52 SCHOOL ST - BUILDING INSPECTION (2) The Commonwealth ol'Massachusetts
Board of Building Regulations and Standards CITY
t�• ,n OF SALGM Massachusetts State Building Code. 730 CMR. 7 edition Revised JUMlllrl'
Building Permit Application TO Construct, Repair, Renovate Or Demolish a
f l One-or Tuo-Family Dwelling
This Section For Official Use Only
v\ ► Building Permit Nutr6cr., I Date Applied: l
Signature: 2Le2�'.
13uilding ommissioner/Inspeclorof Buildings
Date
SECTION 1:SITE INFORMATION
1.1 Pr2 Address: ll cZ y., 1.2 Assessors Map.4t Parcel Numbers
y `� Jc.hn�l 3'r
I.I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
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:
Zone: _ Outside Flood Zone'? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes[] P P y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: U
�11a..n�DZt'
Name(Print) Address for Service:
Signature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work--:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lcial Use Only
Labor and Materials
I. Building S I. Building Permit Fee: $ Indicate how tee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List: /
5. Mechanical (Fire S Total All Fees: $
Su ression
1 Check No. Check Amount: Cash Amount:
6. Total Project Cost: S__'N% 6 l�J ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
W• 1\\ c . S License Number Ispimlion I Lie,
Name of CSI.- I[older
List C'SL-Type(see be ow)--% �
Address, % Description
t
d Al,'l.(fTy` �-". l InrestricteJ a to 35.000 Cu. Ft.)
Restricted 1&2 Family Dwellin
Signature N1 \1asonry Only
cl-li<— Rc Residential Roofing Covering
I"clephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
U Residential Demolition
5.2 Regist\ed Home Ina rovement Contractor(HIC)
�` U
I IIC Company Nam or f IIC 2egistrant Nam, Registration Number
Address
(;1tS/i1��/) n 'J� b Gspi tion Date
Signature T—elet- one --/—�^
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 ...........a No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, , 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.
Signature of Owner Date
SECTION ii7b: OWNEW OR AUTHORIZED AGENT DECLARATION
II v (� M.� S 1^'�p.h ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. I S I
, l C.w.
Prim Name
Signature of Owner or Authorized Agenl Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115. respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) flabitable 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"may be substituted for"Total Project Cost"
Shea Roofing Co.
17 % Foster Street
Salem, MA 01970
(978) 745-7313
, 4vt1 y
PROPOSALr [A (C November 19,2009
SUBMITTED TO: / 41�`F
57 School-street
Salem;Ma. (Q r J qq e J�
We hereby submit specifications and estimates for: L�
To remove all existing.roof shingles from complete main roof.
To install ice and water shield covering (3) feet up from all roof edges, up
all valleys and along all flashing points prior to re-rooting.
To install all new metal drip edge along all roof edges, both horizontal
and vertical.
To install architectural (30 year windseal) roof shingles covering
complete-main roof.
ou a gu 1190 and downspout systems to insure efficient
drainage.
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.
We propose hereby to f imish Material and labor-complete in accordance with above specifications,for the sum of. .
Seven Thousand Eight Hundred and Eighty Five-Dollars ($7,885.00)
Payment to be made as follows;
Upon completion
All material is guaranteed to be specified. All work to be completed in a workmanlike manner according to
standard practices. Any akeration or deviation from above specifications Involving extra costs will be executed
only upon.written.orders,and will.become an extra.charge over the estimate..Altagreements-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 authorized tq c o the work as specified.
