75 TREMONT ST - BUILDING INSPECTION CITY-OF --
3 J PUBLIC PROPERTY W
DEPARTNIEINT
MA roa 120 WA"NCr[1N SnWXr O
741:978-745.95"•F.x,M740.96" .
APPLICATION FOR THE REPAI_ RENOVATION CONSTRUCTION
DEMOLITION OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: �j "c 0 �\ c'� Building:
Property Address:
Property is bcated in a; Conservation Area Y/N Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land `
t Name:
Address: c:—) <
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use New
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: � ����
Mail Permit to _-
What is the current use of theBuilding?Material of Building? If dwelling,how many units?---- �
ari�c
Will the Building Conform to Law? Asbestos?
Architects Name ( )
Address and Phone
Mechanles Name 5 `' �� Q�\�\`1
Address and Phone HIC Registration 0 \50 --
Construction Supervisors License f1
Estimated Cost of Project -- permit Fee Calculatlon
Estimated Cost X$71$1000 Residential
Permit Fee$ Estimated Coat X$11/51000 Commercial
�3 An Additnai$5.00 is added as an
Administrative charge.
Make sure that all fields are property and legibly"written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury
Date
I
N
D
C
a
3
0
y Qy G O
V r.
E.. •3 a V $
g a a a 4 ---
ad a
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CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR
120 WASHe4GTON STREET a SAL EM,ly,SSSACHUSEr.s 01970
Workers' Compensation Insurance Affidavit Builders/C ntractors/Electe{cians/Plambers
A licant Informatio
Please nt Le
gft
Name (Business/OrganiZation/Indiv;dusl): `��.2. l;
Address:_'YJ j
city/state/zip: �x J r\ J �c
Phone
Fam
mployer?Check the appropriate box:
ployer with 4. 0 1 am a eneral co Type of project(required):
es(full md/or g ntracmr and Ipart-time). have hired the sub-contractors 6. ❑New construction
le proprietor or partner- listed on the attached sheet t 7. 0 Remodeling
have no employees These subcontractors havefor me in any capacity. workers'co g ❑Demolition
[No workers' com . ' �• insurance.
p insurance 5. ❑ We are a corporation and its 9. ❑Building addition
required) officers have exercised their 10.0 Electrical 3-❑ I am a homeowner do' repairs or additions
myself co p.WOE right of exemption per MGL 11.0 Plumbing Y [No workers'comp. c. 152. §1(4),and we have no repairs or additions
insurance required)t employees.[No workers' 12A Roof repairs
comp.insumnoe required•) 13•0Other
Any aPDEcaut Nat etxeka box MI mutt also fill mu the saaoo below showing their workme'com policy iotmmatloy
t Homeowners who submit Nis elBdavit' all pardon 6
tCoodsctma that check this box must attach a"tionsl rheet�ho gwm' the mwork sad am a ceuttactma must submit a ease&nkkvit mdiating suck
abeoatractom utd their workm,come•Policy inimmatien.
injormatlan.am an employer that Is providing warten'compensation insurance for my employees Below Is thepo/fey and fob site
Insurance Company Name:
Policy#or Self-ins. Lic.#:
Expiration Date:
Job Site Address:_ 1"j � t-•�m.���
City/State/Zip:Attach acopy 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 a Page
can lead t the imposition nuof mber
fine up to$1,500a d and/or one-year imprisonment as well as civil penalties in the form of a STOP WORK ORD R trend a fine
In es to 5250.0o a day against the violator. ra advised that a copy of this statement may be STOP W to the Office of
Investigations of the DIA for insurance coverage verification
do hereby certify an er the pains and penalties ofperfary that the injormatiaa provided above is true and correct
Signature-
Dt • 6 � D�
agile
[6.Other
use only. Do not write in this area,to be completed by city or town of lciaL
Town:
Authority(circle one): Permit/License#
d of Health 2.Building Department 3. City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
Person
Phone#
information and instructions for their employees
its General Laws chapter 152 requires all employers to provide workers compensation
an employee is defined as"...every person in the service of another under any contract of bite.
