133 1-2 NORTH ST - BUILDING INSPECTION F('c kir
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The Commonwealth of 1t�1'assarhu.5sett'sCES
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Department of Public Safety
Massachusetts State Budd*r7g76o 'c�(VE(WRA '/t; n
Building Permit Application for any Building other than a One-or wo- ily Dwelling
(This.Section For Official Use Only)
Building Permit Number: Date Applied: - I Buddhig Officfal.:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1 Z31/)- �/uitn Soik. U" �
No.and Street City/Town Zip Code Name of Building(if applicable)
I SECTION 2:PROPOSED WORK
Edition of MA State Code used_ If New Construction check here O or check all that apply in the two rows below
1 Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
_(1 Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No fY
Is an Independent Structural Engineering Peer Review required? I Yes ❑ No C3�
Brief Description of Proposed Work: 9_ CL ,. Ae-J 6m tl ,. ; taI/<---JX ,(.:r-& V<mk J)
�n 3 ct f :n
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):
SECTION4: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.)
SECTIONS:USE GROUP(Check as a plfcable) - -
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B.
Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h Hazard H-1❑ H-2 13. H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ 1-2❑ I-3❑ I-4 O M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IS ❑ IIA ❑ IIB ❑ IIIA O - IIIB ❑ IV O 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:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ -
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: _NIA I listoric Commm,ion Rcvicjnx�•s:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑. Yes❑ No ❑
SECTIONS: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:
t l H
I
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
7 �1 �—�. 55
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
ryr-/l.y-_ rl-_ B2)_ GU42-
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Narne 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 Appendix2):
f buildingis less than 35,000 cu.ft.of enclosed's ace and or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional.Res onsible f- Construction Control - - - -
Name(Registrant) eleph e' o. a-ma' a s Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Fi Cs A'5 ho" f
Com any Name
A,1,_ s,r
Name of Person Responsible for Construction License No. and Type if Applicable
Glcf`l3
I Street Address City/Town State Zip
Tele hone No. business Telephone No. cell e-mail address
SECTION 11:wORKERS'COMPENSA'I[ON 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 0 No 0
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE -
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ 0 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)=$
3.Plumbing $
1.Mechanical (HVAC) $ Note:Minimum fee=$ (conta� c�a(ity)
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 ins and penalties of perjury that all of the information contained in this
application is true and accurate to the best of m+ ' edgeand understanding.
Ple s print and sign name - Title Telephone No. Date
2 7rZ'WC / dc;��4-4� ,�� 0152-3
Street Address City/Town State Zip /
Municipal Inspector to fill out this section upon application approval• `
Name Date
Office of Consumer Affairs&Business Regularioa
OME IMPROVEMENT CONTRACTOR
egistration: 62]03
Up— Expiration:--9/_.-f2p`1a3 Type:
Individual
SEAN ANDERSON
SEAN ANDERSON
81 GERTUDE ST. `•
j LYNN,MA 01902 �
Undersecretary
8 Massachusetts Department of Public Safety
.'�F Board of Building Regulations and Standards
License: CS-09866
Construction Supervisor
SEAN L ANDERSOa '�•
12 TREETOPS LN
DANVERS MA 0;192 '
Commissioner Expiration:
10/26/2017
CITY OF SALEK MASSAaR SETTS
BuaDING DEPARTWNf
120 WAUW40ONSm=T,3'DI§Aox
UL(978)745-9595.
FAX(978)740.9846
KUdIlERLEYDRISOOLL THCMM ST.PMW
MAYOR DntECrCiRornl6ucrRoPEmlBtaDndcoDms OmR
Construction Debris Disposal Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR,1 Section sued with the Debris,
and the provisions of MGL cAO, S 54, Building Permit# rly licensed
condition that the debris resulting from this work shall be disposed of in a prope
waste deposit facility as defined by MGL c 111, 5150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
.tf..
Sig ture of applicant
l�l��,�
Date
The Commonwealth ofMtus"Auset/s
Department oflndustrialAccidents
I Congress Street,Suite lee
Boston,MA02114--2017
www.masxgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plnmbers.
TO BE FH"WITH TBE PERMITTING AUTHORITY.
