34 ORNE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
1 Board ol'Building Regulations and Standards CITY
t!y j Massachusetts State Building Code, 780 CMR, ]"edition OF SALFM
"►►..y/ Revised Junuary
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Num Date Applied:
Signature: c�t V-7f1%
I��JJJ Building CommissionerlIptpector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 PropertyAddress: 1.2 Assessors Map& Parcel Numbers
L 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 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owners of Record:
Doovg LD Ca d� 3 Y
Name(Print) Address for Service:
-2f' - 7.yY - s86G
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ teration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other Specify:
Brief Description of Proposed Work': S ,-1/ S /2 S'ZVIA Ro
S
r' e a x/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMclal Use Only
Labor and Materials
1. Building 5 1. Building Permit Fee:S Indicate how fee is determined:
I. Electrical Is ❑Standard Citylfown Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List: r
5. Mechanical (Fire S
Suppression) Total All Fees: S
6. Total Project Cost: S Q6 6 ,�a Check No. Check Amount: Cash Amount:
❑Paid in Full O Outstanding Balance Due:
dr d11-
�6�
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) I
Q/19 �� Zo/Z
"��� Number F pimti n Dale
Name ul'C'SI.• I older L Type(see below) t f
1ST d ����' �� Ixxri ion
ss llnrestricteJ u to 35,000 Cu.Ft.
r C Restricted IR2 Family Dwellin
Signature M Masonry Only
/U/ RC Residential Routing C'overin
rclephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regbtered Fjlome Improvergeat�[ Conlnctor(HIC)�ad�ia/�9
!IIC omp d Name or it IC Re ' I Name Registration N tuber
3 i zo /
J ss �J 7 9 O . O m Expiroon Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 Issuance f the building permit.
Signed Affidavit Attached? Yes .......... No...........Cl
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 Lure of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
4 6G ,as Owner or Authorized Agent hereby declare
that the statements dnd information on the foregoing application are true and accurate,to the best of my knowledge and
'behalf.
/—a /Zf
Signature of Owner oAuthorized Agent Dal
(Signed under the pains and penalties 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_W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115, respectively.
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 of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
}, ••Total Project Syuare Footage-may be substituted for"Total Project Cost"
y °$� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:.I.\II:.`gl FY DNISCUI.I. \
�I.tit 1a 12C Wnsrllni;7o�Sfxea:T 5suvl,M.wncl n'sr:n ti G1970
11:1:978-745-9595 • Fnx:978-7+0•9846
Workers' Compensation Insurance :affidavit: Builders/Contractors/Electricians/Plumbers
3Dlicant Information Please Print Leeiblv
Vafre (13us111css/Organi7ation/individual)
Q
Address: / v • �54 �—
CityStatci/..ip: ✓"WG—OA47 Phone /': 97.0 7
Are yu it employer? Check the appropriate box: 'Type of project(required):
I. I am a employer with 4 4. ❑ I am a general contractor and 1 6. ❑ New construction
uniployces(full and/or part-tinge).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet. : �• Remodeling
Ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
To workers' coin insurance 5. ❑ We are a corporation and its
I P• 10.❑ Electrical repairs or additions
required.) officers have exercised their
right of exemption per MGL I I.❑ Plumb tg repairs or additions
3.❑ I am a homeowner doing all work g P P'
myself. LNo workers* comp. c. 152, §1(4),and we have no 12. ouf repairs
insurance required.] f employees. LNo workers' 13. Other
comp. insurance requi ❑red.]
•Any:ji lifcaut that chucks box ill musl also IID Lan Ille waiOn klow showinU Ihoir workG9 cumpemtaiun policy infurmution.
1 I lumauwncn who submit this affidavit indicating They arc doing all work and then him oulside contractors must aubmil a new ai r.davil indicating such.
-Commcutrs Thal check this box must at1whed an additional.sheet showing the name of the sub<ontrxtors and their workers'comp.Policy infarmation.
l am an employer that is providing workers'compensation insurance for nny employees. Below is the policy and job site
information.
Insurance Company Name14216 —__..._._.[_f. . . ..
Pulicv 4or Self-ins. L�i7 5c. t:: ICZ��__/..... --._-- Expiration Date:S /Z 20
Job S ire Address: !Z y/9N15-7 - City;State/"Lip: y
Attach it copy of the workers'compensation policy declaration page (showing the policy number and expiration date).
