7 ORD ST - BUILDING INSPECTION �� --- The C'onut)onweadth of Massachusetts
yty Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNI SALEM
'ti,-'•' ?eliwd Ihie-'Ul1
Building Permit Application To Construct, Repair, Reno ate Or D i Ish a
One-or To u-Funlill Dtr,-IlinR
This Section For Official Use ill
Building Permit Number: Date A plie
1"IccA.4,�wt� �TeZ`ClCorsG�.'l -- l
Bull ing OI)icial(Print Naune) .'igna ure Date
SECTION 1:SITE INFOR ION
Lyroperty Address: 1.2 Assessors blap& Parcel Numbers
o Q. f
I.I a Is this an accepted street?yes_ no \lap Number farce(Nwntxr j
1.3 Zoning Informad� 1.J Property Dimensions:r��le,
Zoning District Proposed Usc Lot Area(sy ft) Frontage(11)
L5 Building Setbacks(R)
Front Yard Side Yards Rcar Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: La Sewage Disposal system:
Public❑ Private❑ Zone: — Outside Flood Zone?
Chick fifes❑ Municipal ❑ On site disposal s)stem ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Qwnert o(Record:, 1 / its
lS Q t'4 ►Ja l S ko M ✓► gss
N;une(Pnnl) "nT— (a).State.ZIP
�I all* s+ 757/No.and Street Telephone Y Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(-) ❑ Alteration(-) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Spcci ry:
Brief Description of Proposed Work:
QO
r -
SECTION J: ESTIDIATED CONSTRUCTION COSTS
licm Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S $d po I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City town Application Fee
❑Total Project Cost'(Item 6)x multiplier
7. Plumbing S
_. Other Fees: S ___x
1. .Mechanical III\':\C) S List:
\1echanical (Fire
----------------- —
Suppression) S 'total .\II Fees: S_ _
Total Project Cost: I S? Check No, ('heck Amount: - -- Cash Amount: -
Oo� 00 0 Paid in Full 11 Outstanding 11a1;ulce Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
.�p l_ Tyy// -for zzQ
�_0Lg-1N�1 _.--..1__C._._...- Lieensc Number Pvpi stun Dule
Name of C'.SI. I folder ----_
�p List CSL 1)PC(see below)._. .
—`-_tL,Q-R�---� ---- ------- "I)pe DeseriPlian
No. and Street
L Q ) �Q � U 14vestriaed(Buildings ti it)iS.I111U cu. Il
'L .l
R Restricted NU Family Dlsellin g
Cit_ri'uen,.Suue.ZIV M Masonry
RC Rooling Covering
--. WS W'induw;nd Siding
SF Solid Fuel Burning Appliances
75?1-MlZ Insulation
"I'cle hone Entail address D Demolition
5,,2�2 Registered Home Improvement Contractor(HIC) ! Y ( 77�
1,fg4 7/ -Ta ( O/c .1�1 - IIIC RegilAratiun Nunlhcr li.pi lion Uatc
I IIC Compwty N;unc or I IIC Re t Nunw
N . and Street S '�" l2 `r Email address
U
CityMwn,State,ZIP fete hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 25C(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 Issuange of the building permit.
Signed Affidavit Attached? Yes .......... No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
to act on my behalf,in all platters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
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.
1511 a�,4 .i-n I ! !
Print O Ta
cr'.s or:\uthorizeJ Agent's Nm (Electronic.Signuure) Mile
NOTES:
I. :\n Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(not registered in(he Hume Improvement Contractor(HIC) Program),will M) have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
om., t .i Information on the Construction Supervisor License can be found at%%o o.nna lion dp,
2. When substantial work is planned, provide the information below:
Total flour area tsy. R.) I including garage, finished basement attics,decks or porch)
Gross living urea Isy. it.) _ Habitable room count
\umber of fireplaces__-_ ._ _. -.._ Number of bedrooms
Numberofbathroons N'umbcrofhalfbalhs
I. pc of heating s)Stem Number of decks, porches
F\Ile tdel4tIi11gs\4e111 Fnelosed ---Open
i, ,Foal Project Syuarc Footage-m;l) he Suhstitutcd for"Fo(al Project Cost' i
CITY OF SALEM
PUBLIC PROPRERTY
DEPART
MENT
N,1,M
I�', 1frAr/nAUlrl.\j1:1lY1' • f,111•N, M.1U.11.111 V I nJl'17�
I i•.I. /7NIS'/f'IS • I',.Y v7J•'/C•'I.YM
Workers' Cumpeniallon Insurance \i1lJwi1: UuilderVContracture/ElectrlcljnyPtumbers
► 1 Illcan In unn•JUo
1 ' .� In a 'hl
VJInJ �-
i / � n
►tItIrc...a:� I 1�P 4' S-y '
City,Slace,Zip- n n ✓)7C 4f
I'hune N:_78( .Sy'jlL r�
.try 1 u rnyllOyer?Check lhs apprnprlYle box.
