10 NORMAN ST - BUILDING INSPECTION (3) CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12C Wait llNt:':JNSTREET ♦SALL M.MAISAC:LL iLl-ti:191C
9�O� TFI:97S.743-9595 &F.V(:978.74G9846
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CNIR 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. 3150A.
The debris will be transported by:
50�
tname of h uler)
The debris will be disposed of in :
ajJ n ,
(u:une of taciGtY) II�7�
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e43t1d,11111[
J
Cn,
CITY OF SALEM
,. r� f PUBLIC PROPRERTY
r DEPARTMENT
Kt1nn'.RITY DRISCULL
>•I\t'OR 120 WASHING']ON STREL•'C 1 SALEM,MAS.SACI n;Sr:rt10t97.^.
TI:1.:978-745-9595 0 FAX:978-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (� Please Print Legibly
Name (BumnesslOrgamzano Individual): p Jon�Z nc, J Ices IhC
Address: �Z I :Individual):
H'JQ.
City/stareizip: WA0,I A 61012Z Phoney:
Are you an employer? Checkthe appropriate box: 'type of project(required):
1. I am a employer with /0 4. ❑ I ,an a general contractor and I 6 ❑New construction
employees(full and/or part-time).` have hired the sub-contractors 7. ❑ Remodeling
2.❑ 1 ani a sole proprietor or partner- listed on the attached sheet. :
ship and have no employees These sub-contractors 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 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.El I am a homeowner doing all work right of exemption per MGL I I.[] 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' 13.0 Other
comp. insurance roquired.)
-Any applicant that cheeks box 41 must also lill out the section W-ow showing their workers'compenwtion policy infurnution.
?I lumeowm:rs who suhmir this alTdavir indicating they are doing all work and then him outside eontmciors muss submit a new al'Ldavir indicating such.
�Contnctom that check this box must attached an additional shut showing ow name of the sub-contractors and their workers'comp.policy information.
l ion air employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. c?3n
Insurance Company Name:
policv 4 or Self-ins. Lie. Expiration Date:
Job Site Address: 10 b6AW\ 2eT City/stale/Zip: tei.
:%ttach a copy of the workers'compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up (4)S1.500.00 and/or one-year imprisonment,as well us 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 ol'the DIA for insurance coverage verification.
l do herchy cer 'y under the p tilts anti peaahies of,�Perjuty that the information provide aboLo,
s true and correct.
Sicnamre: r'cr _ p I, S Datc: Q
Phttc'i /DI <r7
Official use only. Do not write in this area, to be completed by city or totem official
City or Town: Permit/License Al _
Issuing Authority (circle one):
1. Board of health 2. Building Department 3.City/'town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other --
Contact Person: _ _ _-------_-__-- Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an emplr{vee 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 of compliance 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 perfomtance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
situation Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to yours ua tion and,if
necessary, supply sub-contractor(s) name(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. Self-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 till 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
drat must submit multiple permitilicemse 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 tilled 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The office 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
Revised 5-26-05
www.mass.gov/dia
CONTRACT
Page I of 2
SONTZ
Roofing Servi O1B03-1 e1=
B]SBMnon Ly MB
ITwq M1 5B1m F Fa 781 501M8]BB
July 9, 2007
Mr. Mark Livermore
MARKWOOD REALTY MANAGEMENT
P.O. BOX 300
Marblehead, MA 01945
Re: CONTRACT Roof Replacement— "Lower Roof" (over units 306 & 307 only)
Heritage Plaza Condominiums
10 Norman Street
Salem, MA 01970
VIA EMAIL: markwoodmet(i0otmail.com
Dear Mr. Livermore,
Max Sontz Roofing Services, Inc. is pleased to offer this proposal for the replacement of the
existing roofing system over the above property. We proposes to install a new E.P.D.M. rubber
membrane roofing system at above captioned building location complete with all necessary details
and flashings as per the following specifications:
1. Furnish owner with City of Salem Roofing Permit necessary for application of new roofing
system.
2. Power vacuum all existing stone ballast from roof areas and remove from premises.
3. Install new (5/4" X 6") wood nailer at perimeter of building to meet height of new insulation
and for proper securement of metal edge and terminations.