Authorized Signature:
Signature: f�j / . /
Date of Acceptance: 10 ho
w
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
vl]Ii IN Il:WAt111Xci l US 511 ELT • SA EM, M.\]1.\I:I It ]I.'11s0197�
fr.l.:978.715-9595 • P.\x. 978.711'-1846
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
t ylicant Information Please Print LeeihlY
Name Ulll'InCss Organintio Vlndtvuluuq:�\\\_I C Vv� „� Q
Address:
City;St:ttci/.ip �— �� I'hune if: S "lSS ���
Are you an employer'!Check the appropriate box: Type of project(required):
I.y�,l :lilta employer with `I 4. ❑ 1 um a.-cneral contractor and 1 fi. ❑ New construction
/ unploycex(full and/ur parr-Hula). have hired the sub-contractors 7. ❑ Remodeling
?❑ I ant a sole proprietor or partner- listed on the attached sheet. *-
.ship and have no employees These sub-contractors have 8. ❑ Demolition
working tier me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers'comp. insurance 5. ❑ We are a corporation and its
I R 10.❑ Electrical repairs or additions
required.] otTiecrs have exercised their
right of exemption per MGL I LE] Plumbing repairs or additional
3.❑ I um a homeowner doing all work S P P' ,
myself.(No workers'crnnp. c. 152.g 1(4),and we have no 1 Roof repairs
insurance required.) t employees. INo workers' I J11Glhor
comp. insurance required.]
-sjsy apphcauL oral checks bra rat must also lilt uul the w aiun Wow slwwilig iheir w•o,kas cvnipensmioli pulicy infurnuliun
' I lumcllwners who and mil this affidavil indiuling Ihey arc doing all work a„d then him outside commcton maar auhmit a new mill avia indic:aing such.
•C,mtrteuas that check this box must anwhod.ln additional.chvet shuwiug the nmlw of the sub-eonlrMIOM and their workers'comp.policy inrurmatiun.
l tun an euyluyer shut it providing Ivbrkers'cuntpensatinn insurance fur oty employees. Below is the policy and job site
infurmution.
IlnuranceCompanyName:
Policy µ or Self-ins. Lic. Expiration Dates Q - k �
Job Site Address: city/State/zip:
Altach it copy of the workers'compensation policy declaration page (showing; the policy number and expiration date).
hailurc to secure coverage as required under Section'_5A ul':LIGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 fine
of up to S250.00 a day again st tilt violator. Be advi.Kd that a copy of this statement may be l.urwarded to the Office Uf
III\'ealhallnns UI Ihu DIA IUr Insurance coverage seritieation.
l do hereby terrify under the poi s,utd pe I Iri's o perjury thut the infurnnuNon provided above is trot oral correct.
1 P•:IIII III C' _ . W ; 1)afe
rhl •:,: 9 D
Ufliciul use only. no not write its this area, to be cwapleted by city or town ojjicial _
City or fawn• _._ Permit/License d__
Issuing,\ulburily (circle one): i
1. Berard of He:dth 2. Building Dcpartulcut 3. Ciq'i forsu Clerk 4. Electrical lospcefor 5, Plumbing Inspector
b. Other .__.
(',i alaol Tetsuo: __ .. Phocte 7:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for theircntployees.
pursuant to this ,tatute, an employee is defined as "...every person in the service of another under any contract of hire,
espress or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
.d the foregoing engaged in ajoint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee ul :m individual, partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
SIGL chapter 152. §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewul of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary, supply sub-contractor(s) name(s), address(es)and phone number(s)along with their certifrcate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
:-Xccidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he returned to the 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
self-insurance license number on the appropriate line.
City or'rown Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
Of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permitflicense number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit'licetue 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
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or pennit not related to any business or commercial venture
(i.e. it dug license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I'hc Office of Investigations would like to thank you in advance fur your cooperation and should yuu have sty questions,
please do not hesitate to give us a call.
fhe Daparnnent's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Itcvi,ed ;-2(;-us www.mass.gov/dia -
CITY OF S.-1I.E.NI, l�L-kss k iusETI'S
• BI:ILDLNG DEPARTNI NT
130 WASHLNGTON STREET, 3iO Ftooa
TEL (978) 745-9595
FAX(978) 740-9846
KIMBERLEY DWCOLL
T
,�111YOR �tO.�IAS ST.PIERRB
DIRECTOR OF PLBLIC PROPERTY/BunmL�IG 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 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:
o-V-�S-� C �
(name of hauler)
The debris will be disposed of in
(name of facility)
address of facility)
signature of permit applicant
r ZE
dater
Jebnvlyd.x -