13 SUMMIT AVE - BUILDING INSPECTION The Commonwealth of"OUw Dtts
Board of Building R gl��t�ons�andiS1muid�ES CITY OF
Massachusetts State$tt33ihding Node, 780 CMR SdMar
Revised Mar 2011
Building Permit Application To Con t,�jepz�r3Rlg bA1e(b1i Demolish a
One-or Two-F'cY 111i -Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
c
Building Official(Print Name) - Signature - Date
SECTION 1: SITE INFORMATION
1.1 I! ffld/d :o /
p ddress 1.2 Assessors Map&Parcel Numbers
1.1 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 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 Owngriof Record: SA-e /i;ems It
A ,�,��
X Name(Print) C7City,State,ZIP
ri7 (
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ umber of Units OtbfX ❑,Specify:
Bri f scri on o Pro os Work2:
i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$ YIndicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier is
3. Plumbing $ 2. Other'Fees:.$ ff` -
4.Mechanical (IIVAC) $ List:
5.Mechanical (Fire
Suppression) $ Total All Fees:$
��-77� Check No. Ch_eck Amount:' x• Cash Amount #
6. Total Project Cost: $ p7S ❑Paid in Full . ❑Outstanding Balance Due
Tb
S• ( "` 1, b3$Z� �_Jq 1J
SECTION 5: CONSTRUCTION SERVICES
Construction Supervisor Lice�n�see(CSL) � ` ''
N ����(<V 1 License Number E irati nDaw
Name of CSL Hol er
(�` r�� List CSL Type(see below)
N Jan Street .b ' I Type Description
� '^ �} !iZ G.-� U Unrestricted2 Family
(Buildings u el ing cu.ft.
L 1/1 l ' l/J(.�' R Restricted 1&2 Famil Dwelling
City/Town,Stat ,ZIP M Masonry
RC Roofing Covering
WS Window and Sidi
IK 4 t'l�a�� a1�.�E�mP I � .�ari SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address '� D Demolition
5.2 registered Home Im rovement Contractor(HIC) Cj_/} O �L
�ly� 1 D
HIC Registration Number xpi lion Date
H N CR gistrant Name d .y�� „fn "v ✓
/��(�LI Pt N J�Ie W 4 , Idj_�}��7 q Email address'
� �� N'I
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 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(EleCtp6nic Sr turc) 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
ntaim d in this application is true and accurate to the best of my knowledge and understanding.
JIm dobS
-Print caner s or Au onze Agent's a(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.gov/oca Information on the Construction Supervisor License can be found at www.mass. og v/dus
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 haWbaths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF & .E,�I, �'L�SS.ICHLSETTS
• BUIIDLNG DEPARII[ESiT
• + p 120 W ASHLNGTON STREET,3"FLOOR
Dj TEL (978)745-9595
F.kx(978)740-9846
KIN(B Ri FY DRISCOLL
T
uAYOR HOMAs Sr.P�Rxe
DIRECTOR OF PUBLIC PROPERTY/BUILDDIG CO%LNUSSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information !r ^ Please Print Legribly
Name (Busitxsrs Organizatiotvindividdu�ual[j):
Address: C)5 l�Il�l�l"
City/State/Zip: �1 JJMI�VJ M Nff U—W7 Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.LJ I am a employer with= 4. Q 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time),* have hired the sub-contractors
2_❑ I am a sole proprietor or partner- listed on the attached sheet 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LCI PI ing repairs or additions
myself.(No workers'camp. C. 152,§1(4),and we have no 12, Roof repairs
insurance required.)t employees. [No workers'
13.❑Other.
comp. insurance required.]
*Any applicant that checks box sl most also till out the section below showing their worker'compensation policy information.
'I1, m owmwxa who submit this affidavit indicating they are doing all work and then hire onside contractors most submit a new affidavit indicating such.
=Conuanor that cheek this box most anached an additional sheet showing the tune of the sub-contractwa and their worker'comp.policy information,
l am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. 'Insurance Company Name:
Policy HorSelf--ins. Licie. ti: /"/t/�/S Expiration Date: tx
Job Site Address:/✓. /// ` �//(/ (i City/State/Zip. � w
Artacb 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 S250.00 a day against the violator. Be advised that a copy of this statement may be rorwarded to the Office of
Invemigmioas of the DIA for insurance coverage verification.
l do hereby a rtify under the sins and penalties ofperjury that the information provided ybovf is true and correct.