Massachuse
pursuant to this Statute. "
express or implied,oral or wrInGIL two or more
o r is defined as"an individual-Partnership,association'corporation or other legal entity,ns employer,er,or the
4a employer engaged in a joint enterprise+and including the legal representatives of a deceased top Y
of the foregoing of a
partnership.a association or other legal entity,employmg employees However the
receiver or trustee of f Navin not more than throe apartment&and who resides therein,or then such
of the how
owner of a dwelling who employs persons to do maintertsnc0.construction or repair work on such dwelling
dwelling
house of another thereto shall not because of such employment be deemed to be an employer-"
or on the grounds or building appurtenant
MGL chapter 152,§25C(6)also states that"every state or local lieemhag agency shall withhold the Issuance a or
renewal of&license or permit to operate a business or to construct buildings the commonwealth for any
table evidence of compUaace with the insurance coverage neal sttrequiri subdivisions shall
applicant who hu not produced acceptable of its political
152,§25C(7)states"Neither the commonweeal dence of compliance with the insurance
Additionally. GL contracts chapter
the performance of public work until acceptable
enter into any nts of this chapter have bien presented to the contracting authority."
requireme
Applicant 1 to our situation and,if
'on affidavit completely,by checking the boxes that apply Y
Please fill out the workers' compensate address(es)and Phone number(s)along with their certificates)of
supplysub-contracmr(s)name(s), Partnerships(LLP)with no employees other than the
necessary. Lim Companies(LLQ or Limited Liability
insurance. Limited Liability to carry workers' compensation insutance. If an LLC or LLP does have
members or Farmers,are ui required
Be a d that this affidavit may be submitted to the Department of bmdustiial
employees a policy is required. ur advise Also be sure to sign and date the affidavit. The affidavit should
Accidents for confirmation of insurance coverage. or license is being requested,not the Department of
be returned to the city or town that the application for the permit you are required to obtain a workers'
Industrial Accidents. Should you have any questions regarding the law or if y es should enter their
1 lease call the Department at the number listed below. Self-insured comPam
compensation policy,P line.
self insurance license number on the a
City or Town Officials provided a space at the bottom
Please be sure that the affidavit is complete and printed legibly. The Department hasp the applicant
permit/license number which will be used as a reference number. In addition, i applicant
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding PP
Please be sure to fill in the pe applications in any given year.need only submit one affidavit indicating current
that must submit multiple Per y)and under
er "the a Brant should write"all locations in (city or
policy information(if necessary)and under"Job Site Address PP the city or town may be provided to the
town). A copy of the affidavit that has been officially stamped or marked by tY
roof that a valid affidavit is on file for future perm its'as'!icser Anew aEidaXic moat be filled out each
applicant asp a license or permit not related to any business or commercial venture
year.Where a home owner or citizen is obtaining person is NOT required to complete this affidavit.
(i.e. a dog license or Permit to bran leaves etc.)said
you in advance for our cooperation and should you have any questions,
The Office of Investigations would to thank y
Y
ve us
please do not hesitate to gi
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
o flee of Investigations
600 Washington street
Boston,MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
wlwf 120 WAMNGMU shear•UUa.HAnACH =rr%01970
1'M MUS-9595•FAm M74a.9"
Construction Debris Disposal Afildavit
(required for aU danolition and movation work
In accordance with the sixth edition of the Sht Buildins Coda.780 CUR section I11.5
Debris,and dw provisions of MOIL a 40.S 5*
Buildin0 parndt d is issued with the condition that the debris realti23 0Om
tins work shall be disposed of in a properly licensed waft disposal meiuty as dented by MC EL a
1 i 1.S 150A.
The debris wiL be transported by:
(now athsaw
The debris will be disposed of in :
(name of facility)
(addna of fhcdity)
N 4�
SIa7lifltf Of P6tmlt aQFltpa<
lad -7 c
din
Shea Roofing Co.
Salem, MA 01970
(978) 745-7313
PROPOSAL
SUBMITTED TO:
'IM Tremont St.
Salem, Ma. 01970
We hereby submit specifications and estimates for:
To remove one (1) layer of old asphalt strip shingles from complete main
roof.
To install all new Architectural roof shingles covering complete main roof.
To install all new metal drip edge on all roof edges both vertical and
horizontal.
To install new roof vent pipe flanges.
To install a new Velux skylite.
To clean up and remove all roofing debris from job site.
We propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
/dollars$
Payme o be made as follows;
=0
All material is guaranteed to be specified. All work to be completed in a workmanlike manner according to
standard practices. Any alteration or deviation from above specifications involving extra costs will be executed "
only upon written orders,and will become an extra charge over the estimate. All agreements 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 to do the work as specified.
