23 ORCHARD - BUILDING INSPECTION � The C'ummomvealth of Massachusetts
// /J ►� Board ul'Building Resolutions and Standards CITY
� OFSALEM
Massachusetts State Building Code, 0 C'MR, J editionBuildingPermit ppli lionToConsinir, Renovate Or Demolish a( e-or Twu-Ful/rng
This SeclioVor Official Use Only
Building Permit Number: 14 4 - Date Applied: .•J
Signature: j44 ��3d� z>
Building Cam ssi ns t f Buildings !Tate '
ECTION 1:SITE,INFORMATION
1.1 Property Addre' 3 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes ono Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Fmmage(11)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zama Informatiooa: 1.8 Sewage Disposal System:
Public O Private O Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Check if esO
SECTION 2: PROPERTY OWNERSHIP'
2f
ner'of Reco jaN �fnl) Address for Service:
1
i
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O 1 Alteration(s) O AdditiJ103
Demolition 0 Accessory Bldg.O 1 Number of Units_ Other O Specify:
Brief Description of Proposed Work': T P d
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use only
Labor and Materials y
I. Building IS 1. Building Permit Fee: f Indicate how fee is determined:
�. Electrical S Cl Standard City/Town Application Fee
O Total Project Cost(Item 6)x multiplier x
J. Plumbing s 2. Other Fees: S
4. Mechanical (11VAC) s List: 6�
3. Mechanical (Fire s
Suppression) n Total Alf Fees:f
r/ Q� heck No. Check Amount: Cash Amount:
♦ 6. Total Project Cost: s ! O Paid in Full O Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES r
5.1/Licensed Construction Supervisor(CSL)
/7/l il dam/ _ 1liccnse✓N Number lixpi Ionl/yute�
Nun ol'CSI.' IloWr _ I.iA CSL Fype(me below)
a, _ f Ikscri Lion
Address /// _ U I Im"ricteJ u to 35.000 Cu. Ft. r
R Restricted 1&2 Pomil Dwellin
Signa u M M Only
A7o nr �Q!of— RC Residential Rocifing Covering
I'dephone Residential Window and Siding
SF Residential Solid Fuel Burning A liam:c Installation
D Residential Demolition
3.2 bt Hv ImprGgvernest Contractor(HIC) � ?
Regulra ion Number
I IIC pant ame dx IIIC Regist t Name'" ��Q��� n o is �a
AJJre ✓1� A7� � 7d(�},r Expiration Data
Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL f 2SC(6))
Workers Compensation Insurance allidavil must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permil.
Signed Affidavit Attached? Yes ........ No...........O
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 behalf,in all matters
relative to work-authorized by this building permit application.
Si ure orOwner Dote
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 �� �� jl�`� as Owner or ughorized A rat hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf.
a
n orlde /X l h 7'
Si or uthoriaed Agent Date
Si under the sins and nalties of 'u
NOTES:
1. 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 rW have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 7110 CMR Regulations 110.1116 and I l0.R5,respectively.
1. When substantial work is planned,provide the information below:
Total floors 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 ofhalf/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
). "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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11a.: VS-70-9593 r 1'.ys:973•74C?Ix46
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
%pplicant information Please Print Le ihly
Nalllt; 113ucuw vvgrganirxtiaNlnJrviduull: C
Address:
City'sracc ".ip
y, an employer? Check the atppropriale box: 'Type of project(required):
1. 1 :tin a employer with 4. ❑ I am a general contractor and I 6. New construction
car Io ces full and/or art-time).• have hired the sub-contractors
P Y ( P ❑
2.❑ 1 ;tin a sole pmprictor or partner- listed on the anachcd sheet. 7. Remodeling
ship and have no cmployecs These sub-contractors have 8. ❑ Demolirion -
working for me in any capacity. workers' comp. insurance. q, ❑ Building addition
No walkers'cum insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
raµtircd.] ot3icers have exercised their
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. lNo workers'comp. c. 152, §1(4),and we have no 12.❑ Ru of repairs
insurance required.) r employees. (No workers' 13.0 Other
comp. insurance required.]
-Ally:gyp phcunt that chucks box ill moll atau rill out the wction Wow showing(heir w•orkusi cumpensmiwt policy inlormatiurs
'I lomcuwmn who submit this affidavit indicating they am doing on work atd then hire outside conrwton must ouhmit a new al'fdavit indicting utch.
-Comrtcttus thin chuck this box must mtwhcvd.m additionul.sh..rot showing the n3lue of the subaonirwton and their wurken'comp.policy information.
IF arts an employer thus Is providing workers'c ompen.cadoa insurance for uty employees. Below is the policy and Job alter
injorinution.
Insurance Company Name: .__ ....