1. I:un a cmPluyw with_-•I(� a, ❑ I ,un a jcncral anuraelor and 1 I pe°rPrn)uef(rwlWrfJ):
�•❑ enlpluyceY(lull unlYur purl-lime).r huva hires IhY.rub-tunuaclop 0' ❑1\'ew cunslructiun
I.un J late prnprictor or partner. Iiucd on the anached.nccut I
ship and haw no an lu vela �• ❑Rarnandind
P Y 7ltess eub•conrnetots have rarkind lilr me In any capacity, worked'comp. Initumnce. e' Oamolirion
I Ko I 1�nrkcn'rump,
No Wnrbcrs'sump. iularaoce 1. 0 We an a cmpenli"n and its 9' ❑(IV141, d aJdiliue
3.0
nys
nelr.yuircd.) llrlcarl Itava ctcreircd their 10•O Eltcrrieal repsin er additions
li .r N'lYuwner Juiny all work right arc.eemptinn per hIM 11.0 Plumbinr rupuirl or atlJilinns
C. 1 y8,41 M.and wt have no
nsurance rcyuimd.) l anPluyacs. [No lvarkm' 12.0 Ruul'n,,pu�in
cnlnp insurancerequired.) IIZtither/K•/ B
•1 n> dpla«"ihW chds tNe fl mlul.Jw till u,lt IM wont,"lour lhtl,nne tho,wwhuti runlelr""YIu"puliry inlimnwiuA
'11„m,nlwnrnr-he r,alnlil Ibis sill Jrvl/inJlul.A i
�nlrwh"n that rlofa lAle YaI TIW In,;A,y,in JJ ur'A'ine ill,w;low 11%W hip t"aride rlrletwimirw t.
and Ibm dnria Iha nr"M a/IM t to uh"Y a nls unJWll inJlanlr ng woY,
/urn un erylp/oyrr/hYr lr prvrJdlnr IrYr�I/J'CY/rypf/lf"//an IILfY/IInCf�' �I x ON,notIAfa 4rl�ala fpnl�•Il1IIkY inrsrla lly�
iujurmullrrr� L fits,my f/np/YyffR BIIYIY/J/hl PYnry Yryd fY�a(/�
Imurance Company .Varna: r l
Policy Y or Svlr--ins. Lic,rr' J1� �Y -
7 Espirwwn Dale /3 /l
lob SON �\JJres.v: �--
.11fach" coyy Of Ill" workers'culnpvnfatluRpulley duclerarlun pu
I;u ce 6how1 N the Polleynumber and crplraflurr date).
tlurc lu'aura curoruye aJ reQwrecl uoJcr Sucliun?SA go
e. 132 can lead to the iln
Itil.I'll fit SI 100.old unJ/ur uue-year imprisonment, ue well.l.s civil penahlu in Ihu 1'unn era STOP WORK ORDER anJ a RM
of till fit
i?j0/M.t Juy Iltuinet Ill# r611a1M, I Ie advlecJ that a cony urlhty.lulement may buPl'lu'rw a J J wllha Ullwes„�ea ors
Im.\nquwpn/ul'Jlu MA .or nlrunu'cc a,rcru;c 1a niruhun.
/du/rr•rrAy l t,rti�frn,l.'r dnf f�e d prnuh/ r u�prr/nry Ihur r/lf is urrnYNon
ylv ridfd u0 we(J to, find roarer.
11//lriu/for ml/y, qY,mr wrirf in/hi.r urru, lu Af runnyletrd by niry of town a j..
//uul
( ilr or I'nnn: _
�� Vennifrl.lccnfe 1
I,luiny ,lulhnrily (circlanncl:
I It-,.it J .(Ilr.illll 1. Ilwlfhtiy lkp.ulmeill I. lih.'6. Ihhrr Iun"Clerk J. l'lccfric. l ht+ Iceter i,
f'lumpinl{ Imycclor
I1•gull lcl lot rWll:
I'All ill' r'
Information and Instructions
\l.uj.lcl,a.\efts tA;neNI Laws chapaer I J2 Il',lal(e*all Oepla`a`on In ha wry Kt,it Another provide Worker," Miller 1 ler Ally';U trace f biro.'.
