21 PURITAN RD - BUILDING INSPECTION r-
The Cot nonwealth of Massachusetts
i y Board of Building Regulations and Standards R W
%It NICIP.V.I'IY
t Massachusetts State Building Code, 780 C'MR, 7"'edition PsF
Building Permit Application To Construct, Repair. Renocatz Or Demolish a Rci ivol.homm1% i
Otte- or T)tu-Famih, Dn e•lling 1. 'un,S
This Section For Official Use Only �}
Building Permit Number: Date Applied: Z O`U
Signature:
Building nunissiuner/ Inspector of Buildings Date
— _ SECTION 1: SITE INFORNIATION _
l Property Address: / 1.2 Assessors Nlap & Parcel Numbers
I.la Is this an acceptzd street? yes n(,_ Map Number Parcel Numher
1.3 Zoning Informati�� 1.4 Property Dimensions:
—_. _—``_ pmpo ed Use /Y) Lot Area is to Fronlaxe iit)
i Lam;r!:�g vi>,.r.ct
1.5 Building Setbacks (it)
j Front Yard Side Yards Rear Yard
Reuuired 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 yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. iO 1wner'of Record:
w _�
Name(Print) Address for Service:
9�P 7ys'-.sa6o _
Signature Telephone —
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
N'ew Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units__ I Other ❑ Specify:
Brief Description of Proposed W��ikt:
SECTION 4: .ESTMIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ /J 0l7 t. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier .x
3. Plumbing $ I
_. Other Fees: $
a. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount
(i rota) Project Cost: $ q ^^��
G /��� e.�(/ 0 Paid in Full 0 Outst:mdine Balance Due:____
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name o(CSI.- Mulder
Lot CSL'fype(see hcluwl —
\JJrns l'yPe Description
l- Unrestricted(up to 35,000 Co. 1'1.)
R Resuioed I:c'_ Family Dwellinc
Signature M Masonry Only
RC Residential Roohne Coserine ;
Trlephunc \b'S ResiJral Windups ,wd Sidwc
SF Residential Solid Fuel Bunting \111fliankc 1!le1,111MPtl1
D Residential Demolition _—
5.��r Registered H ie I t-W ent Contractor (111C) /L'/ „�.
/��M TLGFI on SLR l'O/1 - 7 --
HIC Company Name or HIC Regottrant Na ne �QO Registrtration Number
AAr-
�v�1dress ��
-4 _ �/ryf/ 's t.apuatiun Date
Signature Telephone
AN 'E AFFIDAVIT M.G.L. c. 152: 2�C(n))
SECTION 6: WORKERS' COMPENSATION iCVSUR C ( 4
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to prucide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... O No _._..... D
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
, as Owner of the subject property hereby
authorize to act on my behalf. mail mutters
relative to work authorized by this building permit application.
Signature of Owner ----- --- Date --
SECTION 7b: OWNFRt OR AUTHORIZED AGENT DECLARATION
i
as Owner or Authorized Agent hereby declare i
that the statements a d information tin the foregoing application are true and accurate, to the best of my knowledge and
be If.
Print Name
Signature of Owner or Authorized Agent
(Signed under the pairs and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to du his/her own work, or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor (HIC) Program), will not 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 730 CMR Regulations I IO.R6 and 110.115. respectively.
- When substantial work is planned, provide the information below?
Total flours area (Sq. Ft.) (including garage, finished basernent/attics, decks or porchi
Gross living area fsq. Ft.) Habitable room count _
Number of tireplaces Number tit bedrooms
Number of bathrooms Number tit halt/baths
fvpe of heating system Number of decks/ porches
Type of cooling system Enclosed
3. "Total Project Square Footage- may be substituted for "Total Project Cost"
—� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Workers' ('umpcnsa,liiin lnsuranre .lftidaxit: Builders/Contractorsi Electricians/Plumbers
� ) titian! Informrtion " `
Please Print Legibly
\.IIIIC �Hnaae,, t h;_.uu t.t❑,m InJn
/ TiPa o S2 C®/7
Wdre,,: a/S ICRona SO -
C'Ity tit:lte.Zip: l - r x!1 t/►1CiSS Of 4LI Ph 7f�
one 4:
tire sou an employer:' Check the appropriate box: Type of project (required):
j :,Ilia cnlploycr ss ith 4. ❑ 1 :un a general contractor and I 6. New construction
/�]� _
employees(full and'ur part-bole).• hale hired the sub-contractors 7. ❑ Remodeling
?.❑ I .uv a ,one proprietor or partner-
IutCJ on the anached ;heel.
.hip and have no employees these sub-contractors base 8. ❑ Demolition
ssorking for me in any capacity. wi,rkers' comp. Insurance.,, . ,'9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions '-
IeyWfCJ.] - Officers have Cxcrcised their ,-
f 1. Plumbing airs or additions h '
3.❑ I am a homeowner doing all work right of exemption per Iy1GL ❑ big re ddi
P --t
myself. (No workers' cutup. c '152, §1(4), and we have no 12.0 Roof repairsW
insurance required.] s employees. [No workers' 13.0 Other��•O/ ��O �•. ..,
comp. insurance required.]
