12 RIVER ST - BUILDING INSPECTION (2) �v
CITY-OFS-AL
PUBLIC PROPERTY
DEPARTMENT
KI\WFAEY DWCOLL
MAYOR 120 WwSH1r4G W b7n 8 ♦"LEK%AAACH St'19S 01970
'!Vi 978-745-9595*FAX:978-740-98"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION.
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY EXISTING
STRUCTURE OR BUILDING
iA SITE INFORMATION
Location Name: Building:
Property Address: j 2 {�; vpX :S . ScQ ion
Property is Located in a: Conservation Area Y/N Historic Diahi Y N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address: St
CN
Telephone: -) _ 2
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
St P Cl r-e. - rov
-- — Mail Permit to:
What is the current use of the Building? �
Material of Building? If dwelling, how many units?
Will the Building Conform to Law? Asbestos?
Architect's Name
Address and Phone t
Mechanic's Name
Address and Phone�� � n a+_r___-��%�C fi � ^ C Q 1 T 9 7-7 F
Construction Supervisors License# HIC Registration# Z
to
Estimated Cost of lect p Q �(7 Permit Fee Calculation
Permit Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penally of perjury X
Date 1(�/�('
of
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CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KnaWJLWn.naou.
HAVM 120 WAMUIiGT M Sft=0$MEK XXISAO&SUM C,970
n=M743.9395•PAZ M74e•9846
Construction Debris Disposal Aftldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code.780 CMR section it 1.3
Debris,and the provisions of MQ.c 40,S Sop
Building Permit 0 is issued with the condition that the debris resulting ftom
this work shall be disposed of in a properly licensed waste disposal fkeility as defined by MGL c
I It.S 130A.
The debris will be transported by.
1a,) vx yair.l -e , C�L�k (-uC��
(same athsute0
The debris will be disposed of in: l
(name of facility)
- Qn cLt
(addrms of facility) OCIL/ I
sisaatu9 o pemLt apviicaat
dam
i
CITY OF SALEM
PUBLIC PROPRERTy
DEPARTMENT
KIMBERIYY DRISCOLL
MAYOR
120 WA'HMTON STREET a SAL cu,lyASSACIjUSEM 01970
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/plumbers
ADDHeant Informatio
1 Please n Le
Name(Busiaeworgan;mtio✓iedivi&w): l� -
FQ
Address:
City/State/z. D 14 7 Z Phone#: _
F2.0
u an employer?Check the appropriate box:
m a employer with 4. ❑ I am a general contractor and IType of project(required):
ployees(full and/or part-time).• have hired the sub-contractors 6. ❑New construction
m a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodelinp and have no employees These sub-contractors have g
rking for me in any capaci . workers' 8. ❑Demolition
tY co . ins
rap urance.o workers comp. insurance 5. (] We are a corporation and its 9• ❑Building addition
3.
required.) officers have exercised their 10.❑Electrical repairs or additions
I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing
myself.[No workers'comp. ri 152, §10).and we have no g repairs or additions
insurance ngd7 t 12
employees.[No workers' Roof repairs
A comp. insurance required] 13.0 Other
=• iry appaeant that checks box MI mua atao all out the section below abowieg rhea vrorlten'contPmsatiou
Hmneowms who submit this a8ldm Indicating�,an doing an work and thin hire muide con information
Contractors that check this box mist attached ao,"tiood sheet showingthe tractors mum attbmit s O0A'+�davit fodicatlog inch,same of the sub-eonsaeton yW their workers'comp.policy infwmsdoa
I am an employer that Is providing workers'compensation Insurance for my employees. Below Is the policy andJob she
information, n Insurance Company Name:_ 1i CA t—} �O �d l t, C l
Policy#or Self-ins.Lic. #: N C s �j �l Q
Expiration Date: /7 2-
Job Site Address:���
City/State/Zip:
Attach a copy of the workers*,compensation policy declaration page(showing the policy number and expiration date)6
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal
ties ofine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDp ER and a f 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 a
Investigations of the DIA for insurance coverage verification
I do hereby cerrmO under the pains and penalties of perJury that the information Provided above is due and coned
Si2naturc,
D
=Other
only. Do not write in this area to be completed by city or town offlclaL
n:
Permit/License#
hority(circle one):
I. Health 2. Budding Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
son
Phone#:
information and instructions for then employees
ter 152 requires all employers to provide workers compensation
person in the service of another under any contract of hire.
