1 PLEASANT ST - BUILDING INSPECTION 3�I The Commonwealth of Massachusetts
O� Department of Public Safety
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
_ (This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
, O
No.and S City/Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review: red( � Yes ❑ No ❑
Brief Description of Proposed Work: S't' 6' :red(,,.
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): I Proposed Use Group(s):
SECTION 4 BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H4❑ H-5❑
I: Institutional I-1 ❑ I-2❑ I-3❑ 14❑ M: Mercantile❑ R. Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ HIA ❑ IIIB ❑ 1 ry ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information Sewage Disposal: Trench Permit, Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
or
Private❑ or indentify Zone: or on site system❑ required❑permit is enccll trench or specify:
osed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler Sysbem?: Special Stipulations:
y ` SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner (� + _\
Sc.�gvw \ ��l Com/)w �0
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
W ,Ny ew,. � 01s t-� l go%-""
Name Regislr t) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address 5p`rJ City/Town State Zip
Telephone No.(business) Telephone No. celle-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT M.G.L.c.152§25C(6))
A Workers Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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
Is a signed Affidavit submitted with this application? Yes❑ No 13
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)
1.Building $ iE`A 40 _ Building Permit Fee=Total Construction Cost x)-�—(Inse e
2 Electrical $ appropriate municipal factor)_$ (0
3.Plumbing $ ff-))1W
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipa
5.Mechanical Other $ Enclose check payable to CN'A '3� SS✓�ti�
6.Total Cost $ municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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. ,
441
Please print and sign name Title Telephone No. Date
Street Address City/Tow State ip
Municipal Inspector to fill out this section upon application approval: all
Name Da
Shea Roofing Co.
17 '/Z Foster Street
Salem, MA 01970
(978) 748-7313
June 25,2012
PROPOSAL
SUBMIT1Eo 7O; Salem Music School
117 Bridge Street
Salem, Ma.
We hereby submit specifications and estimates for:
To remove all existing roof shingles from complete main roof, rear
extension roof and bulkhead roof.
To install ice and water shield along all lower roof edges and along all
flashing points prior to re-roofing.
To install asphalt saturated felt paper covering all roof boarding prior to
re-roofing.
To install all new metal drip edge along all roof edges, both horizontal
and vertical.
To install architectural (GAF Timberline Lifetime High Definition) roof
shingles covering complete main roof, rear extension roof and rear
bulkhead.
To install up to 100 linear feet of roof boarding if necessary.
To counter flash; re-flash and/or reseal all side walls as necessary.
To install new roof flange on roof vent pipe.
To counter flash and/or reseal the chimney flashing as necessary. If lead
flashing is too damaged on the chimney we will grind it out and re-lead at
an additional cost of$350.00.
To re-flash, counter flash and/or reseal both rear skylights as necessary
To install new Cobra ridge vent along main roof ridge.
To clean up and remove all roofing debris from job site.
The new roof is guaranteed for five years against any problems created
by faulty workmanship.
Wa propose hareby to fWnish material and labor-complete in amoreano--rrith above specifications,to the sum oe
Five Thousand Four Hundred -----------------------------Dollars ($5,400.00)
Payment to be rade as follows;
Upon completion
Alt material is guaranteed to he specified. All work to be completed in a workmanlike manner according to
standard practices. Any alteration or deviation from above Specifications irrvolving extra costs will be executed
only upon written orders,and will become an extra charge over the estimate. All agreements contingent upon
strikes,accidents or delays beyond our control. Owner to carry fire,tornado and other necessary insurance.
Our workers are fully covered by Workman's Compensation Insurance.
Acceptance of Proposal-You are au:h orized to doalle wDrk aspecified. -
AuthorizedSignature:
Gate of Acceptance: �
01 fir[: r _
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
ffidavit: Builders/Contractors/Electricians/Plpmbers
Workers' Compensation Insurance A
Applicant Information Please Print Legibly
Name (Business/Organization/individual):
Address:
City/State/Zip: Phone #:
Are you
you an employer? Check the appropriate box: Type of project(required):
1/171'1 am a employer with '),L, 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees These sub-contractors have g. ❑ Demolition
working for me in any capacity. employees and have workers' 9. ❑ Building addition
[No workers' comp. insurance comp. insurance.$
required.]
5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
right of exemption per MGL 12. Roof repairs
myself. [No workers' comp. P
insurance required.] t c. 152, §1(4), and we have no .
employees. [No workers' IA1 Other
comp. insurance require .1
*Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contactors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. -
Insurance Company Name: O �
Policy#or Self-ins.Lic.#: V 1 00 �� � �� Expiration Date: `� �7
Job Site Address: City/State/Zip: �Ie_v..
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 of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the,form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under t pains and penal 'e�f perjury that the information provided/above is true and correct.
Signature: f`Ht r Date: b ds—
Phone
I \�
Phone# br, .i iia-
Official use only. Do not write in this area,to be completed by city or town offrciaL
City or Town: Permit/License#
7Issuing Authority(circle one):
1.Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector.5.PluEio
6.Other
Contact Person: Phone#:
CITY OF S.U.&%1, .' LNSSACHUSETTS
• BUILDING DEPkRTNlE2NT
si -i
130 WASHINGTON STREET, 3"0 FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
1CIJffiERL.EY DRISCOLL
MAYOR T Ho&w ST.PIERRe
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSSIONER
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# 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 :
(name of facility)
(address of facility)
signature of permit applicant
dati