Failure to secure coverage as required under Suction 25A of.'vIGL c. 152 can lead to the imposition of criminal penalties of a
find LIP m S1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of LIP to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigalions ul'the DIA i'or insurance coverage verification.
l do herc•hy r t' under the
pains
ttutd penalties of perjury that the information provided ubov r i�e and correct.
Date, 7 G 2e//
1111twc.'i 9>9
Official use only. Do star write in this area,to be completed by city or to official.
Permit/License H_
Issuing:Nuthority (circle one):
1. Board of health 2. Building Dcpartmeot .3.Cityffosyn Clerk 4. Electrical Inspector 5. Plumbing; Inspector
6. Other
Contact Person: __.. -.--- Phone th
Information and Instructions
;Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an etnpluree is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
Of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an 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 the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL chapter 152. §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally, MGL chapter 152, §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 of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill 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 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
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 date 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 be sure that the affidavit is complete and 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 yu`U regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennitfliceusc applications in any given year,need only submit one affidavit indicating current
policy information jif.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 burn leaves etc.)said person is NOT required to complete this affidavit.
I he Off ice of Investigations would like to thank you in advance for your cooperation and should you have fury questions,
please do nut hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Rcviscd 5-26-05 www.mass.gov/dia
CITY OF SALEM
Y f'.
PUBLIC PROPRERTY
DEPARTMENT
'd 121 \\.\,I 181:1 T • S.\I I'11- %I.\li\, :I!
171: v78-74j.9;45 ♦ 1:\s: 'i 78 N '18i1i
Construction Debris Disposal Affidavit
(Mluircd lirr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 1 1 1.5
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 MGL c
l It. S 150A.
The debris will be transported by:
-- - (nam•ofhauler) -
I he debris will be disposed of in
(name of laahty)
(address of facil IV) -
bllnafule of permit applicant
-7 G ZO O --
date
+ V
RAPID ROOFING
GENERAL CONTRACTING CO.
P.O. BOX 605 SALEM , MASS. 01970
978-740-0101
MASS LIC 9 128253/144946/CS101965
RAPID ROOFING IS A DIVISION OF COYNE&SONS CONTRACTING CO.
ARCHITECTURAL, SHINGLE ROOFING ESTIMATE
TO. 6/5/2010
DONALD COOK
34 ORNE STREET.
SALEM, MASS. 01970
978-744-5806
JOB SITE ADDRESS.
SAME
RE;.ROOF ESTIMATE # 010-083
COMPLETE STRIP (2 LAYER STRIP) OF 25 YR. 3-TAB SHINGLES (26. SQ)
INSTALLATION OF 30 YR ARCHITECTURAL ASPHALT ROOFING SHINGLES -
ON ENTIRE MAIN HOUSE ROOF AND DORMER ROOFS OF THE BUILDING..
WE AGREE TO.
1. COMPLETELY STRIP THE ENTIRE MAIN HOUSE ROOF & DORMER ROOFS
OF ALL THE EXISTING TWO LAYERS OF SHINGLES ON THE ROOFS OF
THE BUILDING AT THE PRESENT TIME.
2. REMOVE ANY ROTTED ROOF DECKING BOARDS OR SHEATHING ON
THE ROOFS OF THE BUILDING, AND INSTALL UP TO 100 FT.OF EITHIER
ROOF BOARDS OR SHEATHING- FREE OF CHARGE ( ONLY IF ROTTED
AREAS ARE PRESENT).
v
3. INSTALL NEW WATER& ICE SHIELD ON THE FIRST SIX FEET OF THE
MAIN ROOF OF THE PROPERTY. ALSO ON ALL RAKE AREAS, VALLEYS,
DORMERS, CHIMNEYS, OR FLAT ROOF AREAS OF THE ENTIRE BUILDING.
4. INSTALL NEW 15 LB. ASPHALT FELT ROOFING PAPER ON THE
ENTIRE MAIN ROOF AND DORMER ROOFS OF THE PROPERTY..
5. INSTALL NEW 8 INCH WHITE ALUMINUM DRIP EDGE ON THE
ENTIRE MAIN ROOF & DORMER ROOFS OF THE PROPERTY.
6. INSTALL ALL NEW VENT PIPE BOOTS ON THE MAIN HOUSE ROOF
OF THE BUILDING AS NEEDED. (2)4 INCH BOOTS
7. INSTALL NEW ALUMINUM STEP FLASHING ON ALL AREAS OF THE
COMPLETE JOB AS NEEDED.
