136 NORTH ST - BUILDING INSPECTION 44
A
f The Commonwealth of Massachusetts
Department of Public Safety
Ulf 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: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not availaa�b11le) oc,
V
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 e Repair❑ 1 Alteration d I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 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 Pr No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No 'y
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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
1: Institutional I-1❑ I-2❑ I-3❑ I-4❑ M: Mercantile❑ 1- 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 ❑ UA ❑ IIB ❑ HIA ❑ IIIB ❑ 1 rV ❑ 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:
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:
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:
'�-DPov`OUr& Aq�XCejjd
J.
SECTION 9: PROPERTY OWNER AUTHORIZATION
N me d Address"of Pro�pe, Owner
t�W5 1ANDI�Ir CONWAO-50&&. " A6 �JOA 1 S-f' b2Q w 01A
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
- `� f gl13 ? 1'AJ0i .
Title Telephone No.(business) Telephone No. (cell) U e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owners 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 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
ADD CS4A4 ei e ; Abf}M &Cm• CONSTRVCfii.qk
Company Name
�OShcgchL l�lR/l3 lis�(93 �-S ���6/13
Name of P son Responsible for Construction License No. and Type if Applicable
AA AA-IONsR 4- �PNboLfk MPr oa.3 6,?
Street Address City/Town State Zip
WAX?, — KAMPRq\)HWVSpv*M94).covet
Telephone No.(business Telephone No (cell e-mail address
SECTION 11: 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 ❑
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ l`� •p a�
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)—$ li
3.Plumbing $ `
4.Mechanical (11VAC) $ Note:Minimum fee=$ (contactarihtighty)
5.Mechanical Other $ Enclose check payable to
6.Total Cost . $ , �so 00 1 (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 best of my knowledge and understanding.
Plea,e,pripl an)lsiQname � � I �Title 'nn rn Telephone Date
Streetfel•AIAddress
City/Town P • 1 P'T State Zip
If If
Municipal Inspector to fill out this section upon application approval:
Name Date
r '•^v^^` � V/FB T(JPUG920R P/C2���L O�C�/�G
office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Type.
egistration 169375 Individual
- xpiration 6/16/2015:
ANDRESSA CAMPANHA TEIXEIRA
AND SA TEIXEIRA
11 PAULINE ST g `'•'
RANDOLPH, MA 02368 Undersecretary
i�'lassachusctts p•P;-w
tp:u'tment of Bo Public Sarch
ard of ti,Rcgtd:ltimis and Standards
Construru ction Supervisor License
License: CS 105019
ANDRESSA TEIXEIRA
212A BAY STATE ROAD r
MELROSE, MA 02176
R'
Expiration: 12/9@013
- f'unmNssionor
,< CITY OF SaILLDvi, �LkSSACHLSETTS
BUILDING DEPARTNIENT
' p 120 WASHINGTON STREET, r FLOOR
'�eancf I1[_ (978)745-9595
F.*Y(978) 740-9W
KI\[BERLEY DRISCOLL
MAYORT'HoafAs ST.PtFnRI;
DIRECTOR OF PUBLIC PROPERTY/BUILDL\G CO%MUSSIONER
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Ptumbers
Anrilicant Information Please Print Le ibl
Name (Business.Organizatiomindividual):
Address: A 2f\ o
City/State/Zip:_ 6 Phone k: b I
Are ou an employer. Cheek[he appropriate box: 'type of project(required):
1.U 1 am a employer with .� 4• ❑ lam a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contactors
2.❑ 1 am a sole proprietor or partner. listed on the attached sheet. 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 workers'comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their
10.❑ Electrical repairs or additions
3.❑ 1 airs 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.[1 Other
comp. insurance required.]
•Anv apprica it that ducks box dl most also fill out the section below Autwing their workers c°mpenevion policy inrormation.
'I ,Mcuwncn;-ho wtimit this affidavit indicating they are doing all work and then hire outside contractors moan submit anew affidavit indicting such
('.nnraetun that check this box must atnached an additional shed showing the nine of the sub-contractors and their workers'comp.policy infor atioo,
1 am an emptoyer that is providing workers'rompensaton insurance for my etnpluyees. Below is the policy and fob site
information. /j un ,
Insurance Company Name: / rJ�' '1Mf/l•I -^ - lA�j�.p 2NJ / /�/
Policy d or Self-ins. Lic.N:_I�U/GG-��•�W IO�V•yI/t J d �'�O)72 Expiration Date: L ` f
Job Site Address: 136 1 V V UX/! 5 City/State/Zip: 5—
Attach 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
fine up to S1,500.00 and/or one-year imprisonmcn4 as well as civil penalties in the form of at STOP WORK ORDER and a fine
of up to S230.00 a day against the violator. Be advised thata copy of this statement may be forwarded to the Office of
lnvesligaliuns 0i'111c DIA for insurance coverage verification.
