6 OAK ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
�. Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or
is Twtion Fo ly Dwelling
� This Section For Official Use Only
Building Permit Number. LDate Applied:
Building Official(Print Name)' Signa re Date
SECTION t: SITE INFORMATION
1.1D �u opert AddLress: 45T 1.2 Assessors Map& Parcel Numbers
I.I a 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 11) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.1-c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION2: PROPERTY OWNERSHIP'
Owner of Re ord:
(� /Iep
Name Print) City�$tate, "ZIP
9��-95�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Descri Lion of Proposed Work` ` /
Xpe Lai. _ __�2 ( d crc✓
vi �`t% /J,oG✓ rid ho S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost"(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ �/�- �
4. Mechanical (HVAC) $ List: �- r l' \
5. Mechanical (Fire $
Suppression) Total All Fees: $
� Check No. Check Amount: Cash Amount
6. Total Project Cost: $ ��9v �L, ❑ Paid in Full ❑ Outstanding Balance Due:
c�
t
s ,
SECTION 5: CONSTRUCTION SERVICES
5.I Construction Su ervisor License(CSL) Ad(�.�v
/ ( MylQ License Number xpira ion Date
�e of Cal- Ilolder
3 0 � List CSL Type(see below)
No a d Str et Type Description
�� U Unrestricted(Buildings up to 35,000 cu. R.
C¢y/lown,Slate,LI' ,Ol R Restricted 1&2 FunnilyDwelling
Masora
etV Roofing Covering
Window and Siding
SF Solid Fuel Burning Appliances
'�4-- ] 1 Insulation
Telephone Email address D Demolition
5.2 egi�sJt�eyred H e Improvement Contractor(HIC) 15-U
HIC Registration Number Expiration Date
I o any Name HIC RegistKit Name
No.an trect Email address
��3ti=Jo6'�
Ci own,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(l
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........... ❑
SECTION 7a:OWNER AUTHORIZATION 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 be If,in all
matters relative
1to work authorized by this building permit application.
Owner's
Na�ttll V�l
Prml Owner's Name(Elec nic Sign ure) Dail
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. ,ov.oea Information on the Construction Supervisor License can be found at WILL .ivass.¢ov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) 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
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
CITY OF SALEM
n. /a PUBLIC PROPRERTY
DEPARTMENT
.lain:n:I r�stx.�I I
�lay.w
I_':WAHII.\G I I^il'8 CL•1' a 5.\l I!.N,M.ws.u.Ito V I IN,;I
Ihl, 03-713.9395 a 1:1x. 97111-I4C:1846
`oVhrkers' Compensation Insurance :UAdavit: Builders/Cuntracturs/ElectriciansiPlumbers
1 1 tllcant Inhirmution Plc4s Print Le 'ill
�IAITIC 111uaulesyl)raanlrJtinrvinJrouluell:
ldtire.is:
GI ,Sra(c,7.i 9� ��S 7ri6S�
Y P' �'y-�P�L.yi /�/CI ��"�= I'hune ii: � — >
r`•'au an vetployer'!Check the apprnyrlule bur.
II.4l :nn a cmpluyur with_L_ 4. Q 1 airs r general contractor and 1 t yM t'f prujeet(ruqutrad):
/ cnlpluyces((ell end/ur part.time).• huve hired the sub-cuntracturs (n' Q Kuw construction
2.Q I dill a sole propricrtx or Penner- listed on the anached sheet t 7. ❑ Remodeling
ship and have no mnpluyucat These sub-contractors have S. Q Dernolirion
working Air me in any capacity. workers'comp. insurance.
9. Q DwWing addition
I No workers'cutup, insurance S. Q We are u corn partition and its
required.) officers have etcrcised their 1<3 Electrical repairs or additions
3.Q I ant a hotnuuwnur doing all work right of exemption per hIOL 11.Q Plumbing rcpuirs or additions
myself. (No workers'comp. a 131,§I(4),and we have no 12.0 Ruul'aPuirs
insurance required.) t cmPluyecs. (No workers'
comp. insurance required.J 13.❑Other
any.gqd.awe dlat checka boa not must also lilt utll Iho eechua Iwluw dwwuty Ih.hr wwklai cunitl.muelwt Ildiuy inlinmatilla,I lumw,wnen who t,lhmit this omdavit indiu,ina Ihuy no Joint dl vurk and then ilia:w1tuG<untrnnttn mwt.ulm4 a""alndavil inJta W Int vloh.
