trim boards on mansard roofs.
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:
Thirteen Thousand Eight Hundred and Fifty---------------Dollars ($13,850.00)
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 order:,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 a razed to do the work as specified. ►�>�
Authorized Signature: am
g '- 2 - �/""���e'
D / f
Signature: / L/�CJ
Date of Acceptance:
CITY OF SU1� EN4 1ASSACHUSETTS
BuILDLNG DEPARTIIENT
120 WASHINGTON STREET,3"FLOOR
\ TEL (978) 745-9595
FAx(978)740-9846
KI�I8ERL6Y DRISCOLL
'%4AYOR THONtAS ST.PIEM
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(BusuxsaOrganizaziotvindividtnal): � �\\ w N
Address: �`� rc v� r) �1
City/State/Zip: �� h�� Phone #: 'N VV-C-S"'NO
Are you an employer?Check the appropriate box: Type of project(required):
I.Wi am a employer with 1 4. ❑ 1 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 7• ❑ Remodeling
ship and have no employees These subcontractors have S. ❑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 ME]Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL l LEI 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' MCI Other
comp.insurance requited.]
•Any appliam that checks bon gt must also fill out the section below showing their wohea'compensation policy miumnation.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors oust submit a renw andavit indi flu.
:Cmumoton shot check this boa must mumhod an additional abet showing the name of tM sub-contactors aid their workrn'wrap.policy inromution.
1 um an employer that Is providing workers'compensation Ltsuronce for my employees. Below Is the pollcy and job site
informal"
Insurance Company Namc:
Policy M or Self-ins.Lie.M: W LC�� �k�� 1 E�a-= Expiration Date: 16 1�_l�
Job Site Address: I���o� �J'L City/State/Zip:S� �`-� t-,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 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 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.
1 do hereby certo under the pains andpenitifs of perjury that the information provided above is true and comrcL
Signature Psi Dote l a�
PhoneM:
Official use only. Do not write In this area,to be completed by city or town q[jlehaL
City or Town: Permit(License M
Issuing Authority(circle one):
I. Board of llealth 2.Building Department J.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone M:
CITY OF S�1I.EM 1�WSACHUSETI'S
• BUILDINGDEPARTNI NT
' 130 WASHINGTON STREET, 3"0 FLOOR
TEL. (978) 745-9595
FAX(978) 740-98"
KINfBERt RY DRISCOLL
MAYOR THosw ST.PIERRe
DIRECTOR OF PUBLIC PROPERTY/BUIIMING COMNIISSIONER
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 :
(name of facility)
�L 41
S (A dress of facility)
signature of permit applicant
to
d�bd�ira�
Ilk
3 e�yAk
a a)� -. �IF
y�s
9�C/MINB DO�.
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978) 740-0404
CERTIFICATE OF APPROPRIATENESS
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage 1- Other work
as described below will be appropriate to the preservation of said Historic District, as per the requirements set
forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance.
District McIntire
Address of Property- 6 Monroe Street
Name of Record Owner: Browne Realty Trust c/o Roger B. Tyler
Description of Work Proposed:
Installation o/Trigon Mini Guard II telephone system mounted on the south side o/the ftont entry— 12"H.r
4.3"W x 2.5" deep at base and 3" deep at top. Finish to be stainless steel.
Dated: ,Tune 11, 2012 SALEM H TORICAL CQMMpISSFO j
By:
The homeowner has the option not to commence the work(unless it elates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.