.Policy 4 or Sclf-ins. Lic. M: _.. .. .... .._ EApiratlon Date:
Job Site Address: 6 citylstatezIy: &
Attach a copy of the workers'compensation policy declaration page (showing the policy ntnnber and expiration date).
Failure to secure coilerage as required under Section 25A ul'1lGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1.500.00 and/or one-year imprisonment,as well as civil penaltics in the form of a STOP WORK ORDER and a fine
of up to 5250.00 it daty against the violator. He advised that a copy of this stuicincnt may be forwarded to the 0111ce of
Im angaunns ul'the DIA for insurance eoveragc ycrification.
l do hereby Lcrir�fy ander the aitt.v o//n/d/,''tenol ics of per%ttry that the inforinulion provided above is true and correct.
si,':i,iturc �-L�a� Date' f ld
I'll. e
Of/ieial use only. Do not tsrite in this area, to be coutpleted by city or lown a/JiciuL
City or fawn: __ _ Pennit/l.icensc g__
Issuing Aulhurily (circle one):
I. hoard of licadth 2. Building Department 3. Cil.w fowu Clerk 4. Llectrical Inspector 5, Plwnbing Inspector
6. Other
Contact l'crvou: ._ Phone 1:
Information and Instructions
.V assachusens General Laws chapter 152 requires all employers to provide workers' compensation fix their employees.
Pursuant to this sratute, an employer is defined as"...every person in the service of another under any contract of hire,
ekpress or implied, oral or written." - -
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
,d the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,pnutncrship,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."
a states that"eve state or local licensing agency shalt withhold the issuance or
152 _$C 6 also
.�IGL chapter , �+ O t'Y
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
yore p _
applicant who has not produced acceptable evidence of cump)lance with the insurance coverage required."
Additionally, NIGL chapter 153, §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 ol'cumpliance with the insurance
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 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 Jute 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 line. -
City or Town Officials
Please he 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 fill in the ponnit/license number which will be used as a reference number. in addition, an applicant
that must submit multiple pernio'license applications in any given year,need only submit one affidavit indicating current
policy information Iif 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 home 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 bum leaves etc.)said person is NOT required to complete this affidavit.
I he t)Ifice of love5tngauons would like to thank you in advance fur your cooperation and should you ha%c any questions,
Please du not hesitate to give us a call.
"ncc Dcpartmrnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investlgatlons
600 Washington Street
Boston, MA 02111
'ref. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
K.vi+ed 5-26-05
www,mass.gov/tile
1
CITY OF SALEM
^ i PUBLIC PROPRERTY
' `"` •� DEPARTMENT
RaK V�/
\I 120 WASHING!ONSIR[f:T • SAIrM. MAiaAI.IItitI"ii'.:19!- -
'fel:9'8-7ii-9i95 • PAx:978.74(.98416
Construction Debris Disposal Affidavit
(required fur Lill demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 1 1.5
-_- .� Dcbris,_and-the provisions.ot:MGL c-40,S 54;_
Building Permit H 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:
(name of hauler)
The debris will be disposed of in
r
ame of facility)
"
(address of faci ' yv)
signature of permit al5plicant
date
CoUla Construction PROPOSAL Page 1 of 1
".I'ptr-Jec!ending[o an trnJinis'hed compusilinn"
3 oak Street No. #4810
Salem, MA 01970
978.335.7065 Date: 8 April, 2010
Proposal Submitted to: MA Construction Supervisor License#100562 HIC#150617
Name Megan Riccardi Job Same
Address 23 Orchard Street Address
City/St/Zip City/St/Zip Salem, MA 01970 City/St/Zip
T: 978.335.3295 T:
We hereby submitspecifications and estimates for:
ITEM DESCRIPTION
1 Approximately 10 square existing roof to be removed and replaced with 30-Year Architect Shingles.
2 Ride Vent to be installed.
3 Ice and Water Barrier to be applied to leading edges.
4 Aluminum drip edge to be applied on all leading edges, and rakes.
5 New lead flashing to be implemented around chimney.
6 New soil pipe flange to be installed.
7 Antenna and satellite dish to be removed.
CoDa Construction to remove and dispose of all debris in compliance with current legal 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:
$3,895.00
With payments to be made as follows: $1,895.00 deposit, $2,000.00 upon completion.
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.
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 1%:% per month, 10% per
year) associated with the collection of overdue balances ninety (90) days or more after invoice for rvice(mod material rendered by
Co Da Construction.
Authorized Signature C 1�Xf�,t4 � �f 06'\J-J
1('('9;P7';ANt('V OF PROPOSAL
The above prices, specifications and conditions are hereby accepted. You are authorized to do the wo as specified. Payments will
be made as outlined above. p , CL 0,—t
ACCEPTED: J Signature r j
Date: ���� Signature
HI, 1 S7i i u; YUR l of U Co.S'.S'/U/:R. I
Customer Copy ❑ . Office Copy Other ❑
ti