141R NORTH - BUILDING INSPECTION t / 2 fhe Commonwealth of Massachuscits
Board of Building Regulations and Standards CITY
N OF SALEM
MCISSaehUSClb Slate B ' ding Code, 780 CMR, 7 edition
Revised Jurnrrrr
/Idding Permit Applic 'on To Cons[ 1, Repair, Renovate Or Demolish a /. -'/RAY
Two-Fumi Dwelling
V is Section F 01'icial Use Only
�J u' d' P umber: Date Applied:
Si at e: -
Building Curnih(sillittibmiripw of Building MCC
SECTION 1:SITE INFORMATION
'r �y 1.1 Property Add/ress:,�,y/ 1.2 Assessors Map& Parcel Numbers
yNV U Isty
Zr— --,Fb,E�F�+
/// 1.la Is this an accepted street?yes no Map Number Parcel Number
` 1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq B) Frontage Ili)
I.! Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
;New
r Supply:(M.G.1,c.40.§54) 1.7 Flood Zone Informs 1.8 Sewsga Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check if es0
SECTION . ROPERTYOWNERSHIP'
rrofRtx�jr�1
) ®- Add ss or Service:Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(chock aB that apply)
uction O Existing Building O Owner-Occupied O Repairs(s) O Alteralion(s) O Addition O
O Accessory Bldg.O Number of Unit Other O Specify:
tion of Pro sed p po ork'•
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials ORlclal Use Only
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S O Standard City/Town Application Fee
O Total Project Cost'(Item 6)x multiplier x
J. Plumbing I S
2. Other Fen: S
4. Mechanical (fIVAC) S List:
3. Mechanical (Fire S
Suppression) Total All Fees:S
�� Check No. _Check Amount: Cash Amount:
6. Total Protect Cost: O Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Am License Number ENPimtiun IYate
Nwp tC.l'l-11,ld r ^ LisI(.-SL f)pelsee below)
♦!J. �Q' 1 e��/ s f Descri ion
,Add ss U Unrestricted u to)3.000Cu.Ft.
R Restricted Is2 F,—ay Uwellin
Si turf M M. OnI
RC Residential Routing Coverin
I'c fa WS Residential Window and Sitting
SF Residential Solid Fuel Rurning A fiance Installation
D Residential Demolition
5.2 gbtered Hoene Impror meat Contnctor(HIC) 5��17
I IIC p Y ur H egist time ReiiistralAn Num
Add Expiration Dale
Sigru re i elephwm
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS2.f 2SC(6))
Workers Compensation Insurance affidavit 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.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7s:OWNER AUTHORIZAT46N TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative to work authorized by this building permit application.
(
7beha
Dale
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
and information on the foregoing application arc true and accurate,to the best of my knowledge and
2t uthorized Agent safe
7An
the sins and realties of 'u
NOTES:
er who obtains a building permit to do his/her own work,or an owner who him an unregistered contractor
stered in the Home Improvement Contractor(HIC)Program), will-W have access to the arbitration
or guaranty fiend under M.G.L.c. 142A.Other important information on the HIC Program and
tion Supervisor Licensing(CSL)can be found in 790 CMR Regulations I IO.R6 and I IO.RS,respectively.
bstantial work is planned,provide the information below:
rea(Sq. Ff.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq.Ff.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Foolage"may be substituted for"Total Project Cost"
id's Canstructidn 'OS A L Page I of I
inishedcnr ^ citron"
3 oak Street No. #4810B
Salem, MA 01970
978.335.7065
Date: 8 April, 2010
Proposal Submitted to: MA Construction Supervisor License #100562 HIC#150617
Name Geor e & Mean Woods Job Same
Address 141 R North Street Address
City/St/ZipSalem, MA 01970 Ci /St/Zi
T: T:
We herebysubmits specifications and estimates for:
ITEM DESCRIPTION
Wan
imatel 15 square existingroof to be removed and replaced with 30 -Year Architect Shingles.
ent to be installed.
Water Barrier to be applied to leadingedges.
um dri ed a to be applied on all leadingedges, and rakes.
shin to be im lemented around chimne s.
il i e flan es to be installed.
tter comers to be installed front section and joints resealed.
Construction to remove and dispose of all debris in compliance with current le al standards.
30-Year Manufacturers Guarantee on all materials
All labor fully guaranteed
We hereby propose to furnish labor and materials-complete in accordance with the above specifications, for the sum of-
$5,675.00
I
With payments to be made as follows: $2,675.00 deposit, $3.000.00 upon completion.
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.
n A y alterati on or deviation from above specifications involving extra costs will be executed only upon written orders,and will become
an extra charge over and above the estimate. All agreements contingent upon strikes, accidents, or delays beyond our control. This
proposal subject to acceptance within 30(thirty)days and is void thereafter at the option of the undersigned.
LyCear)
r accepts responsibility for payment(s) of all legal fees, costs, expenses and interest(at the rate of 1'/,%per month, 10%per
ociated with the collection of overdue balances ninety (90) days or more after invoice for services and material rendered by
nstruction.