Massachusetts General Laws chap ,
Pursuant to this statute,an employes is defined as"...every lx
express or implied,oral or written."
o er is defined as"an individual,partnership,association.corporation or ocher legal entity,or any two or more
ed in a joint enterprise,and including the legal representatives of a deceased employer, v the
An empl y cmHowever the
of the foregoing engag partnership,association or other legal entity,employing employees.
receiver or trustee of an individual,p than three apartments and who resides therein,or the occupant of the
owner of a dwelling house having not more Lion or repair work on such dwelling house
who employs Persons to do maintenance.construc be deemed to be an employer."
dwelling house of another thereto shall not because of such employment
or on the grounds or building appurtenant
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the thfor ere or
operate a business or to construct buildings is the commonwealth for ny
renewal of a license or Petask to table evidence of compliance with the insurance coverage requrired
applicant who has not produced acceptable norof its litical subdivisions dull
Additionally,MGL chapter 152,§25CM states"Neither the commonwmeelle�vidence of compliance with the insurance
enter into any contract for the performance of Public work until ingacc a
Presented to the contracting authority."
requirements of this chapter have been p
Applicants 1 to our situation and,if
it completely,by checking the boxes that apply Y
Please fill out the workers' compensation affidav address(es)and Phone numbers)along with their certificates)of
Supply sub-contntctor(s)name(s), Parma
rsbipa(LLP)with no employees other than the
necessary. Limy Companies(LLC)or Limited Liability
insurance. Limited
bility e not required to carry workers' compensation insurance. If an LLC or LLP does have
members or p q�t re Be advised that this affidavit may be submitted to the Department of Industrial
employees,a policy is re Also bet may
to sign sad date the affidavit The affidavit should
Accidents for confirmation of insurance coverage.
be returned to the city or of
town that the application for the permit or license is being requested not the.Department
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- Seif-insured comPantea should enter their
self-insurance license number on the line.
a
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Deparnne°t has Provided a space at the bottom
the applicant.
number which will be used as a reference number. In addition.an applicant
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding PP
Please be sure to fill in the permit/license given year.need only submit one affidavit indicating current
le rmit/license applications in any y ci or
that must submit multiple Pe under"Job Site Address"the applicant should write"all locations in ( tY
policy information(if necessary)
and ed or marked by the city or town may be provided to the
- town)."A copy of the affidavit that has been officially stamped Permits or licenses Anew affidavit must be filled out each
applicant as proof that a valid affidavit is on file for future
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
ea a dog license a permit to bum leaves etc.)said person is NOT required to complete this affidavit
and should you have any questions,
The Office of Investigations would like to thank yo
u in advance for your cooperation
please do not hesitate to give us a can.
The Department's address,telephone and fax number
The Commonwealth of Massachusetts
Depart MW of Industrial Accidents
Offiee of Invesdgtttions
600 Washington street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass-pv/d1S
NORTHSHORE ROOFING & SEALCOATING
281 Andover St. Danvers,MA 01923
(978)977-3816 Fax:(978)762-4667
Mrs. Elizabeth Nugent 09/29/06
12 River St.
Salem , MA
(978) 740-2443
The following is to be completed :Apply a single-ply EPDM rubber roof system on the two flat dormer roofs .
1)Remove the existing roof systems down to the bare roof deck and legally dispose of the debris .
2)Replace any deteriorated roof decking up to 50 sq.ft. if and where needed at no charge.
3)Re-nail any loose roof decking if and where needed .
4)Apply%2-in.high density fiberboard insulation which will be mechanically fastened .
5)Apply EPDM rubber membrane .060 60 ml.which will be fully adhered .
6)Re-flash all penetrations with uncured membrane .
7)Apply heavy gauge aluminum flashing.032 around the entire perimeter of the roof.
8)Remaining pitch roofs will also be stripped down to the bare roof decking .
9)Replace any deteriorated roof decking if and where needed up to 50 sq. ft. at no additional charge .
10)Apply 6-ft.of ice and water barrier around the perimeter of the roofs.
11)Remaining exposed roof decking will be covered with 30-lb. asphalt roof paper.
12)Apply new aluminum flanges over all vent pipes .
13)Apply 8-in. aluminum drip-edge flashing around the entire perimeter of the roofs .
14)Apply a 25 year premium three tab asphalt roof shingle(color: charcoal)as required by the historical committee.
15)All roof related debris will be legally disposed of by North Shore Roofing.
16)Five year warranty on workmanship,twenty-five year manufacturers warranty .
TOTAL PRICE : $6,750.00 *Includes roof permit*
PAYMENT TERMS
1/3 DEPOSIT REQUIRED: $2,250.00
BALANCE DUE UPON COMPLETION: $4,500.00
„Acceptance of Proposal
l--By signing this proposal you have accepted all of the terms as stated above .