4. Slice existing rubber membrane to deter from stretching beneath new roofing system. Existing
membrane and associated insulation material to remain.
5. Install new 1" (R=6.0) flat panel polyisocyanurate roof board insulation mechanically attached
and secured to existing structural roof deck.
6. Install new Firestone, or equal 60mil. (.060) E.P.D.M. rubber membrane fully-adhered roofing
system over all roof areas. (using the largest membrane sheets possible).
CONTRACT
Page 2 of 2
-Heritage Plaza Condominiums
July 9, 2007
7. Fabricate and install new bronze aluminum edge/fascia metal on outside perimeter area of
building.
8. Remove existing and install new E.P.D.M. rubber base flashings at all existing vent pipes,
upper walls, exhaust fan curbs, roof drains, etc.
9. Install new .040 bronze (to match existing roof areas) aluminum perimeter metal at all open
roof edge areas.
10.Complete clean up of all roof levels and grounds at completion of project.
II.Furnish owner with Max Sontz Roofing Services, Inc. (10) TEN year guarantee upon
completion.
12.All roofing work will proceed continuously until completion of project, weather permitting.
TOTAL BASE PRICE:
NINETEEN THOUSAND THREE HUNDRED TWENTY FIVE DOLLARS. $1%325.00
(Massachusetts Sales Tax Included)
Terms: $6,000 upon acceptance of contract; progress payment of$5,000 upon delivery of
materials; $5,000 progress payment upon 95% completion; balance of$3,325 upon
completion of roofing work. All change orders paid upon invoicing.
"Owner to provide adequate access to building perimeter, electrical service and bathroom facilities for duration of
project. Max Sontz Roofing Services, Inc. assumes no 1 iability for asbestos (if any) abatement, nor the removal of
same. All OSHA guidelines will be adhered to as required for this project.
Very truly yours,
MAX SONTZ ROOFING SERVICES, INC.
Bradley J. Sontz, President
71.
'- Board of Building Regulations and Standards
Construction Supervisor License
Lice a GCS 75259 -
i r l�jrt dateM141965
E Iletidrt
>� T2�1:4I2008 Tr{f 6599.
Re`slCij`��.
BRADLEY J SON' -
7 MnKINLEY.RD
MARBLEHEAD,MA 01945 Commissioner �,�I
PUBLIC PROPERTY
DEPARTMENT
1
KI.�pFJLhY O�RCI)11
HAYUt
130 WwsurAr-um srULT•3MkK.MAWAOR3t1-M 01970
Tti 9 US-9s9s•FNC V&740.9W
APPLICATION FOR THE REPAIR RENOdATI N CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCC«ANCY FOR ANY EXISTING
STRUCTURE OR BIM OWG
1.0 SITE INFORMATION
Location Name: `; A7A e�1;nry�� t Buiidly
Address
OSf-
Property Is located In a;Conservation Area YM P0 Hlstaio Dlstrld YM
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
Name:
Address:
Telephone:
3.0 COMPLETE THI8 SECTION FOR WORK IN EYI821Np BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use Now
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation I
of existing building New
add Description of Proposed Work: 1
&hcJe, sl� I4gl) 1 "
{n Wv D(o0 LPQV1 VAVoX6rc 14
-- - -- Mail Permit to; 1611nc erJJceS r IHC SrZ S4ScTn � - "
r ,��;
What is the Curcent use of the Building? o 0
Material of Bu'ddirg C. if hrnM many unitaT�
Wit the Building Conform to Lave? 2
Asbestos?_---=
AmKaeas Name
Address and Phone JyG�s f C
Mec wWo Name
Address and Phone H� Registration f/
Construction Supervisors UCansc a)
t of Project: �—� permit Fee C"latlon
Estimated Cos
Permit Feel Estimated Cost X$71$1000 Residential
Estmated Cost X S11/S100o CMMWGial---_._ -.-
An Additbnal woo is added as an
Administrative Charge•
Make sure that all flelds are properly and legibly vrritten to avoid delays in Processing-
hereby undersigned does hereby apply for a Building Permit to build th a e fated �,4C,
X des
specftatlons. Signed under penalty of perjury
Date '� t 02.
N
y
s A �( .�
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