18 PICKMAN RD - BUILDING INSPECTION The Commonwealth of :asasetts
Board of Building Regulatioandandards CITY OF
Massachusetts State Buildin80 CMR SALEM
Building Permit Application To Construct, enovate Or Demolish a RevisedMar 2011One-or Two-Family
This Section For Official Use Only
/t Building Permit Number:
Date pplied:
Budding Official(PrintName) ✓0 l .3
Signature Da
SECTION 1:SITE INFORMATION
1.1 Property Address: , \ 41.4
2 Assessors Map&Parcel Numbers
l.la Is this an accepted street?yes_ noap Number Parcel Number
1.3 Zoning Information: Property Dimensions:
Zoning District Pro sed Usep0 t Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
Front Yard Side Yards
Re
Required Provided Required Provided at Yard
Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: p t�
��. O Name(Peat) —�' _— r SC.7Vr—� / '
City,State,ZIP
No.and Street 4— Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altera[ion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work: $ c ;
. r_ C
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
abor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Fown Application Fee
3.Plumbing $
❑Total Project Cost'(Item 6)x multiplier x
2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees: $
6. Total Project Cost: $ Check No. Check Amount: Cash Amount:
❑Paid in Full ❑Outstanding Balance Due:
i
r
SECTION 5: CONSTRUCTION SERVICES
7-fNCS
pervisor License(CSL)
License Number Expiration Date
List CSL Type(see below),Z`S_,�� Type Description
�� \� �� 1 Unrestricted Buildin so to 35,000 cu.ft.
Crlyfl'own,State,_ZIP \ Restricted 1&2 Fame Dwellin
M Maso
RC Roofin Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
�_��� Insulation
i ele hone Email address I D Demolition
5.2 Registered Home Improvement Contractor(HIC)
W \\ ; �� mow. 1'5a_0 `k� -� ' g L
HIC Comport Name or HIC Registrant Name HIC Registration Number Exp ion Date
•NQNand Street,,,
1�. Email address
Cr /Town,St Z q — Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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 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
I,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.
Print Owner's Name(Electronic Signature) Date
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.
Iola
t �l1 _ ll / f
Print Owners or Authorized Agent's Name(Electronic Signature) Da
NOTES:
te
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.gov/oc Information on the Construction Supervisor License can be found at www.mass.gov/dr)s
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"maybe substituted for"Total Project Cost"
CITY OF SalLEM, NA SSACHUSETTS
BUILDING DEPART3tENT
i Ire 120 WASHIINGTON STREET, 3so FLOOR
T EL (978) 745-9595
FAx(978) 740-9W
K1%jBERf F_Y DRISCOLL TriOAtASST.PYE.RR6
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUfLDNG CO%NISSIONER
Workers' Compensation insurance Affidavit: Builders/(ontractorjElectricians/Plumbers
Applicant Information Please Print Legibltl
Vattle (BusinessOrganizariun.'Individual): y�.��
Address: "�:io rN-_, py-4--N,
I
City/State/Zip: kSLw M6-_ . _f\q_, b>h\ Phone
Are you an employer?Check the appropriate box: 'rype of project(required):
0711.am a employer with r"-) — 4• ❑ 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am n sole proprietor or partner-
listed on the attached sheet.: El Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
(Nok ice S. ❑ We are a corporation and its
workers' comp. to.❑ Electrical repairs or additions
?:gaited.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 l.❑Plumbing repairs or additions
myself. (No workers' comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. LN'o workers'
comp. insurance required.] 13.❑ Other
.Any upplic:mt slut checks box of most also fill out the section below showing their worker compensation policy infbrmation.
'I lumeowne"who submit this atridavit indicating ihcy arc doing all work and then hire outside contractors total submil a new afridavit indicating such.
=Gmmnx:uurs that check this box must attached an additional shect showing Lite mmne of the subcontractors and their workero'romp.policy information.
I am an employer that is providing workers'c•ontpensatiott inrurancefor my employees. Below is the policy and job site
;?,formation. Et, .N
Insurance Company Name:_
Policy 4 or Sclf--ins. Lic, tl: Jp�C.--'�Q'0��� Expiration Dater"dam
\^
Job Site Address: � ` City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
Fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
OF up to S250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of
Investigations ofthe DIA For insurance coverage verification.
I do hereby certify under due pains and penalties of perjury that the information provided above is true and correct.
4iercuure; Date:
I,
Phone d: _
i
- Official use only. Do not write itr this area,to be completed by city at town official
City or Town: _ Permit/I3cense
Issuing Authority(circle one)
1. hoard of Health 2. Building Department 3.Cilylrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
' h.Onier .._..-..-_,_
Contact Person: _._ _. Phone 4:
I — —
° CITY OF SAL.EM, NWSACHUSETTS
a BuELDLYG DEPARTMENT
130 WASHI.IIGTON STREET, 3}°FLOOR
TEL (978) 745-9595
F.kx(978) 740-9846
K1%fBERLEY DRISCOU
MAYOR TH0.%W ST.P1ERRs
DIRECTOR OF PUBLIC PROPERTY/Bi 12NIG COMMISSIONER
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 It 1.5
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 be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S I50A.
r
The debris will be transported by:
(name of hauler) ---8
The debris will be disposed of in
i
(name of facility)
%
(address of facility)
� s nature of permit applicantant
t
10
�O —
date
JcbrialCdx
+y-
IY E •.7 .
a�
" Shea Roofing Co.
17 % Foster Stree
t
Salem, MA 01970
(978) 745-7313
y'
PROPOSAL
SUBMITTED TO: John Davidson October 5,2013
18 Pickman Rd.
Salem, Ma.
We hereby submit specifications and estimates for:
To remove all existing roof shingles from complete main roof and garage.
To install ice and water shield on all lower roof edges, up all valle s
under all flashing points prior to re-roofing. Y and
To install asphalt saturated felt paper covering all roof boarding g prior to
To install all new metal drip edge along all roof edges, both horizontal and
vertical.
To install architectural (GAF or Certainteed ) roof shingles covering
complete roof as mentioned above.
To install up to 100 linear feet of roof boarding if necessary.
To counter flash, re-flash and/or reseal all s'fdewal
To install new roof flanges on roof vent pipes. Is as necessary.
To install new roof air vents as neccessary.
To counter flash and/or reseal the chimney flashings as necessary. If lead
flashing is too damaged on the chimney we I grind it out and re-lead at
an additional cost of$350.W \ \5 `�
To clean up and remove all roofing debris from job site.
! We propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
Eleven Thousand Eight Hundred and Eight Five---------Dollars ($11,885.00)
Payment to be made as follows;
One Third to start balance upon completion.
All material is guaranteed to be 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 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.
Acceptance of Proposal—you are a thori ad to do the wor
specified.
Authorized Signature:
Signature:
Date of Acceptance: '�Q