Authorized Signature:
Signature: -
Date of Acceptance:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
KIMBERLEY DRISCOLL
MAYOR
120 WASHMTON STREET•SALM.MASSACliUSEM 01970
Workers' Compensation Insurance ARldavit: Builders/Contractors/Elecq{cians/Plambers
Applicant Informatio
Please fit Le
Name(Busm"1101`91U Eation/Individual): >-� _ n
Address: .s\ .
City/State/Zip: J$-Y� Phone #:_
F
e you an employer?Check the appropriate box:
I am a employer with 4. 0 I am a general contractor and IType of project(required):
em
ployees(full and/or part-time). have hired the sub contractors 6 ❑New construction
I am a sole proprietor or partner- listed on the attached sheet t 7. 0 Remodeling
ship and have no employees These sub contractors have
working for me in any capacity. workers co g ❑Demolition
[No workers, comp. insurance 5. ❑ We am a cow. insurances
rporation and its 9 ❑Building addition
required-]
officers have exercised their 1 O.C]Electrical repairs or additions
3. I ys a homeowner doing allp.work right of exemption per MGL I L0 Plumb'
myself.
Ncequroredf comp. c. 152, §1(4),and we have no 12: f repairs or additions
employees.(No workers repairs
comp.msuraace required•] 13.❑Other
'Airy appaum that checks box MI mutt dw fill out the section below showing their wsakao'compensation ry iolotmatb6
tConteacton that check this this&ffkhwk box mutt shad en
they an doing su work and man hie ouniJe eonrratxaa mutt attached an additional sheet showing the acme of the submit a near affidavit indicenot OWL
.sub-contraeton and their woken'comp.policy infmteatinp,i om an employer that it providing workers'compensation insurance for my employees Below is Ihs policy and Job sits
injormadon
Insurance Company Name:
Policy#or Self-ins.Lic.#:
Expiration Date:
Job Site Address:_3� h V L
City/State/Zip: . Zj\ 1�Attach a copy of the workers'compensatlon policy declaration page(showing the poncy 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$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form'ma STOP WORK ORDER and a fa
of up to$250.00 a day against the violator. Be advised that a copy of this statement mayof be STOP W to the Office a
Investigations of the DIA for insurance coverage verification
/do hereby certify under the pains and penalties ojperlmy that the tajormanon provided above it true and correctSi n
D t •
Phone
=Other
only. Do nor write in this area,to be completed by city or town oJJiclaL
n•
Permit/License#
hority(circle one):
Health 1. Building Department 3. City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
son:
Phone#:
information and Instructions °for their employees
ter 152 requires all employers to provide workers compensati contract of hire,
pursuant to this
Massachusetts General Laws chap person in the service of another under Y
statute,an employee is defined as"...every pe ,
express or implied,oral or written two or more
pfo r is defined as"an individual.Partnership,association,corporescn or other legal entity.or any
An
ed in a joint enterprise.and including the legal representatives of a deceased employer,or the
of ern" employing employees. However the
of the foregoing a of a armership.association or other legal entity, or the occupant of the
receiver or trustee of an ind �g not more than three apartments and who resides therei. ork on such dwelling house
owner of a dwelling house who employs Persons to do maintenancc. f such emplctionoyment
y repair "
dwelling house of another thereto shall not because of such employment be deemed to be an employer.
or on the grounds or building appurtenant
MGL chapter 152,§25C(6)�o states that"every state or local licensing agency shall withhold the lasnanee or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
produced acceptable evidence of compliance with the insurance coveralls tical subdivisions
�required.-
who �
applicant has not p of its P°
Additionally,MGL chapter 152,§ZSC(7)states"Neither the commonwealth
evidence of compliance with the insurance
enter into any contract for the performance of public work until acceptable
requirements of this chapter have been presented to the contracting authority."