I rho ltereby rertlf under Me pains cord penaties of perjury that the informarion provided ayoveI.true
and t� •o� rrect.
sionat ire' Dutc ',tl II ^^11
Phone
Q)Tzrial use only. Do not write in this area,to he completed by city or town ojjlcial
City or Town: ._ Permitll.lccnse#
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.C'ityffuwn Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone q:
[
CITY OF S.U.F.M, -NA-kss kcHus E-ns
BI:ILDL\G DEPAR-D.M iT
120 WASHLNGTON STREET, 3° ROOR
T EL (978) 745-9595
Fax.(978) 740-9846
KI\t$ERIEY DRISCOLL
MAYOR THo%LksST.PtERim
DIRECTOR OF PUBLIC PROPERTY/BUaDD4G CO`MSSIONER
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:
�3 . OUK DV 5regTQ/C'=
(namc or hauler)
The debris will be disposed of in :
(name of facility) .
k - �-6_ve,�.e Wl►�-
(address f Facility)
signature of p rmi[appEicant .
ilatc
Adam General Construction
11 Pauline St, Randolph, MA 02368
(781)922-3358 * (857)888-3153
Address of Project: 136 Nort t,--Salem -� 11/17/13
Costume can orth's Landing Condo Association (97'9)314-1318
ctor. Andressa Teixeira 781-922-3358
CSL - 105019 HIC - 169375
Project Manager: Adao Teixeira 857-888-3153
Expected approximate date of commencement of project:
Expected approximate date of completion: 2 to 5 days
WE(CONTRACTOR) HEREBY PROPOSE TO FURNISH LABOR AND MATERIALS -
COMPLETE IN ACCORDANCE WITH THE SPECIFICATIONS BELOW:
PART 1 -ROOF REPLACEMENT
Contractor will furnish all labor, materials, equipment, apparatus,tools, transportation and
services necessary for the proper installation and completion of the project named above. This
work will include:
A. Prepare area to start work;
B.Protect body of the house to avoid damage;
C. Strip existing roof,
D. Replace any rotten or damage plywood, (paid by costumer);
E. Install drip edge aluminum on all leading edges (rakes & fascia);
F. Install 3 feet of ice &water shield on all leading edges & valleys;
G. Install Tri-flex paper to protect the wood;
H. Install new boot pipe;
I. Install 28 square of lifetime architectural asphalt roof shingles,
J. Install ridge vent;
L. Install 2 sq of Rubber Roof,
Contractor will install the asphalt shingle roof in accordance with manufacture's specifications,
so that manufacturer's warranty will not be voided. To leave a long term, weatherproof asphalt
shingle roof.
Clean up.
1. Tools, equipment, surplus materials, and debris resulting from the shingle roof installation
shall he organized and cleaned un_ or removed and disnosed of by contractor_ on a da.ilv basis.
PART2—PAYMENT
A. Total cost for the project, labor and material is $13,350.00
B. An advance payment in the amount of$6,675.00 will be provided to the contractor prior to the
commencement of the work. The balance of$6,675.00 will be paid upon full and satisfactory
completion of the work.
PART 3 —INSURANCE
Contractor will carry General Liability Insurance and Workers' Compensation Insurance and
will provide Certificates of Insurance to Client, with Client named as Certificate Holder,prior to
the execution of any work, upon request.
PART 4—WARRANTY
Contractor unconditionally warrants all materials and workmanship for a period of seven years.
Any defects in the materials or workmanship will be repaired or replaced, at the discretion of
Contractor, at no cost to Client.
Authorized Signature (Contractor)
PART 5 -ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are
authorized to do the work as specified. Payment will be made as outlined above.
ACCEPTED: 'elf,
Signature (Client): e:
Additional Specifications
'-Homeowner chooses roof shingles colors,
-During a roof job,the nail could break the sheathing during the nailing of the shingles,
-We are not responsible for any of the cracks that may arise in any walls or ceilings,
•-Please cover all your floors in your attic to protect from dust and debris,
*-Permit costs vary from town to town and are included in this bid.
*RUBBER ROOF IS RECOMMENDED FOR ANY FLAT PARTS OF THE ROOF,
SHINGLES WERE INSTALLED AND MAY BE CONTRIBUTING TO LEAKS
*FOUND MANY SOFT SPOTS ON ROOF SURFACE WHICH CAN INDICATE WOOD
REPLACEMENT
*NAILS ARE STICKING OUT OF THE SHINGLES AND ARE GETTING RUSTED AND
CUTTING SHINGLES
*STEP FLASHING NEAR WALL WAS NOT INSTALLED, AND SHINGLES WERE
INSTALLED ATOP OLD FLASHING
North's Landing Condominium
136 North St.
Salem, Ma.01970
11/18/13
To whom it may concern,
We, North's Landing Condominium Association have approved Adams General Construction to perform
the work on the roof replacement, agreement signed on November 18, 2013.
Laura Michalski Dean Ganz
Trustee�ycee 5'1 Trustee