53 SUMMER ST - BUILDING INSPECTION OLI The Commonwealth of Massachusetts
W
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR INSPECTIONA ED SALEM
M&dMr$Z011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling 7915 M
This Section For 9fficial Use Only
Building Permit Number: Date Applied:
s
Budding Official(Print Name) Signature Date
j SECTION 1:SITE INFORMATION
n 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
S 3 llt�,?7M-1 SC
I L l 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 ft) Frontage(ft)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Regdved 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 COwe2f Re d:
5S_
✓��Gv2 S/ t�ear� i'f'14 O! R?Z�
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply),'
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Ofher peci : O
Brief Description of Proposed Work': ^}
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:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ /
4.Mechanical (HVAC) $ List: / h
5.Mechanical (Fire $
Suppression) Total All Fees:$
6.Total Project Cost: $
j�7 Check No. Check Amount: Cash Amount:
Ce / ❑Paid in Full ❑Outstanding Balance Due:
YYltl t lJE-C> s1 5
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Sunervisor License(CSL) CS 1UJ�` '> �? ✓b��a
���/ — License Number Expiration Date
Name of CSL Holder
List CSL Type see below
No.and Street Type Description
�?'1t f (`, „ ,/) itnd 0�75� U Unrestricted(Buildingsu to 35,000 M.ft.
/G ! I�07)l�_� J�� f R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Ho Im ovement Contractor cc�{{C) q /(
�)! [SA K 1�0&7 /5yS 77 @
HIC Registration Number Expiration Date
C C�p�y Names 1,Reillnt Name
S F �'�✓X
No.and S )5e% /1�1 .�•���.� �7y Email address
City/Town,� State,ZIP ���( Telephone O2O
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152.§ 25C(6))
Workers Compensation Insurance affidavit must be comp) and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuance a building permit.
Signed Affidavit Attached? Yes ......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTO�RAAPPP-LIES FOR B ILDING PERMIT
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I,as Owner of the subject property,hereby authorize /° * 5
to act on my behalf,in all matters relative to work authorized by this building permit application. .
PrintOwner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this applicati n Ulci G is truenand
/accurate to the t of my knowledge and understanding.
1 /!�JG I/ C>
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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. 142A.Other important information on the HIC Program can be found at
www.mass.gow'oca Information on the Construction Supervisor License can be found at www.mass.sov/dns
27 When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq.ft.) Habitable 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"
COASTAL ROOFING CONTRACT
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DATE - s;-t s
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GENERAL CONTRA90R'S AGREEMENT
tlVdG the ownw6)ofthepremhes described below,hereby authorize you as contractor mfurnoh all necessary Irwtedah,ll�or and wwkmanship winsWLmw
struct and place the impsovemwns descibe l herein amosding to the foil-wing specifications,terms and mndltions on the premises described below.
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The Commonwealth ofAfassachusefts
Department of Industrial Accidents
Office of Investigations
606 Washington Street
Boston, MA 02111 .
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information � Please Print Le 'bl
Name (Business/Organizadon/Individual): /O yr C2
Address: �JT--
City/State/Z' m l 4A0k.5-)hone #: a
Are you employer? Check thgappropriate box; Type
an of project(required):
1. am a employer with 4• ❑ I am a general contractor d I T Q
employees(full and/or part-time).* have hired the sub-contractors New construction
2.0 I am a sole proprietor or partner- listed on the attached sheet 7. Q Remodeling
ship and have no employees These sub-contractors have g, ❑ Demolition
Working for mein any capacity. employees and have workers' 9 Building
[No workers'comp. insurance comp. imurance.t ❑ g addition
required.] 5• ❑ We are a corporation and its 10.Q Electrical repairs or additions
3.❑ I am a homeowner doingall work officers have exercised their
11.Q Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
insurance required.] t c. 152, §1(4), and we have no 12.0 Roof repairs
employees. [No workers' 13.Q Other
comp. insurance required.]
*Any applicant that checks box NI 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 thou entities have`
employees. If the sub-contractors have employees,they must provide their workers'comp,policy number.
I am an employer that is providing workers'compensation Insurance for my employees. Below it the policy andJob site
Information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: 6 .ZV 19 Y S �5 05`��/
I Expiration Data: �
P
Job Site Address:_ of 5"UMwe/i Sl4�er lr, /!')9 City/State/Zip. 9 70
Attach a copy of the workers'compensation phcy declaration page(showing the policy number a— expiration
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 is 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 a�nd/penaties ofgerjury i th nform 1161 provided ab•ve isa 'nue and correct.