•C'MIMh.n that chcek this bran must allaehod an addai.eatl..hM.Auwint The nattta of the nte.een tacton,and then wuhera'tang.iiii Infgmatiwt.
/nna on eeapleyer that it providinif iverkers'ro'npe nrnlion blsarauce/br sty etnpluyerr. Be/utv Is the pu/ley unJ/ub xiN
iu`urutuNo4
Insurance C'umpany Valnt:
Policy Ir or Sulr-ins. Lic.d: Expiration Data:
Job Site Address: 6(/ (./�,� T- - C1ty+Slate2lp: ,t/ olf
/
attach a envy of 11/e workers'compensation policy duclaruN°n page(showing the policy number and explratlun date).
pailuru to sucurc cuverage as required undur Sccliun 23A ul'JIGL c. 152 can lead 10 file imposition of criminal penalties of a
rites up to.S1.500,00 and/or use-year inlpris.nuncnr. Js well as civil Penulllul in the furor of a STOP WORK ORDER and a Rne
of up fit i?50.00 is Jay .Iyuinal the violahv. Ile advised thus a copy,urthia slulctnunt may,be lurwardcd Iu the Otlice of
I111'�pI1�JIPllla vl dlu ILIA :Or II' irince.:110era�e 1e1'1 ale Jlltln.
Ida hereby I erlify na,i¢ a,ains a ed p rnlNev ufpo/nry'but the in/brmWlon pruvided ubuve is true and eorreeb
-
- 2 3
Uf/ivia/axe uldy. Do Olaf Ivrife in this area,to be cumplefeJ by airy or fowOO u//icialt
I
I
('itv or Iowa: Pt:nnit/Lleenat 0, I
Issuing Atilhurity(circle nnc):
1. Iluard of licalth 2. Ihulding Mparrinent I. Cil%r'fu.su Clerk J. Llcctrical lospector 5. Plumbing Inyycefor
6. Other
l'unlael I'e nun:
- I'hune �1:
Information and Instructions
>Iassa:IlLLSCltS Central Laws ehaPttr 1 j2 regWrcs all t111ployers to provide\vu(ke fars' when under I tic their ct of hi ees.
1'ursu:uu w dais aatwe,an empfurre is defined us"...every parson in the service of another under any contract of hire.
e%press or Implied. oral or written."
An wnpioper is defined as"an Individual,partnership,association,corporesun ti other legal eased or any two r the
more
„r the 1,gegoing engaged In a joint enterprise.and including the legal rePfesClllatives JI 1^deceased
eesPlliowever the
Iecelver Jr uuslea of.us individual, ptumership,association or other legal entity,employing ' P y
owner of rdwelling hatssa having not more than three apartments and who resides therein,or the occupant of the
dwclling h�use of another who employs Pc"Grit to shall notdo nbecause of such employment be deetenance.culltruction or repair work d tuon ube an emPlJyer-"
or on the grounds or building appurtenant
SIGL chapter 152. g25C(6) also states that"every slate or local licensing al;ency shall withhold the Issuoncr or
renewal of a Ilecase or Permit to operate a business or to construct buildings In the commooweuUh for any
applicant who has not produced acceptable evidence of cumpUaace with the Insurance coverage required:'
\dditionrlly,�IGL dwpar l s?, g25C(7)sates"Neither the commonwealth nor any of its political subdivision shall
inter into any contract for the perfomance ufpublic work until acceptable evidence ofcunlPliarlu with the insurance
have been presented to the contracting authority...