Authorized Signature \
k("'A I'ANCl'_ Or PROPOSAL
The above prices, specifications and conditions are hereby accepted. You are authorized to do the work as specifi d.Eayments will
be made as outlined above.
ACCEPTED: Signature
Date: "� lQ O
Signature
77h i:�'h ) 01 ' P f)R )'01
Custorer Copy 0 Office Copy ❑ Other ❑
CITY OF SALEM
PUBLIC PROPRERTY
"f DEPARTMENT
.I\u:;X:1'Y:)X I iCl 41.
\LNl M 12C WASHING I0.X S I'XELT * SAL UM.MMLSACIII iE I IS a1970
l'iA; 178.71i9595 • 1:.\x. 978.7.4C�)Sih
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
k ) tlicant Information Please Print Le ihly
Vane(aucuwti()rrggmiratiaNlndivlduul):
Address:City,Slaw,Zip: ) Phone I!: �01&-��f—.��fOS
Are you all employer! Check the appropriate box: 'Type orproject(required):
1. I ant a employer with 4. ❑ I am a guneral contractor and 1 fi. ❑ New construction
nlployces(full antl/ur part-unic).' have hired the sub-contractors
.❑ 1 ;un a sole proprietor or partner-
listed on the attached sheet. �• ❑ Remodeling
ship and have no employees .. These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. 0 Building addition
I No wotiters'comp. insurance 5. ❑ We area corporation and its
required.]
officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 aril it 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 12.0 Rouf repairs
insurance required.] r employees. (No workers' 13.0 Other
comp. insurance required.]
'Any:gptlw'ant autt chucks box ill must atbe IOI our atc sec11on Wow showing Ihoir woAms cuntpununion policy ioli,rnwlium
'I lomeuwnen who submil this affidavit indicating Ihcy ate doing all work a,W Ihen him outside cu,uracton most submit anew al'rdavil indicolins bitch.
l'omrwows that check this box must mfachtd an additional shurl showing the nano of the suls eontractots and their wurken'coop.policy infix marion.
/unr ml rru/duyrr thus,Lr pruvrding workers'c•oelprnsntinn iu.ruranee fur ury Burpluyrex. Below is the policy and job sits,
itiformuriom
Insurance Company Name:, �r'Q�IY!__.. .
Policy 8 or Self-ins. Lie.,,#: aaC�G/� /'f.. ... ..- EApiratton Date:
Job Site Address: ��� /Vt]/LTLI .)fi- C'ily,Slate/Zip:
- Attach it copy of the workers' cutnpumution policy declaration pale (showing the policy number and expiratiun date).
Failure It)secure coverage as required uodcr Sec(iun '_5A ul'.}IGL c. 152 can lead to the imposition of criminal penalties of a
fine up b)S1.500.00 and/or ume-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
orup ro 5250.00 It Jay against the violator. Ile advised that a copy of this smtcmcnt may be forwarded to the Office of
lim .%mgaunns of dlc UL\ for insurance coverage vcrrtcatmm.
/Ju hereby cot ',r uu./cr t/lr pu 7ta•,old �nohicr u/'prrjury that she information pruvir/s,r/above is lots,and correct.
Date' at � /e
'TV (`"JYir_JV Ori CiJv VV�� L /I
I'hln••�i'
O[Jiciul use only. Do not write In this area,to be completed by city ur town o/JiciuL
City or Town: _._ _ PerinitiLicense 8__
Issuing Authority (circle one): - I
I. hoard of llydth 2. luilding Department 3. <:ilyifown Clerk 4. L•'IectricaL.lnspecfor 5. Plumbing Inspector
b. OI tier
Cmuacfl'enuu; -_ -_ I'hoocl:
Information and Instructions
Massachusetts Gcneral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this suatute, an employer is defined as"...every person in the service of another under any contract of hire,
e�press or implied.oral or written."
An eurpluyer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
,,t the hrrcgoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of :ut 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 these unds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
.IGL chapter 152. ¢25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewul of it license or permit to operate a business or to construct buildings in the commonwealth for ally
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally. NlGL chapter 152, §2542(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 insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Pleasc fill cut the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) name(s),address(es)and phone nunmber(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
employces,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 aff idavit should
he returned t6 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 he sure that the affidavit is complete:md printed legibly. The Department 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 till in the pennit/license number which will be used as a reference number. In addition,an applicant
that mint Submit multiple penniu'licetse 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 filled out each
year. Where a hone owner or citizen is obtaining a license:or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he 01,11ce ul Investl.atmns would like to thank you in advance for your cooperation and Should you liave any questions,
plcasc do not hesitate to give us a call.
"the Dcparunent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
R;%i.cd i-26-05
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
....r � j DEPARTMENT
::I, : HI I- Rlx 0I I-
>I ,, arc ,
I_(1 W.N±:uN, ON 5 n(trr 0 S."F.M. Ms;.;n, i It ;r i i;
l:978-.'4 9595 ♦ PAX:978-740.9846
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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
V� (name of hailer)
The debris will be disposed of in
/Sl....-..-
name oZLL"f facility)
(address of 1, lity) )
signature of permit applicant
(la re