I'i,rnu.mt to Jill*,latuta, An rmplgrrr Is Joined as e ry P'
;%pro"Or ,mphcJ, oral or wrntan" of an Iwo or more
\n rrnpfuhar 1,dunned L"an individual, Partnenhip,.Issaewnuo,coryarauun car abet lebal ennry, Y
t the turegOmg engawd ,n a Join' cmnerynsa,And ulcludin{the legal reprenialy i,pla,playing gn,�lo)eee INliwevcrhhe
ecely t or t(ustcr ol'.m indivlJual, Poe nterp ship,assoejauoa or other legal¢nary,cmp Y { ' P
rtons to do rttaintenancr,cunvtruction°111en1 be de med to ineempl yer."
owner of a Jo2JCs u hates having not mars has hree apartments and who reside$therms car th An e occupant cat the
.Iw.•Ihny house of anoher who employ. {x
or on the.rounds or building appurtanant hereto shall not because of such employ
\IGL chapter 1 S2. 425C(6) also'states that"Ivory slate ar local Ilcensla{agags i +bag witlheld the bsuaac or
hs
elawlietilk for
ny
grace wick the Insurance coverage routs rd,"
rrnrwrl of s Ilona car prrntic d uprraa a husineu or cs of c rnpuln't buildings la Col'ill political
subdivisions ehall
Applicant who has not produad;SCep),batesle r'Neither he ommonwcalth nor anY
1dJilionully, slU chupter I S., i- 1
,ntar into any cOntract for he Pert'omtanwa, pt,1' work the CaltUaclin{authority."
ufonmpliatmc w ith he insurance
requirrmenu of this eltuptrr have been p'
Applicants p to our situation an4 if
ensation affidavit completely,by checking the boxes shot apply Y
addritC4 sad phone number($)along Wilk their lrtiflcu d(s)of
Plcasr Iill out the workers' comp with no cmployt.'es other than the
necessary,supply sub-contruclor(t)nuneU), '
workan' camper ution insurance' if an LLC or LLP does have
inswancs. limited Liability Cmnpanies(LLC)or Limited Liability Partrt•nhips(LL
,rlelnbers car puAtten, are u°ad ��dvlsri red to J hat thin aly1davit may be submitmd to the DePrrhnattt of industrial
an,ployees,a policy is req ' Also be sots to slgtt uad dote lbe efildsriL he )cpaallirtmen should
wasted, not Ih1 l)sp
ucidanu Par confirmation of insurance eovcrnge uired to obtain a workers'
he rcttmrned to the cisjr or town that the applicati'naf,rrell rrding the low rur if ybu,IuinY•rr�t
Industriltl.\¢indents. Should you havr any 4
calnpenaaliun policy,pl•$a•call the Deportment at the number listed below. Self-insured compaaiea should enter their
sclf•insursnee license number anh te appro Idlild line.
Clly ar-rows Officials
the a lieanL
Plrnsc he$Jiro that rhtu affidavit ll out*in�ha ovens the Otilc mplete And printed legibly.
InvestigatiDons has o conOPeomignt tact ct you r inarddi providedo i n,in J Plum
f the aI's utc fur y
Of I,a ba sure to till in the pl ,ut in the a ens the which will be uaad;ma Sit,
eference nunlbar, In addition,an app scam
s"the h ant should write"u11 luculiuna in (city car
III. m,uts,rbmit multipir pannit'licena application$in any given year, ned only submit can°aliidavit r indicating
cures
ilimPolicy iuformution of necessary)anJ under"lab Yia AJdres`d car ntarkod by dlr city or town may be p
tuwn).",\COPY of the ut'fldrvit that has vidicd
bean ofncialiy rump'
Applicant as proof,that a valid affidavit is un file for Allot*Palmia car licenses. A saw a to any business
mull be tilled out each
te
Where a hump/p nsf Or to ;jIjzcn is burn laavue.)ObtainingJ Pers nJs NOT requiteot d otcomplete th l utfldav Imu,ereiat venture
rc ,>i ricc,d Invesrigatiuns cruuld III• to drank you it aJv;utca 1'.or yuur caaprraliun and shuuld you haw•ray gwsltons,
ploa.e du nut hesltara to give us a call.
