0046 WASHINGTON SQUARE SOUTH - BPA-14-1268 $ 2S
1_5 - 1 Lf ,-1 z68 RECEIVED
INSPECTION VICES
The Commonwealth of Massachusetts ' tip
Department of Public Safety , � 3 ( P 42
W
Massachusetts State Building Code(780 CNIR) ' k♦ •'
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(Phis Section For Official Use Oily—)—.
Building Permit Number: Date Applied: Building Official:
'SECTION 1:LOCATION(Please indicate Block N and Lot N for locations for which
�s a street address is not available)
)y0 W t a1.r fUr'. S4 _ QWO NA/ell AclN elA/ yQ✓7T
No..and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2.PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building lH,- Repair SiefAlteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Revi/W reyuired? Yes [INo ❑
Brief scription of Proposed Work: �i -f e•A An. / > '-'e / O ov T ,fY(f/e'•-
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-t ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ ' F2❑ H: Hi h Hazard H-1 CIH-2❑ H-3 ❑ FI-4❑ H-S❑
1: Institutional I-1 ❑ 1-2❑ I-3❑ I-4❑ M: Mercantile❑ R: Residential R-l❑ R-2❑ R-3❑ RA❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION G:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB Cl HA ❑ [IB ❑ IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CAIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ Permit is enclosed❑
Railroad right-of-way: I'Ia[irds to Air Navigation: \IA I li ( n r'nnmi c m I r ir•rv.I r:r s:
Not Applicable❑ Is Structure within airport approach area? _- Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code:. Use Group(s): __ Type of Construction:_ Occupant Load per Floor:
Does the building contain an Sprinkler System?: _ Special Stipulations:
3 '21 —SkWT Tb CDNTz W—,-pr,
__ , ,„nn SECTION 9: I'ROPEIC Y O4VNEII AU'1'f10RIZA'rION
,N;unq S_dZ1fA'ddress of?Rro erh'Owner
,W✓,.ZJV
P �il✓Uu./�v`� �16 �a✓7� 5'I�' �(Q JR /Tn��� �!( �
r• game(i g tJUL 011¢ No.and Street City/Town Zip
(! --Property Owner Contact Information:
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.R.of enclosed space and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Nome(Registrant) Telephone No. a-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Compaann'Name
G�o/�702 Q
Name of Person Responsible for Construction License No. and Type if Applicable
1V bra,Ste,w JF S/zn /7-4
Street Add e City/Town State Zip
y gal
Telephone No. business Telephone No. cell e-mail address
SECTION 11:1VOItKEIiS Cl)\1NGNSr\PION INSURANCE AFFIDAVIT M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the hIA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes IV No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Ih.m Estimated Costs:(Labor
'C
and Materials) oral Construction Cost(from Item 6)=$
1. Building $ DDi — Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor`)_$
3. Plumbing 5
4. Mechanical (HVAC) S Note: Minimum fee=$ (conta�pipi lit
5. Mechanical Other $ Enclose check table to
Py
6.Total Cost $ 101,099, (contact numicipa1 ty)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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 o my knowledge and/understanding.
JTA4 lI/ 4ezl i /r/ a G� Y/� 277
Please print and sigja46anie 'Citlee Telephone No. Date
Street Address City/Town State "Zip
Municipal Inspector to fill out this section upon application approval: ..i
Name Date
a
CITY OF S:U EM, ANSSACHUSETTS
BUILDING DEPARTNIL-.NT
1'_0 WASHCVGTON STREET, 31O FLOOR
TEL (978) 745-9595
N_x(978) 740-9846
K1\IBERLHY DRISCOLL
� ,MAYOR THo&L-xsST.PIEMEI
DIRECTOR OF PUBLIC PROPERTY/BUR.DING CONLMISSIONER
Worlters' Cornpensation Insurance Amdavit: Builders/Contractors/Electricians/Plumbers
:% t tlicant Informatinn Please Print Le )hl
NatnC(Iluaincss Organiralion,'InJividu:J
Address: 420 ill p 2
City/State/Zip: _ )ir///, %lIYG/ Phone #: / Ze- 24il Zgee
Are you an cmpluycr:'Chcck a appropriate butt: 'type of project(required): _
I.IT t am a employer with 4, ❑ 1 am a general contractor and 1 6. ❑New construction
omployees(full and/or part-time).' Have hired the sub-contractors
i 2.❑ 1 ants sole proprietor or partner. % 'lisldd on the attachcd'shect. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working liar me in any capacity. workers'camp. 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,❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers' comp. C. 152, §1(4),and we have no 12.[ hoof repairs
insurance required.) t employees. (No workers'
comp.insurance required.) I7.❑ Other
-Any applwian d ck al ches box at moat also fill out th cti e seon below sho Willa Thor wotken'cumpenaaliun policy inln bnation.
