36 SUMMIT ST - BUILDING INSPECTION 3 Y' F
The Commonwealth of Massachusetts F
O
Board of Building Regulations and Standards CITY ITY
d ! Massachusetts State Building Code,730 CMR
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
k—Bduflrdinn'a
ding Permit Number: Date` pplied:
Official(Print Naune). - '' Signature Date
SECTION 1:SITE INFORNIATION
operty Address; 1.2 Assessors Map&Parcel Numbers
I.la 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 R) 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: LS Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIPI
2.1 ,Qwwnt of Record: e l �y�
(AX-e- Ltl� E1� Imo% �'1� 01 Gl 70
me(Print) City,State,ZIP
q/e '5t/vnw j17-,� 1) - M-3
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-:
is a 004
\ Y
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials Offleial Use Only
I. Building $ I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ [I Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Nechanical (HVAC) S List: 1��
5. Mechanical (Fire $
Suppression) Total All Fees:$
r, Check No. Check Amount: Cash Amount:
�/• 6. Total Project Cost: $ S I Y O d 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) I
d9� i. �i S- a3 , y
LR I '^�1C_d C License Number Expiration Date
Name of CSL Ho dl er
q � � `� D List CSL Type(see below) G � i✓
t '„' lvu'.+'r� / ILt.��/(Y �fL 'type .- DescriptionNo. and Street
II J�l^� U Unrestricted(Buildings u to 35,000 cu. It.)
1�teal �� I '/q at� J R Restricted I&2 FamilyDwelling
Cityffown,State T� M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Dcmolilion
5.2 Registered Home Improvement Contractor(HIC) 1 .5O a.7
f),-M.0,-c P1 Qa, L� HIC Registration Number Expiration Date
HIC Company Name or HIC egistrant N, e
No. Street p Email address
igI It—, • C& MA aFDI f�X-Lid-�`Ioy
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
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby,attest under the pains and penalties of perjury that all of the information
coot ' d it application is true and accurate to the best of my knowledge and understanding.
Print Owne ' lorized 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. 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.masssov:/dos
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 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" 7d f
I�
CITY OF S.1LEM. NLNSSACHUSETTS
BUILDING DEPAR'111ENT
Q M. 120 WASHQVGTON STREET, 3x°FLOOR -
\� �� TEL (978) 745-9595
FA,X(978) 740-9846
(rJ.,iBFRt F.Y DRISCOLL TtiomAs ST.PIERRE
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDNG CO\C�IISSIONER
Workers' Compensation Insurance Affidavit: Buildeirs/ContractordElectricians/Plumbers
A r alicant Information Please Print Le ibI
Name (Busine...tiOrganizatiun.'Innndividual):
Address:
OP%,� I Phone H: Q 7 g 'C.70
Are you an employer?Check the appropriate box: 'type of project(required):
I. I am a employer with_'_ 4. ❑ I am a general contractor and 1
6. ❑New construction
employees(full and/or part-time).° have hired the sub-
contractors
2.❑ 1 am it 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 I0.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.[so workers'comp. C. 152, §1(4),and we have no 12,❑ Roof repairs
insurance required.)t employees. (No workers' 13.❑ Other
comp. insurance required.)
•Any applied nut chucks box Al musr alsu rill out the action below showing their workers'compensmiun policy oub matiun.
r I lorneowtx•n who submit this afdnvit indicating they arc doing all work and then hire outside conitactors muff submil a new a(lidavit indicting such.
=(:umriton thul check this box mtut anach d an additional shect showing the mmnc of the sub-contractors and their workers'comp.policy informaion.
lam an employer tliat is providing workers'conrpensadon irrrurance for my employees. Below is the policy and job site
information. +ft t 1
Insurance Company Name: ��_ __V V`✓=U I •.j-.K 5---�Jl r ' 7
Policy U or Sclf-inv. Lic. H:-A W "8c- 7 01 3 Expiration Date:�" � `t
Job Site Address: 36 savti`_ w, _!a _— City/Stair/Zip7, kLy. MO 0I47J
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 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigaione ofthe DIA for insurance coverage verification.
/do hereby certify under t ins surd penalties of perjury that the information provided above is true and correct
Sienuu I Date:
Phone 1: g7 L J g'�j o L)
Official use only. Do not write he this area,to be completed by city or town official
City or own:
Issuing Authority(circle one):
1. Board of Health 2. Iuilding Department 3.Cilylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.0111cr
Contact Person: _.,_......__ Phone B:_,
CITY OF S'U�F-\d, NKI SSACHUSETTS
i . e Bt;amm,DEPARTMENT
120 WASHINGTON STREET, 3'FLOOR
: TEL (978) 745-9595
Fla(978) 740-9846
KIJBERLEY DRISCOLL
MAYOR Tmo.sw ST.PIEma
DIRECTOR OF PUBLIC PROPERTY/Bt:ILDNG CONNISSIONER
Construction Debris Disposal Affldavit
(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
l 11, S 150A.
The debris will be transported by:
(na a ofhauler) `
The debris will be disposed of in
�G
(name 'Facility)�� t
(address of facility)
signs re of irn applicant —
/C)- 3
late
1.
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Cunstructiun Supen isor Spccialtc .00111111
_
License: CSSL-099681
ERIC DEMPSEY
7 RICHARDSON.STREET s
BILLERICA MA701821,
Expiration
Commissioner 05/2312014
✓/ee �oanvnra�uUea/� a�✓��amac%ueella .
Office of Consumer Affairs&Business Regulation
HOME PROVEMENT CONTRACTOR
RegistraIMtion: 4150272 Type:
' Expiration 32-112014 DBA
i DEMPSEY CONST&.ROOFING '
-:g� t
- ERIC DEMPSEY
I 7 RICHARDSON ST�
a BILLERICA, MA 01821:r Undersecretary
i .
f
J
' Dempsey Roofing, LLC
P.O. Box 383
Billerica, Ma 01821 Phone: 978-670-8904
Fax: 978-362-3102
Proposal
Customer
Name Mike Lord Date 10/22/13
Job Site 36 Summit Street Order No.
City Salem MA Rep
Work 617-212-6647 FOB
Q... ...... Unit Price TOTAL !
Install tarp from roof to ground to protect siding& landscape.
Install
existing layers down to roof deck& re-nail where necessary.
Ito
broken or rotten plywood/roof boards will be replaced up
to 1 sheet 1/2" COX or 16' roof board.
Any additional broken or rotten plywood/roof boards will be
replaced at a cost of time and material. I
Install Vice &water shield underlayment, along all eves&valleys
Install 151b felt paper on reminder.
Install 8"white aluminum drip edge around entire perimeter.
Install LTD Lifetime GAF Timberline or CertainTeed Landmark
architect roofing shingles(color and manufacture chosen by
homeowner).
Counter flash and caulk chimneys where necessary.
Install 1 new 3"pipe flange.
€Cut in and install shingle over ridge vent. !
E!Remove all roofing debris.
This is a labor, materials, dump and permit proposal. €
*Re-work 5 skylights: Ice&water up skylight walls&flash
4ith owners help. No guarantees.
€ E
Payment Details
8 Cash
Check
O TOTAL $5,800.00
Make check out to or cash $5,400.00
Dempsey Roofing LLC. Office Use Only
Signature of acceptance