Appltcanb the boxes that apply to your situation and,if
Please fill out the workers` compensation affidavit completely,by checking
1 sub-contractors)name(s).address(es)and Phone nuaiber(s)along with them certificate(s) th
Of
necessary, LLP Y
Companies(LLC)or Limited Liability partnerships(LLP)with no employees other than the
insurance. Limited Liability d to carry workers' compensation insurance. If an LLC or LLP does have
members or partners.are not require be submitted to the Department of Industrial
employees.a policy is required Be advised that this affidavit may and date the affidavit. The affidavit should
Accidents for confirmation of insurance coverage. Also be sure to sign not the Department of
or town that the application for the permit or license is being requested
be returned to the city questions regarding the law or if you are required to obtain a worket e
Should you have any que w. Self-iosured companies should enter their
Industrial Accidents ��at the number listed Belo
compensation policy.Please call the Department
self-insurance license number on the a L1ate line.
City or Town Officials ent has provided a space at the bottom
the applicant.
Please be sure that the affidavit is complete and Printed legibly. The Deto contact you partment ant.
of the affidavit for you to fill out
int eevent
umber which will be used as aOffice of Investigations reference number. In addition,an applicant
Please be sure to fill in the permit/license application in any given Year.need only submit one affidavit indicating curte°r
that must submit multiple P and under"Job Site Address"the applicant should write"all locations in (city
policy information(if necessary) or marked by the city or town may be provided to the
town)." A copy of the affidavit that has been officially stamped
applicant as proof that a valid affidavit is on file for future pennita c.'icense"`"'�`tiew aF,'idavir moat be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or Permit to burn leaves etc•)said person is NOT required to complete this affidavit.
for your cooperation and should you have any questions,
The Office of Investigations would like to thank you in advance
Please do not hesitate to give us a call.
The Department's address,telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
ofnee of instigations
600 Washington street
Boston,MA 02111
Tel.#617-727 Fax 900 ext 406 of 1-877-MASSAFE
pevised 5-26-05 wwwmm.gov/"
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
W>o�r.atr trauma.
Wraa 130W SnWa•SuaxVAUM UWU01f70
TIES M74&%fS•PNc m74&gW
Constmedon Debris Disposal AMdavit
(required fa AN deawlidou ad mnovadoa work)
in accordance with the sixth edition of the State Building Code,780 CMit section 111.3
Debris,and the provisions of MGL a 40.SA
Building permit 0 is issued with the condition that the debris resulting Soot
this wort sWI be disposed of in a properly licensed waste disposal&edify as defined by MOL a
It1.S130A.
The debris will be transported by:
(n.me a[trmlr)
i
i
The debris will be disposed of in :
(new of facility)
(addrm of hcility)
sisnan"of pama applicant
dark
•;elnw7J�r
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
Ww��sr tavaoott.
NAvaa 130 WAswmwl+ M S1at=r>:•SAtFar.Mumcsr:um 01Wo
I'm 9MUS-M•FAm M744984
Construction Debris Disposal Affidavit
(required for all demolidon and renovation work)
In accordance with the shah edition of the shoe Building Code,780 CMR section 111.3
Debrisq and the provisions of MGL a 40.3 S*
Building permit 0 is issued with tits condition that the debris moulting flom
No wort shall be disposed of in a ympody licmued agars disposal&duty as dented by M(3L e
111.S 130A.
nm debris will be transported by:
(cams otttsai.r)
The debris will be disposed of in:
(aama of facility)
i
(addmu of&cdity)
sisaamm of permit applicam
date
.;ebi.mLJus
Shea Roofing Co.
Salem, MA 01970
(978) 745-7313
PROPOSAL
SUBMITTED TO: Paul Lemieux 10/10/06
39 Fort Ave.
Salem, Ma. 01970
We hereby submit specifications and estimates for:
To install all new architectural thirty year (30) roof shingles covering
complete main roofside extension and side entrance roof.
To install new vent pipe flange on roof vent pipe.
To install all new metal drip edge on all roof edges, both horizontal and
vertical.
To install two (2) new roof air vents.
To cover rear shed dormer roof, using double coverage roofing fully
adhered.
To remove old wood gutters and replace them with new 4" x 5" aluminum
gutters on front and rear sides of main buildings
To clean up and remove all roofing debris from job site.
We pJspose hereby to furnish material and labor-complete in accordance with above specifications,for the sumof:
f G� --/ dollars$ " 4� _
Payment t ye frfaQJa as follows:
All material is guaranteed to specified. All work to be completed in a workmanlike manner according to
standard practices. Any alteration or deviation from above specifications involving extra costs will be executed
only upon written orders,and will become an extra charge over the estimate. All agreements 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 to do the work as specified.
Authorized Signature: v
Signature:
Date of Acceptance: 0