'I lomaowtwn who submit this alTldnvit indicating they arc doing all work.and then hiro uulsida cuntncton mail submit a new air,davit indicating such.
K'nmmc tun that O wk Ibis boa must amochal an addilkaxal ahwt showing dw nune of the subaunlncton and the I workers'comp.policy inlonnarion,
l um on employer that is providing workers'cunipen,vatlun insurance jot my employees. Below is Nhe po!!cy atd Jub.ci(e
fuforniation.
Insurance Company
Policy ill or Sclr-ins. Lie. 0: L /,?/ ei i-l0 aL/_m /o— //� Expiration Date:
Job Site Address: /A,,9 fqh d Ciry/State/Zip: �1ri7. / /s/,
Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of&IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.01)mud/or one-year impri.conntent,as well as civil penalties in(hit form of a STOP WORK ORDER and it fine
or up to S230.00 a day against the violator. Ile advi.;ed that a copy of this slalemcnt may be furwardcd to the oI'IItlC of
Invcsligwiun.c ul'the nIr\ for insurance coverage veriticaliun. -
l do hereby certify tit r the pains atd penalties perfury that the infurrnotiaa provided ubave i.v true and correct
5i •n I re' 9 / `na Data: ���
011idol use at//. Du nor write ht thix area, to be completed by city ur town offivi"I -
Ciry nr'fuwlc _ I'ermil/I.Icente 4
Iesuing Authurily(circle one): -- - _- --- --
I. Board of llcallh 2. IluildIng, Department 3.Cilylrown Clerk 1. Electrical 6npcctor 5. Plumbing Inspector
0. Other
Contact l'enun: Phone !f:
CITY OF SALEM, MASSACHUSETTS
�`•. BUILDING DEPARTMENT
120WASHINGTON STREET,3mFLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR Tf IOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING 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, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will bee transported by:
(name of hauler)
The debris will be disposed of in:
/rear dl/7
(name of facility)
_�StilY�r 12/,
(address of facility)
Signature of at/P plicant
Date
JIM
Professional Roofing Contractors , Inc .
James W. Shea, President
P.O. BOX ,M S CHUSETTSDEARBORN STREET
SALEM,MASSACHUSETTS 01970
PHONE (978) 744-6888 FAX (978) 744-8814
professionalroofin-@verizon.net
PROPOSAL
I
72.
July 7, 2014
Mr. Anthony O'Donnell
Peterson O'Donnell Funeral Home
167 Maple Street
Danvers, MA. 01923
RE: O'DGnnell-F-uneral Home,Salem, MA
To re-roof one section of garage roof with the following steps:
1. Remove two layers of roofing shingles.
2. Replace any rotten roof boards at an additional cost of$6.00 per ft.
3. Apply 15 lbs. of felt paper.
4. Apply new GAF Timberline roof shingles. All shingles will be hand nailed with hot
dipped galvanized roof nails.
5. Install new ridge cap shingles on two ridges.
6. Clean up and remove all roofing materials.
7. This proposal does not cover and in no case shall Professional Roofing Contractors, Inc. be
liable for the removal or damage to HVAC units, conduits, gas lines, water lines and
electrical lines whether located above,below or in roof system.
i
TOTAL COST............................:.......................$19600.0
ACCEPTANCE OF PROPOSAL..............................................7 .......
TERMS OF PAYMENT..................
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