•:\uy.�pphcam that checks btu NI must also till out the section below+hawing their workers'compensation policy information.
' I lomcuwners who submit this al'fidavd indicating they are doing all work and then hire outside contractors must submit ti new aftidtviD indicating such.
'('ontr.�cntrs that check this bus must it I,hod an additional.+heel showing the name ol'the sub-contractors and their workers'comp, policy information.
/nor an employer that is providing workers'compensation insurance jar my emplayres. Br/uw is the policy and job site
injonnulion. (Q .v
Insurance (*ompuny Name:
Policy X or Self-ins. Lie, a:41C- 7o/C 7.3 V01z ®05' Expiration Date:"5
J / City, :
Job Site ,\JJress:�/ ®�/��T4� �"' Y P 1� •s
number and expiration date).
page (showing the olio p
r declaration ( g policy.\ouch a copy of the workers' compensation poll p K
t 1 the imposition of criminal penalties of a
. . � '� e. 152 ears lead ( P
f-ailurr w .acute u,y�rage as required undo Sect
ion _5.\ of � 1(tL P
;oomo and'or one-year imprisonment. as well as ciyll penalties m the Corm of a STOP WORK ORDER and a fine
tines roS1.- .. -.
p
t,l tip to \2Jt1.IIQ .Igalll st IhC v IUIa lslf. lie ads IseJ that a CUpy of Ihli statement Inay he h)ryc afJeJ t0 Iht.l)If1cC-Uf
Ina>n_.m,t 1, of the I)1:\ 1,,r insti,aiwe oneragc ,cnlwanon.
/ Jn hereby rert( under the pains and penalties ,J perjury�that the in/imnutian provided abort i.% mre wed a orrect
Date
yyuure
U/Jirial use still•. Do not write in this area,is he a uurpleted by riry or rows oJJicial
( ins or fua it: _ . Permit/lAcense q . . __. ..—
Issuing \uthorin Icircle one):
I. Board of Ilcalth 2. Building Deparinlcnt 3. ('ih, Ilrssn Clerk 4. Electrical In
S. plumbing Inspector
b. Other - - - -- - - --- _._
('ontoctPerson: -- _- ------------ Phone Ill:—
_ --
Information and Instructions
i,cu, IJcneral I alv, ch.gncr I �' rryuue, .111 cngdoscr, to pro, iJc lsorkcrs cong,cn,.luon for their cmplovees.
I'm'o.utt to till ,(.nutc. .ul rntphrree I„Iel'.n.cd as ' c,ery person nt I r ,cn I,c of .0 1, ther under .IIt% .on tract of lure.
or inphcd. oral or \moan "
\:i o mfrlarrr i, &fMCJ .Is *.III :n,h,:Jual, raltr.enhip. .r,,ot:1.rllon. .orporation or oilier !ccal cnnty. or .up tsvo or inure
I IhC GncCoing cn_.rgeJ ul a joint eluclpr1w, and incluJule the Ie_al mirc•,cntatlsc, of-a lc,c.j,cd emploser, or the
or ou,lcC of an jndlt IJual. p.utncr,hip. a„oclatwn or other legal Ctuu}. cnlplo-%Inu elltplu,ees. I IUNe>er (lie
,..,:ter ,I I oA%Clllllg 1111r11C has ntg nol :norC th.ut three .Ip.trintcnu.nlJ ,sho reside, ILcrcln. or the occupant of the
,h,ci:ulg house of.ulot her ss ho en q,Ito, per,on, to do nett menace,e. construction or repair ,s ork on ouch ohs el l trig house
,,I m the __tounds or bolding appullCn.lnt theleto ,11.111 not hccau,c of ,u:h cnlplu,ntcn( be deemed it, he in cntphi.�er."
\H J. cb.tplcr 1>2. ,'SCiN also ,laic, that 'every .fate or local licensing agency ,hall withhold the issuance or
rencssal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has nut produced acceptable cv idence of compliance with the insurance coverage required."
\JJwonally. MGL chapter 152, �'S( I-I ,I.ttes 'Neither the conlnlunwcalth our any of Its political suhdiv t,lons ,hall
Cuter into any contract for the perforinutce of public lsork until acceptable C,IJOICC Uf CJIrlpltarlcC with the insurance
icquucmcnts of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the bores that apply to your situation and, if
necessary, supply sub-cuntractorts) nanlefs), address(es) and phone numbers)along with their certificate(s) of
insurance. Limited Liability Companies f LLC) or Limited Liability Partnerships(LLPI with no employees other than the
members or partners, are nut required to carry workers' compensation insurance. If an LLC or LLP dues have
employees,a policy is required. Be advised that this affidavit may he 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 returile'dtothe 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
,elf-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
ot'tire affidavit tier you to till out in the event the Office of Imestigations has to contact'you regarding the applicant.