Date of Acceptance_%�_� Home owner
r
N.SA
Pet;Mr
[ember of the Better Business Bureau Mass.Reg.#128691
ACORD -CERTIFICATE OF LIABILITY INSURANCE 10/ o/l DATELI10/2 o YOS
PRODUCER (978) 745-6464 THIS CERTIFICATE IS ISSUED AS A MATTER of INFORMA O
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
66 Coning Avenue ALTER THE COVERAGE AFI.ORDEO BY THE POLICIES BELOW.
P.O. Box 958
Salem td!1 01970- INSURERS AFFORDING COVERAGE NAICIF
INSURED ANFKRERMaTaukilus IRS LiG.
North Shore Roofing INSURER 8:Hartford
281 Andover Street INSURER C:
NBUR O:
Danver6 SA 01923- INWRERE
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW WAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POUCV PERIOD RIDICATED.NOTVWMSTANOWO ANY
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO VkNICH TMS CE FMFTCATE MAY BE ISSUED OR MAY PERTAIN,
THE INSURANCE AFFORDED BY THE POLICIES OESMBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE UMITS SHOWN MAY HVAVE BEEN REDUCED BY PAID CLAIMS. _
R DD'L POLURIFECTTVE POLICYEAFRATION
LTR NERD TYPE OF INSURANCF. POLICY NUMBER DATE(HUN IYV DATEROWOON'YI LOUTS
A GENERAL LUUUTY / / / / ,:ACH OCCURRENCE C 900,000
E MMEflCWI GENERAL LIABILITY pARFYI i Ba�oNeei,rO,la o 300,000
X CLAWS MADE LJ OCCUR 00434410 OS/24/2006 05/24/2007 vIED EI[PI ono I•wn • 51000
PERSONAL S ADV INJURY I 500,000
/ / / / ::ENERAL AGGREGATE S 1,000,000
GENL AGGREGATE LWRAPPLIEB PER: >RODUDTS-COMPIOPAGG F 1,000,000
POLJCV JFR.Co-T
AUTOMOBILE LIABILITY / / / /
COMBINED SINGLE LIMIT
ANY AUTO i Elm xWPNj I
ALL OWNED AUTOS / / / / iIMILY INJURY
WHEDULED AUTOS I-MI IW11O^)
HWEDAUTOS / / / / I,!KHLY INJURY
NON-OWNED AVIOS 1�01P¢Ww0
ROPERTY DAMAGE
GARAOELUMLITY 0IND ONLY-EAACCIDENT 0
ANYAUTO / / / / OTHER THAN EA ACC 4
LLITO ONLY: AGO
E%CWSWNIRM-A LIABILITY / / / / FACH OCCURRENCE I
OCCUR �CIIUMS MADE I:*REGATE 0
•
OPOUCTIBLE
RETENTION S I
8 WORKERS COMPENSMNII AND SC5425394 07/25/200E 07/25/2007 ]I,' TORYLIUIS SR EM VERE LIABILITY
ANY PROFRMFTORIPARTNER/EAECUTIVE E I..EACH ACCIOSNT • 100,DD0
OYIN.IN M"N.,XCLUOC�T / / / / EA.DISEASE-FA EMPLOYE • 100,000
IT YIN.d•PRO WEPT
SPECIAL PROVIbIDNB I OASEgBE-POLICY LWR a 500,000
OTHER
DESCRIPTWN OF OPERAT0NSN,OCATIONSNENICLE5M=LU2IONS ADDED BY ENDORWINUNTIBPECML PROW&ONE
Roofing
Job Loaation:12 RSYes street BSA,,, ML 01970
CERTIFICATE OLDER CANCELLATION
(978) 762-4667 ( ) SNOULD ANY OF ENE ABOVE mwll:mm POLICIES Be C1.NCELLEG BEFORE ME
SO RATION DATE THEREOF, THE W&U NG MSMIM WILL ENDEAVOR To MAIL
30 DAYS WRmEM NOME TO THE CeNTIFKJATE HOLDER NAMED TO THE LEFT,BUT
W• and mcm• Nugent FAILURE TO 00 80 SNALL IMPOSE NO OMUGJATIOY OR L40k1TY Of ANY HIND UPON TNR
INSURER,RS AGENTS OR REPR2NeNTA1'NM
AUT,!r!3r AEPR23CWATNE
%% /I' I
ACORD 25(2401108) 0 ACORD CORPORATION 1988
�,r INS0261DIMLDs ELECTRONIC LASER MANG,INC.-(MG) "O PAq•I 02
L0/L0 39Vd ON39V 301,4nnSNI 3S08 98ELSDL8L6i 91:60 9001/01/01