Signazure: fvt It U 2 a e,
Phone #: .
7Other
only. Do not write in this area, to be edmpleted by city or town ofJlciaL
n: PermitUcense Y
hority(circle one);
Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
son: __ Pirone 4:
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ACORD'
CERTIFICATE OF LIABILITY INSURANCE: DATE
THIS ER. THIS
IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPOA THE CERTIFICATE
23-2015
HOLDER iH13 CEfiTIFICATE DOES NOT AFFIRMATIVELY Oq NEGATIVELY AMEND, -)(TEND RIGHTS
ALTEII THE COVERAGE
AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A COI I THE BETWEEN
THE I33UIN0INSURER(S),AUTHORIZED REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDEII.
IMPORTANT: If the certificate holder Is an ADDITIONAL INSURED,the Potky(les)must be endorsed. H SUSRO:IAT10N IS WAIVED,
subject to the terms and conditions of the policy,certain policies may require an endorsement A statement on his tertif'cats does
not confer rights to the certificate holder in lieu of such endorsement(s).
PRODUCER
MARKETING ASSOC INS AGCY NNAME.CONTACT
ONE
150 WELLS AVE,#1 PHONE
NEWTON.MA 02459 1 No Ed: FAX
ENAL bC No:
INSURER(S)AFFORDING COVERAGE
INSURER ACE AM Iq A NSORANCE CGNPANY NAICr
MSURED
VALDEZ WILSON DBA MASTER ROOF ASURER B:
&UNIENVIOUS-MA INSUq ER c
PO BOX 63
MILFORD,MA 01757 1"SURER D.
NSURER E
INSURER F:
THIS CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED
ABOVEE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CO'IDITION OF ANY
CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR M'Y PERTAIN, THE
INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, E:;Y PERTAIN
AND
CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN RE1) ED BY PAID CLAIMS.
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ANYPRGPRIETOgMAq TNEWEXECUTIVEY-r-N, X VnC STATU- ( T(,
OFFCEAMEMBER EXCLUDED? IYI N/A TOR Y LiNIIS ;q
(Mamm"Yw NH) LJ 6$62UB
03-15-2015 03.18-2016 E.L.EACH ACCIDENT $100,000
ESC O 4505PS74
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OSCRIPTICN OF OPERATIONS be bw E.L.DISEASE-EA EMPL( (EE $500000
EL DISEASE POLICY LI:nT $100,000
OESCFRFM OF OPERATIONS/IOCAnONS/VEHICLES IANrch ACOR 0 I01.AddNb he
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THE WORKERS'COMPENSATION POLICY DOES NOT PROVIDE COVERAGE FOR VALDEZ,WILSON DBA MAS ER ROOF.
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STAL WINDOWS
100 CUMMINGS CENTER,
AND EXTERIORS SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE
100 GUMMING$CENTER,
SUITE 236-H - CANCELLED BEFORE THE EXPIRATIOII DATE THEREOF,
BEVERLY,MA01915 NOTICE WILL BE DELIVERED IN ATIO11 gATE WITH THE
POLICY PROVISIONS.
AUTNORQEO REDRESENTATIVE
ACORD 25(2010/05) ~
The ACORD name and logo are registered m6arkstol�qtlllgACORDCORPORATIC1.All rig is reserved.
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aQT'Y OF SALEM, MASSAMUSE M
BUILDING DEPARTMENT
120 WASHINGTONSTREET,3'0ftoOR
TEL.(978)745-9595
KRMERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBLIC PROPERTY/BUII.DING 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 c40, 5 54; Building Permit#f is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit 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 applicant
s7��s
Date
T
Salem Historical Commission
120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978)740-0404
CERTIFICATE OF APPROPRIATENESS
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
Reconstruction 'Xa� Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other work
as described below will be appropriate to the preservation of said Historic District, as per the requirements set
forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance.
District: McIntire
Address of Property- 53 Summer Street
Name of Record Owner: Delores NanQle
Description of Work Proposed:
Replacement of roof on main structure an barn with GAF Slateline in Antique Slate.
Re flash both chimneys and skylight, repair skylight if needed, repair sidewalls and remove/reattach clapboard
as needed, all to replicate existing. No changes in color, material, design, location or outward appearance.
Dated: May 7, 2015 SALEM HISTORICAL C,O�MM�ISSION
By:
The homeowner has the option not to commence the work(unless t relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals)prior to commencing work.