8. INSTALL NEW 30 YR.. ARCHITECTURAL ASPHALT ROOFING
SHINGLES AND CAP ON THE ENTIRE MAIN HOUSE ROOF AND DORMER
ROOFS OF THE PROPERTY.
9. INSTALL NEW BOX VENTS ON THE ROOF OF THE BUILDING.
10. REMOVE AND INSTALL NEW LEAD FLASHING ON THE EXISTING MAIN
HOUSE CHIMNEY OF THE PROPERTY.
11. WE AGREE TO REMOVE ALL ROOFING DEBRIS FROM THE PROPERTY.
TOTAL COST OF JOB..................................$ 9,000.00
WE HEREBY PROPOSE TO FURNISH ALL MATERIALS AND LABOR-COMPLETE IN
ACCORDANCE WITH THE ABOVE SPECIFICATIONS FOR THE SUM OF....
$ NINE THOUSAND DOLLARS-$ 9,000.00
WITH PAYMENTS TO BE MADE AS FOLLOWS....................
$ 4,500.00 DOLLARS DOWN/ $ 4,500.00 TO BE PAID IN FULL UPON THE
COMPLETION OF THE WORK....
L 51
NOTE-THIS PROPOSAL MAY BE WITHDRAWN BY US IF NOT ACCEPTED WITHIN-21 DAYS.
ANY ALTERATION OR DEVIATION FROM THE ABOVE SPECIFICATIONS _
INVOLVING EXTRA COSTS,WILL BE EXECUTED ONLY UPON WRITTEN ORDER,
AND WILL BECOME AN EXTRA CHARGE OVER AND ABOVE THE ESTIMATE.
ALL AGREEMENTS ARE CONTINGENT UPON STRIKES,ACCTDENTS,OR
DELAYS BEYOND OUR CONTROL.
NOTE; WE CANNOT ACCEPT ANY RESPONSIBILITY FOR ANY DAMAGES.OR DEBRIS FALLING INTO ATTIC AREAS,
CUSTOMERS SHOULD COVER VALUABLES,GREAT CARE WILL BE USED TO PROTECT THE EXTERIOR STRUCTURE
BY COVERING THE EXTERIOR WALLS,OBJECTS,AND FOLIAGE WITH TARPS TO HELP PREVENT ANY DAMAGES
DURING THE STRIPPING OF THE ROOF,HOWEVER SOME DAMAGE AND MARRING COULD OCCUR BEYOND OUR
CONTROL,
HOMEOWNERS MUST MOVE ANY VALUABLES AWAY FROM THE BUILDING,PRIOR TO THE STRIPPING OF THE
ROOF.
NOTE; IF MORE LAYERS OF ROOFING MATERIALS ARE FOUND THAN INDICATED ABOVE IN THE ESTIMATE,THE
OWNER OF THE PROPERTY WILL BE IMMEDIATELY NOTIFIED,THE OWNER ACCEPTS ALL RESPONSIBILITY,AND
(AGREES)THAT,ANY EXTRA CHARGES WILL BE ADDED FOR THE LABOR AND THE REMOVAL OF THE EXTRA
DEBRIS,OVER AND ABOVE THE PRICE OF THE ESTIMATE....
NOTE.IF FINAL PAYMENT HAS NOT BEEN RECEIVED OR PAID IN FULL AT THE TIME OF
THE COMPLETION OF THE WORK, AS OUTLINED IN THE CONTRACT,AND RESULTS IN ANY
TYPE OF COURT ACTION.. THE OWNER OF THE PROPERTY OR CONTRACTOR OF SAID JOB.
OTHER THAN RAPID ROOFING COMPANY AGREES TO PAY ALL COURT FEES, ANY
ATTORNEY FEES,AND INTEREST OF 12%COMPOUNDED EACH MONTH.,ON THE FINAL
BALANCE OWED TO RAPID ROOFING CO.
ACCEPTANCE OF PROPOSAL
THE ABOVE PRICES,SPECIFICATIONS AND CONDITIONS
ARE SATISFACTORY AND ARE HEREBY ACCEPTED.
YOU ARE AUTHORIZED TO DO THE WORK AS SPECIFIED.
PAYMENTS WILL BE MADE AS OUTLINED ABOVE..
DATE OF ACCEPTANCE
SIGNATURE
SIGNATURE- a � C
SIGNATU
PLEASE MAKE ALL CHECKS PAYABLE TO
CHRISTOPHER R. COYNE SR.
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