i mal mre' Date:
PhoneX:
Ojjlcial use only. Do not write in this area,to be completed by city or town official
City or'rmvn: Permit/License N
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ Phone ti:
rNr•�nurnrr,rrrirrrr�/�r�r'.�fraor�rUr/!' _
Office of Consumer ARairs&Business Regulation License or registration valid for individul use only
ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistration: 158930 Type: Office of Consumer Affairs and Business Regulation
4 xpiration: 8/20/2016 DBA 10 Park Plaza-Suite 5170
1 Boston,MA 02116
DAWN MELANSON CONSTRUCTION
DAWN MELANSON
85 EXESOUTH
HA RD. tart' /Jl�
SOUTH HAMPTON,NH 03874 Undereecretary IMP.--ILI
Not v id without signature
I �
� j
Massachusetts -Department of Public Safety
�l Board Of BuildingRegulations and Standard
s
Construction Supen isor Specialh rT
License: CSSL4)99891 {
DAWN All MELAPJSON,�
85 EXETER ROAD 9
SOUTH HAMPTON NH.'03927 _
Expiration
Commissioner 11120/2015
Restricted To: CSSL-WS-Windows and Siding
CSSL-RF-Roofing
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For D"s licensing information visit: www.Mass.G,ovtops
DM CONSTRUCTION
85 EXETER RD.
SOUTH HAMPTON, NH. 03827
603-394-9944 OFFICE
5/21/15
13 SUMMIT AVE
SALEM,MA.
STRIP&REROOF-MAIN HOUSE,INCLS ALL ROOFS
We hereby propose to furnish all labor necessary for the completion of work at THE ABOVE ADDRESS.
Please see attached sheet for job specifications.
All work performed by us is guaranteed against workmanship for a period of TWO(2)years from job
completion date. Any defects becoming evident during period of guarantee,uopn written notice of the dwelling
owner,shall be promptly repaired at no additional cost.
All material is guaranteed to be as specified,and the above mentioned work to be performed in accordance
with specifications submitted for above work and completed in a professional manner for the sum of:
$5,725.00-INCLS LABOR,MATERIAL,&DEBRIS REMOVAL
*BACK CELLAR ENTRY ROOF TO HAVE POLYGLASS ROOF SYSTEM(FLAT ROOF)
*SEE ATTACHED SHEET FOR JOB SPECIFICATIONS&PRICE BREAKDOWN
Any alteration or deviation from above specifications involving extra costs,will be executed only upon written
request and will become an extra charge to the dwelling owner. Workers Compensation and Liability Insurance
to be supplied by DM Construction upon request. A deposit of 1/2 the total cost is required before iob start
date. Balance due upon completion.
*Please remove all gardening and/or yard decorations from perimeter of dwelling. Please remove any
valuable decorations/hangings from interior walls and any valuables in the attic should be covered or
removed. DM Construction is not responsible for any damage to these items during the work performed.
Respectfully submitted: Dawn Melanson-Owner
Note: This proposal may be withdrawn if not accepted within thirty(30)days. This proposal must be signed
and dated before any work is performed.
ACCEPTANCE OF PROPOSAL
The above prices,specifications,&conditions are satisfactory and are hereby accepted. DM Construction
is authorized to do the work as specified by code. Payment will be made as outlined above.PLEASE MAKE
CHECK PAYABLE TO I�4WN MELANSON. _
Signaturef —/y/ Date
Signature Date 6
fN�
n
h�
�� t L r
i DM CONSTRUCTION
85 EXETER RD.
SOUTH HAMPTON, NH. 03827
603-394-9944 PHONE/FAX
1 5/21/15
!� 13 SUMMIT AVE.
SALEM,MA.
STRIP&REROOF-MAIN HOUSE,INCLS ALL ROOFS
SET UP ROOF STAGING AS NEEDED
PROTECT LANDSCAPE&DWELLING
STRIP&REMOVE ALL ROOF MATERIALS DOWN TO ROOF DECK
REPLACE ROTTED ROOF DECK W/ 1/2"CDX PLYWOOD IF NEEDED-$2.50 PER SQ FT
RENAIL ROOF DECK WHERE NECESSARY
INSTALL 8"DRIP EDGE,INCL FASCIA&RAKES
INSTALL 1ST 6'ICE/WATER MEMBRANE UP FROM EAVES
INSTALL SYNTHETIC ROOF GUARD ON REMAINING ROOF AREAS
INSTALL STARTER SHINGLES ON EAVES&UP RAKES
INSTALL ARCHITECTURAL SHINGLES
INSTALL RIDGE VENT
INSTALL CAP SHINGLES
REPLACE VENT PIPE FLANGE(S)
INCLS LABOR,MATERIALS,&DEBRIS REMOVAL
TOTAL: $5,725.00