93 TREMONT ST - BUILDING INSPECTION IThe Commonwealth of Massachusetts
/ Board of Building Regulations and Standards CITY OF
l I Massachusetts State Building Code,780 CMR SALEM
1�
yl Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One- Two-Family Dwelling
/this ection Or Official Use Only
Building Permit Number: Date Applied:
C � 0 If
Building Official(Print Name) Signature Date
SEC ION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
l.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 ft) Frontage(II)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'of Rec rd: _.
�\\. \\: () v x,Zc-
Name(Print) City,State,ZIP
`� �\ \
No.and treet Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work : ;
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost°(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
-� Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) Y03 15%� 3 )
License Number Expiration Date
Name of CSL Holder `S�
List CSL Type(see below)
No.and Street
Type Description
Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
S) I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) \SI�) ��_,.,� '—) I 3
W ,�\ " '—, 'S HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
NQ.and Street Email address
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 .........A No...........❑
SECTION 7a: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(Electronic Signature) Date
SECTION 7b:OWNERS 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 application is true and accurate the best of my knowledge and understanding.
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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"
Shea Roofing Co.
17 % Foster Street
Salem, MA 01970
(978) 745-7313
PROPOSAL April 22,2011
SUBMITTED TO: Phillip Turner
93 Tremont Street
Salem, Me.
We hereby submit specifications and estimates for.
To remove all existing roof shingles from complete main roof and front
porch.
To install ice and water shield along all roof edges and along all flashing
points prior to re-roofing.
To install asphalt.saturated felt paper covering all roof boarding prior to
re-roofing.
To install all new metal drip edge along all roof edges, both horizontal
and vertical.
To install architectural (GAF Timberline Lifetime High Definition) roof
shingles covering complete main roof and front porch.
To counter flash and/or reseal the chimney flashings as necessary. If lead
flashing is too damaged on the chimney we will grind it out and re-lead at .
an additional cost of$250.00 per chimney.
To re-flash, counter flash and/or reseal all sidewalls as.necessary.
To install up to 100 linear feet of roof boarding if necessary.
To install new roof flange on roof vent pipe.
To install new Cobra ridge vent on main roof.
To re-flash, counter flash and/or reseal the skylight as necessary.
To remove old satellite dish stand from main roof.
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 furnish material and labor-complete in accordance with above specifications,for the sum of.
Five Thousand Six Hundred and Eighty Five---------Dollars $6,686.00
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 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 SM ENN NIdSSACHUSETTS
• BUILDINIG DEPAItn(ENT
a 120 WASHINGTON STREET,3'a FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KINBERL F.Y DRISCOLL
T
MAYOR 2-tOMAs ST.P�RRH
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%IMISSIO.iER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information (( Please Print Leeibly
Name(BusinesvOrganiratiorvindividuw):
Address: )
City/State/Zip: Q�s` _ )`t\� Phone #:
Are you an employer?Check the appropriate box: Type orproject(required):
l.M I am a employer with �A— 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time),* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9, 0 Building addition
[No workers comp.insurance S. 0 We are a corporation and its I0.❑Electrical airs or additions
required,] officers have exercised their
3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.[No workers' I3.❑Other
comp. insurance required.]
•Any applicant that checks box dl must also rill out the section below showing their worked'compensation policy infunnadoa
t l lomeownen who submit this affidavit indicating they ate doing all work and then hire outride eontmciots roust submit a new affidavit indicating such.
:Connmxon that cheek this box most attached an additional shoes showing the name of slnt sub tneton and their workers'comp.policy information.
lam an employer that b providing workers'compensation Insurance for my empleyem Below Is the polloy and Jab site
information. pp
Insurance Company Name: �� � -Q �
Policy#or Self-ins.Lie.#: W ���p�� \ a Expiration Date: ��I
Job Site Address: "5 C z..�.w a-\ City/State/Zip:
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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 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.
l do hereby certify under thep#ns and pent al ties ofperJury that the information provided above is true and correct.
Siurature• IIL'./V✓t'� �V�'� Date• SI I I I
Phi 1't Y- 5 9 D -'11
OJJicial use only. Do not write in this area,to be completed by city or town of iciai
City or Town: Permit/License#
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 M
CITY OF SM.&M. TNL-�SSACHUSEM
• BuELDLIIG DEPARTMENT
WN120 WASHNGTON STREET, 1'FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIIIBERLEY DRISCOLL
MAYOR THoMAs ST.PmRRB
DIRECTOR OF PuBLic PROPERTY/BUELDING CONMaSSIONER
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:
(name of hauler)
The debris will be disposed of in :
(name of facility) n`
(ad2lress of facility)
signature of permit applicant
date
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