fhc U;p•Iruncnl's cal lta+s, tcicphunr aTh Co�onweslth of Massachusetn
Deputrnent of Induurial Accidents
O111c of Isva ftsdons
600 WaSWigton Street
8aston, MA 02111
fel. q 617.727.4900 ext 406 of 1.817-MASSAFE
Fax 4 617-727-7749
l j ],,.iif www.mau.jov1diet
CITY OF S.V1 F.Nt, 1tiLkSS.1CFjUSETI"S
8L[LDLNG DEP.IRT-%LNT
120 W. SKSIGTON STAEBT, }1O FLOOR
TEL (978) 745-959S
K11G3EAUY DRLSCOLL F,lx(978) 740.9846
MAYOR I)icimU ST.PMAU
DIRECTOR OP PL SLIC PROPERTY/at:MDL%qG CO-%USSIONEE
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 I 11,S
Debris, and the Provisions of MOL c 40, S 54;
Building Permit p I i
lI Is issued with the condition that the debris resulting from
I, S I SOA.work shall be disposed of in a properly licensed waste disposal facility as defined by IVIGL c
The debris will be transported by:
(name ut'hauler)
The debris will be disposed of in
Llrrk A �12 "�c
(name Dr racrliry) "
L (iddrt,a or' cony) "
+iyna are OrPcrmt Jpphc+nt
L
-- Page No. of Pages
^` Y - WM. TRAHANT JR. CONSTRUCTION, INC.
-"r 411-1 GENERATION ROOFING
- 215 Verona Street
49 LYNN, MASSACHUSETTS 01904
(781) 599-1211 •_(781) 844-4551 • FAX: (781) 581-0855 H.I. LIC. #141778
. I \OBMITTED!"'N Tq' 1 1 t'C r t PHONE DATE
L 8I 86`I yg� //- /l-moo ►(
STREET JOB NAME
CITY, `ATE and ZIP CODE JOB LOCATION
Z
We hereby submit specifications and estimates for: We hereby submit specifications and estimates for:
SHINGLE_RO_OF _ FLA_T/RU_B_BER_R_O_O_F
Stri nbre roof ❑ Sweep entire roof clean
e ce any bad boards up to 100 linear feet ❑ Strip entire roof
--- -----------------------------------------------------------------------
Ins ice and water barrier first three feet up roof ❑ Mechanically fasten down ISO board insulation
Ins ce and water barrier in all valleys and along dormers ❑ Install 060 Rubber Roofing on entire roof
2stall
!eight
b. felt paper on remainder of roof ❑ Install metal flashing around perimeter of building
inch drip edge ❑ Flash chimney(s), pipe(s) and wall(s)
❑ Install-ridge vent ❑ Edge caulk all seams.
la h or re-flash chimney(s) ❑ Install new copper center drain
Ins[ I-new pipe flanges ❑ Other:
_ In 30 stall year shingle ❑ other C r10.rC r ❑ Clean up all debris
❑ Install gutters and downspouts ❑ Labor and materials guaranteed 100%for five years
❑ Install trim coil
---- --------------------- ----------------------------------
❑ Install new fascia boards
---------------------------------- ----------
❑ Install new rake boards — —
❑ Install sky light(s)
❑ Of
C n up all debris
Lab nd materials guaranteed 100%for five years
All shingle roofs are nailed by hand.
Pe Propose hereby to furnish material and labor — complete in accordance.with above specifications, for the sum of:
Total Price($
"*IF YOU ARE HAVING YOUR ROOF STRIPPED, PLEASE COVER ALL VALUABLES IN ATTIC, AS
WE. HAVE NO CONTROL OVER DEBRIS THAT MAY FALL THROUGH ROOF BOARDS."
All material is guaranteed to be as specified. All work to be completed in a workmanlike
manner accordingingtoto standard practices. Any alteration or deviation from above specibca_ Authorized
bons involving extra costs will be executed only upon written orders, and will become an Signature—P
extra charge over and above the estimate. All agreements contingent upon strikes,
accidents or delays beyond our control.Owner to carry fire,tornado, and other necessary
insurance.Our workers are fully covered by Workman's compensation Insurance.
�1CCPptanre IIf FIDPOSal—The above prices, specifications
and conditions are satisfactory and are hereby accepted.You are authorized to Signature JGI�✓"`•G '�^-�wc�l
do the work as specified.Payment will be made as outlined above.
Date of Acceptance: Signature
Please mail yellow copy to above address. '
I