0009 SALT WALL LN - BPA-15-277 A -1-11 0*0
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One- or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: Date Applied:
N Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATIONITI
1.1 Pr erty Address: 1.2 Assessors Ma &Parcel Numbers a
m
it 1.1 a Is this an accepted street?yes_ no Map Number Parcel Number — =1
m
I� 1.3 Zoning Information: 1.4 Property Dimensions: Dr T10
1 Zoning District Proposed Use Lot Area(sq III Frontage(fl) C?P
1.5 Building Setbacks Tt) CD
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 wner'ofLIM Recu N.- -SoiJ( r �O
Name(Print) City,State,Zl V
N .and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin wner-Occupie Repairs(s) Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specity:
Brief Description of Proposed Work2.
Lkl
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ ! 1. Building Permit Fee: $ Indicate how fee is determined.
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x inultiplier x
I Plumbing $ 2. Other Fees: $
4. Mechanical (BVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees $
I /I d� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ t l 000 v ❑ Paid in Full ❑ Outstanding Balance Due:
SG JT 'To CONT • LA /I '1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /1ac-t-I& cr
CL1\Jib b , ` License Number Expnauon DateDate b
Name of CSL Holder
n M Lpu n ^W✓nl� List CSL Type(see below)
No. and Street V Tye Description
C)M( Unrestricted2 Family
(Buildings u el ing cu.ft.
3 U — R Restricted I&2 Famil Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
r :��— ^��� SF Solid Fuel Burning Appliances
I Insulatio
mai n
Telephone El address D Demohtion
5� Rggistered Home Improvernscit Contr ctor(l-ld(C) q-pir t /te
HIC Registration Number Expir [ikon Date
c pi IC Am n N e or H G.Rs rant
� .andp f C ' eSi Email address
OJAA �
City/Town,State,ZIP 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 Gbl- -1 h &tc(�Lt/v
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's➢ ame(Electronic Signature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
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. I42A. Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www,mass.gov/dps
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 halfibaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
it
CITY OF S.U.EM INLkSSACHUsETTS
BuMDT,NG DEPART\lENT
M 130 W.\SHINGTON STREET, 3w FLOOR
TEL. (978) 745-9595
FAx(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR THO\tAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BCII.DrNG CONMSSIONER
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:
(na re of hauler)
The debris will be disposed of in
(name of facility)
r
(addreO of facility)
signature of permit applicant
date
dcbn,of f.doe
Offices: I i 1 t
383(Rear)Lowell Street,Suite 2G 6'�0Wakefield,MA 01880 pot
`°`
"fel. 617-571-9056
e PETER RYA
"1 352 Main Street,Suite 3C
and 9A Gloucester,MA 01930
�! Inc. Tel: 978-559-7333
ROOFING, nc rustw.PeterRyanAndSon Roo fing.com
Submitted To: lob location:
Stanley Burba
9 Salt Wall Lane 9 Salt Wall Lane
Salem, MA 01970 Salem,MA 01910
Phone# 978-744-7532
Email: None
Proposal dote: April 9,2015
We are pleased to hereby submit this proposal to furnish materials and labor,completely in accordance with the below specifications:
(Additional charges may apply for any change's not included below in proposal either by request of owner, at-if Peter Ryan and Son Roofing finds
unforeseen circumstances that will affect the performance, quality or integrity of this job). In the event legal action is taken to enforce any provision of
this agreement, the prevailing party shall be entitled to all its reasonable costs, including reasonable in-house or outside anorney's fees.Not responsible
for debris in attic. RUE K
11
Strip entire roof to hare wood and re-shingle: $11A00.00
• Strip existing shingles down to bare wood
- - - Check for rotted wood on roof decking,and replace as needed
• Nail down any loose wood
• Install ice&water shield to first 6-feet,and in all valleys and around any protrusions
• Install premium synthetic underlayment(in place ofstandard 301b.felt paper)
BBB, Install all new 8"white drip edge on perimeter and step flashing,where needed
• Install manufacturer suggested starter course of shingles
• Install IKO or GAF Lifetime/architectural shingles in color of your choice
• Install ridge vent
• Cap ridge vent properly with manufacturers suggested cap(GAF Timbertex®or IKO Hip&Ridge 12)
• Properly flash any protrusions and all new pipe flanges,ifany on roqf
Clean Up:
• Will cover area with tarps to minimize debris and remove debris related to work
• NOTE: Please cover any belongings in the attic,as they will get dusty,ifapplicable
PAVMENT�TERMS
COStdetBllS. (Includes cost of ermit,labor,dum &°material ? iEPaVMeniSChedule.o(rin; . r«a",
1't payment due upon signing: $3,000.00
Total Cost: $11,000.00 Total balance due upon completion: $8,000.00
Kindly remit payment to"Peter Ryatt". Thank you!