Please he sure to till in thepermir,license number which will be used as a reference number. In addition, an applicant
That must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address" the applicant should write "all locations in (city or
toss n)." A copy of the affidavit that has been officially stamped or marked by the city or town iiray be provided to the
.Ippheant as prouf that a valid affidavit is on file fir future permits or licenses. A new affidavit must be tilled out each
y CAI-. Where a home owner or ciiiten is obtaining a license or permit not related to any business or commercial venture
H e. .I Jog license or permit to burn leases etc.),aid person is NOT required to complete this atfidavit.
I-he t mice of In,estigations tsould like nl thank you in advance tier your cooperation and should you have any questions,
rlca,c do nor he,it.rte to gtse us a all
I he I)cr.unnent': iddress, 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
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR"['NIENT
II I '/'Y 'J _ -i'1 '4= '/i J,,
Construction Debris Disposal Affidavit
(required lirr all dC1110litIUt1 :utd ronuvatiun work)
�i l t i t In accordance t t he sixth edition of the e State Building Cole, 780 Ch1R section 111.5
io "Debris P
and the provisions ns of .b iCiL c 40, S 54;
Building PC-Mil it is issued with the condition that the debris resultin- from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will lbe transported by:
(namc of hauler)
The debris will be disposed of in
�ynnwe4ij Tkans•►(�2 . S.�' rj
(name of Iacihty)
LYi1AWau .inn g2 g'4 5'
_7 I,ul/Ire„of ij 4L i v)
— V
,iguatwc ,/ prnnrt applicant
712 y16('
,fat
Page No. .._ w oT
WM. TRAHTAR GENERATOIONSROOFICNGON' INC
t t 215 Verona Street
LYNN, MASSACHUSETTS 01904 H.I. LIC. #141778
" (781) 844-4551 FAX: (781) 581-0855 i w�
PRO SAL SUBMITTE C/J.'
qE
it JOB NAME. >q
STREET 1 u r
JOB LOCATION '
CITY.STATE and DP CODE
Sa
�r f- We hereby submit specificationsand estimates for: ,• "- -� .� ,
.. x .,.
..,..We hereby submit specifications and
�. wr for rnRFR ROOF
ewlN[h�F ROOF
0 Sweep entire roof cl�`���-----=-- f
Lg Strip entire roof -
- — - §6 Strip entire roof ,, &.,
® >
Replace arty bad boards up to 100 linear feet #{ !
GIL
N Mechanically fasten down ISO board.insulation
• J8 Install ice and water_ barrier
arr e►first three feet up roof• Roofing on entire roof a r
d ll valleys and along, ormers W Install
( 'install ice an water 060 Rubber
--- in a---- -" Install metal'flashing around perimeter of building
Install 151b. felt paper on:remainder of roof
Flash chimney(s), pipe(s) and wall(s)2
Install eight inch drip edge'
Edge caulk.alf seams
W Install ridge vent ` - , ❑.Install new copper center drain I
RFiash or re-flash chimneys) IftA) LET 0 Other: _
j� Install new Pipe flanges, f r`'
k other IJ Clean up all debris
�Install 30 year shingle_C7
-. 'Labor and materials guaranteed 100%for five years
i nstail`gutters and downspouts
0 Install trim toll _
j 0 Install new fascia boards'
p Install new rake boards _—
•0 Install sky light(s)` _ --r ,
0 Other:
to Clean up all debris ---
R Labor and materials guaranteed.100%for five years
All shingle roofs are nailed by hand. C
er°)t — complete`in accordance
°se hereby to furnish material and labor with above specifications,�f/or�the/slum of:
a d ? . Total Price($
IF YOU ARE HAVING YOUR ROOF STRIPPED( PLEASE COVERALL VALUABLES IN ATTIC, AS (tJ f+ �uTl.l°PS T �a.
WE HAVE NO CONTROL OVER DEBRIS THAT MAY FALL THROUGH ROOF BOARDS. - 1O
All material is guaranteed to be as specified. All work to be completed in'a workmanlike Authorized
manner according to standard practices. Any alteration or deviation from above spec Mica- Signature
lions involving extra costs will be executed only upon written orders, and will become an g �
extra charge over and above the estimate. All agreements contingent Leon strikes.
insurance.ante.Our eliys workers are fully covered by workman'Co our control.Owner to carry mp Compensation insurance.
and r necessary
(Acceptance of Prapasa1—The above prices specifications
and conditions are satisfactory and are hereby accepted.You are authorized to. Signatures
do the work as specified.Payment will be made as outlined above
•� '-Signature
Date of Acceptance:
(lease mail yellow copy to above aderess.