requirements of this chapter
Applicants
Please fill out the workers' compensation affidavit compolYhone nutnber(s)along with theuing the boxes that lcertificate�i).ufy to your on msQ if
necessary, supply nub contrretor(s) m una(s),rddrcLimitsges)' P
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees h usher than the
member or partners, are not required to carry workers' compensation insurance. if an LLC or LLP dons have
members o,u artner is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents forconttms reqution of insurance coverage. Also be sure to sign and date the uflldavlt, The affidavit should
he rcumsed to the city or town that the application for the regarding the law it or liceur if youe is are required to obtang requested not in a workers'[of
industrial Accidents. Should you have any y
compensation policy,please call the Deportment at the number listed below. Self-insured companies should enter then
.elf-insurance license number on the apprropriala line.
cityClry or'Cowa OfnclaU
he sure that the affida vit is complete :end printed legibly. The Department hus provided it space at the bottom
Of the a of unit for you to fill out in the anent the Office of Investigations has to contact you regarding the applicant.
I'Ituse be sure w till in the Ise number which will be used sot a reference number. In addition,an applicant
that moat submit multiple pennitllicaluta applications in any given year,need only submit ono affidavit i in ndicating current
policy informatinnthe ice":s in that has been officially stite d under"Job Samped or marss"the kedlby�Itauc y orld town nalocy provided w the or
Y P
town)."A copy
applicant as proof that a valid affidavit is on file for futurepelmlte or licenses. A raw affidavit Islust he tilled nut sac
year. Where a hums owner or citizen is obtaining a license or pennit not related to any business or commercial venture
(i.e. a dug license or permit to bum leaves ctoJ said person is NOT required ro complete this affidavit.
luvtsriyatiuns would like w thank you in advance fur your cooperation and should you hsva:my questions,
I he I)i lice illplcabe du nut hesitate to give us a call.
the Ucp:lnineltt's address, talephune and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
ofltee of Invesdgadons
600 Washington Street
Boston, MA 02111
"ref. 0 617-727.4900 ext 406 or 1-877-MASSAFE
Fax M 617-727.7749
x:•. . d :.'o-us www.man.gov/dia
I
CoDa Construction `E"OPOS:' L Page I of 1
"F..A-ieriar s/ecirdis[s, Ghat allvm%s hm-e.I ou covered
3 oak Street No. # 51711.
Salem,MA 01970
978.335.7065 Date:May 17, 2011
Proposal Submitted to: MA Construction Supervisor License#100562 RIC#150617
Name Ronaldo Ramos Job Same
Address 6 Oak Street Address
City/St/Zip Salem,MA Ci /St/Zi
T: 978.998.9533 T:
We hereby submitspecifications and estimates for:
ITEM I DESCRIPTION
F5
1 Stri and remove 12'x 12' asphalt roof area.
2 Relace with 25 asphalt shingles to match existing.
3 An rotted wood to be determined upon removal of shingles, and replaced at material cost.
4 Ice and water shield applied.
All flashings to be done accordingly.
CoDa Construction to remove and dispose of all debris in compliance with current legal standards.
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:
$495.00
With payments to be made as follows: $2,00.00 deposit,$295.00 upon completion.
All material is guaranteed to be as 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 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.
Customer accepts responsibility for payment(s) of all legal fees,costs, expenses:and interest(at the rate of V/2%per month, 10%per
year)associated with the collection of overdue balances ninety(90) days or niowatter invoice for services and material,rendered by
CoDa Construction.
Authorized Signature
The above prices,specifications and conditions are hereby accepted. You are authorize4 to do the work as sp ified. Payments will
be made as outlined above.
ACCEPTED: Signature
Date: Signature
Customer Copy 0 Office Copy Other ❑
" CITY OF S.UY.NI, NL-1SS.kC iusETTS
• SULLDLNG DEP.1RT ONT
' 120 W.1.iHNGTON STREET, Yo ROM
TEL (978) 745-9595
FAX(978) 740-98"
KI3®ERiEY DRMOLL
MAYOR T Ho.�us ST.PrERRs
DIRECTOR OF Pm tc PROPERTY/HCILDLNG CONNISSIONER
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 k 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 IVIGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
o� 3 Ai
d' e
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