Aonlicant Information Please Print Iaeibly
Name(Business/Oiga<uzetionandividual):
Address: /2 -rf -fc{S'
City/state/Zip: LIPutta, O 19 L Phone#:
Are you ao employer?Cheek the apprapriate box: Type of project(rei]u]red
1. a employer v+iPo, .empmyees ifi+11 c?n- )•' - 7. ❑Neer cons�tructi
2.❑Iama,sok mPrmershipamibBwwempbyeo WOt]M fmmem g; it9"'"""""""'B
my capacity.[No wo.1'en,comp.mbuance required.] 9. ❑Demolition'
III 3.01 am a homeow�doing all work myeelf.[No workers'c—p.iesmaotx aquued.)t
4.El l am a homeowner em will be hiring c®bsctms to candua all work m my property. I vnll 10❑BIII]dltlg adtiltid
emere that all contractors eitherbave Workers'Weapenatloa mnnane or are sole 11.0 Electrical repairs❑ gtepaus
12. Plumbing
s.❑7®ageoeral co�ctoraddlheve hind Poe euD-t actae lilted on the aam�ed sheet: 11El Roofrepeus _
-71xm sub-wnbmcton have employes and bow worms'eomp.ioswanMS
6. We are a wrpoiatiw and its officers hM esemisd dwirright of exemption perMGL a 14.❑Other
15Z$1(4).and we havem employees.[No workers'tamp:i11MMM a TegUk .]
-Anyappbrmt trot dmb box#1 neat also fill om fie section hebw sbocviog lea workers'eompemtiou pobry mfwmacm.
t Homeowma wbo submit diis affidavit mftathithey are domg all worF err tkmbbe ouW&Wm'ermt mast'1 a new affidavit mdicatmg such:
[Contractors that check this box mug attached an additional ahers slowing the name of file wb- ldmitots anil state Wheffic w uoi dome emit a heve
employees. Iftbeaub�b?ctmahav CMOOYe.4tbey-MFUVi6th- wmaers':oomRWLcymmAb?F. 7 -
I am as employer thafispmvi&ng ttmrhers'compensation ins#rauee for my esiiyl4}ees Below fs thepe [w4job site-
Informadoa.
Insurance Company Name: t'- f S —
Policy#or Self-ins.Lic.#: - -1 P�V `'�, ���IS expiration Date: /`7'1�t/?1.i/16
1
Job Site Address: j.�3 CRY/State/zip: (lCN/,e,-. �'t
Attack a copy of the workers'compensation policy declaration page(showing the policy number and'expirstton date).
Failure to secure coverage as required under MGL c. 152,§25A is a cruiunal violation punishable by a fine up to$1,500.00
and/or one-year imprisomffint,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.A copy of bite statement may be forwarded to The Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains godpeAalner ofperjuiy that the information provided above is true and correct
Signatures Date-
Phone �C7 R91 ?
Oj w-W use only. Do not write in this area,to be completed by efry or town QBfcfaL
City or Town: Permif/1Acense#
Issuing Authority(cirele one):
1.Board of Health I 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 employee 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 performance of public work until acceptable evidence of compliance with the mstmance
requirements of this chapter have been presented to the contracting authority,"
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and hone n p umber(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLL7 or Limited Liability Partnerships(LLP)with no employees other then the
members or partners,are not required to carry workers'compeasation 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. Alan be sure to sign and date the affidavit. The affidavit should
be 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 lime.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Departrnent has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that unmet submit multiple permit/license 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 most be filled 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.a dqg license or permit to burn leaves etc.)said person is NOT required to com pl@te this affidavit.
The Departrnent's address,telephone and fax number:
The Commonwealth of Massachusetts
Deparhnent of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Big A's Home Improvement
Danders,Ma 01923
(85'n8912589
Licensed and Insured
Chaz Fisher
133 'h North Street
Salem Mass.
Chimney:
--2 Chimney to be taken down to just below the roof line.
-These areas to be framed and plywood.
Main roof:
-Complete Strip of main roof and disposal
-There will be a dumpster on sight for disposal.
-Purchase and install ice shield underlayment Is'6 feet.
-All other areas to have 301b felt underlayment
-Purchase and install 8" white drip edge
-Purchase and install 30 year Architectural shingle color of choice within standard colors.
-Cover rake boards in front and back with white metal where missing.
Rubber over bathroom:
-Rubber roof to be ripped off over your bathroom.
-framed to pitch off,purchase and install plywood and new rubber roof system to be
purchase and Installed.
Gutter and downspout:
Installed to catch run off from rubber roof.
Interior of bathroom:
-Remove insulation in ceiling in bathroom only.
-Remove ceiling in bathroom only.
-Purchase and install new insulation in this bathroom.only.
-Purchase and install new blue board in ceiling only.
No painting is included in this proposal at this point.
Total 14,300.00
Deposit before start to purchase material 5,000.00
2"d payment when main roof is done 4,650.00
Final payment when complete 4,650.00
Thank you for choosing Big A'S Home Improvement,
Sean Anderson
Nu a 2j 2c4T