Respectfully Submitted by: — Accepted hY. JA
Our craftsmanship is 100%gua anteed a 10-years. AI t warrantees are through the manufacturer.All warranTe6s will be nut&void if job is not paid in full.
Peter Ryan and oofing,Inc.License#178871 --"thank you for letting us serve you!!!
cc: Peter/Leo
The Commonwealth of Massachusetts
{ Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
www.ntass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ` J Please Print Legibly
Name(Business/Organization/Individual): ( a),/', �
Address: V�� w Lam,
City/State/Zip: { v d t Phone#: �
Are you an employer? Check the ppropriate box: Type of project(required):
1 V4�n a employer with &12 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
listed on the attached sheet. 7. ❑Remodeling
2. I a sole proprietor partner- These sub-con&actors have
ship p and have no employees 8. ❑Demolition
wor}ing for me in any capacity. employees and have workers' 9,
Building addition
o workers' co insurance comp.ihsurance.t
re comp. 10. Electrical repairs or additions
required.] 5. Q We are a corporation and its
3. I am a homeowner doing all work officers have exercised their 11.❑ Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL 12.0 Roof repairs
insurance required.]t c. 152, §1(4),and we have no 13.❑ Other
employees. [No workers'
comp.insurance required.]
*Any applicant that checks box Nl rrustalso till out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then him 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-contractors have employees,they must provide their workers'comp.policy number•
I ant an employer that is providing workers'contpensation.insurance for my employees. Below is the policy andlob site
information. �� Ito
Insurance Company Name:Policy#or Self-inns.Liicc._#.r, % � Expiration Date:
Job Site Address:/ ..YGIM ul �t y� 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 of criminal penalties of a
fine up to S 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 the pains and penalties ofperjury that the information provided above is true and correct.
Stcnature. `J^ �A /\� Date.
Phoned
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5, Plumbing Inspector
6. Other
Contact Person: Phone#:
CS License: #CS-I04865, Expires 07-0I-20I6
Massachusetts -Departmentof Public Safety
Board of Building Regulations and Standards
construction.Su purrism. .
f_icensw CS•104WS
.
CLINTON A GALYIN
229 Vernon StrceC QQQ s
Wakefield MA 0 980
Expiration
Commissioner 07/0112016
HIC/Clinton Galvin, #I752JI3,/Expires May I, 20I5
' I�� ( !.)!//.If I f!`t/I(/)r f /f f! (!Cl/!/i4✓f�
„_. Otace of fOnsumcr Aftalrs 3.Dullness Regale I!or
IMPROVEMENT CONTRACTOR
agistration: 1762.13 Type:
� &PIration: 611/2015 Corporation
EMPIRE 1 HOME IMPROVEMENTS
CLINTON GALVIN
95AUDUBONRD#315 ✓�'«s-�., =
WAKEFIELD,MA 01880 Undersecretary
HIC/Peter Ryan: #178871,Expires May 28,2016
� Oft'ice of CuasaamP ACtairs�'11UvVness RcJ,nkitian
py „�pMEIMPROVEMENT CONTRACTOR Type:
c!S glatratfon: 178071
xpiration: 6128i2015 Corporation
PETER RYAN&SON ROOFING,ING..
PETER RYAN
383(REAR)LOWELL ST.SUITE 2_ ,r,�;,d,....�..✓�- .-.
QJAKEFIELD,MA 01800 1 'nde -cCr to ry
�I
AUMORIZATION FROM CONrRA-CTORS FOR SECCOM,PARTES TO
PULL PERMITS'
COWANY c.UII
fi7t-
DATE
To whom it may conomc,
to:pnll'pennits for this company my H
Siguaila�e:
Prmtedr 1.=J�
Notary
Comm
J