70 WASHINGTON ST - BUILDING INSPECTION (5) qr"RVIC -81
The Commonwealth of Massachusetts
Department of Public Safety, ,UN Z Q y;P
Massachusetts State Building Code(78,
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
1\ SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1J 70 U1/+ T crA , X i,AQ. 01976
No.and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2•PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building C9' Repair�tion ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
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 Enginee"Z Peer Review required? Yes ❑ No ❑
Brief Descriyylion of Propos d Work .CiE G'7a2�P.UP T!/U✓vt. VOOT -TC).S 2,1
Ne.41 L'(/2h lC, 0(v0 illy 4l ezed ' u P2) J r,4 .
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 CMR 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-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
R Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-1❑ 1-2❑ I-3❑ I11❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U. Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IHB ❑ IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer tu-780 CMR 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❑
Private❑ or indentify Zone: or on site system❑ required ❑ or trench or specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: paA Hist,m, eou»n i�sion �.•�-ielc�'roa�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:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of PPjoperty Owner
?O (,(A(4t-jA f
Name(Print) No. and Street City/Town Zip
Property Owner Contact Information:
AIrl 1,94.A'
,Title Telephone No.(business) Telephone No. (cell) e-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.ft.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
Name(= T ephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
9NWJ R -7a-
Name of Person Responsible for Construction License No. and Type if Applicable
a a G'"Wi- s dl!P
Street Address City/Town State Zip `
qx-j fie faa -2V Vign rcb A« (P ue-A r 2ah , rye�
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11: NSAI ON iN�tU A vt 1.Ai-? L Avil' M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the is mince of the building permit.
Is a signedAffidavit
Adavit submitted with this application? Yes VNo ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ IV Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ D appropriate municipal factor)=$
3. Plumbing $
4. Mechanical (HVAC) $ p Note: Minimum fee=$ (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contac,.-ram _ucipality)and write check number here
SECTION 13: SIGNATURE OF BUILDb,G 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 to the best of my knowledge an understanding.
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Please rint and sign p me Title Telephone No. Date
4� PCU12GJU /2 .It_ J'�,O oy,?q /� q7a
Street Address City/Town /-��State Zip
Municipal Inspector to fill out this section upon application approval:
Name
06/08/2016 11:56 9787444288 CURNS VERNET PAGE 01/01
AIM
rofessio al 1[X'1oofihn.,cr Contractors , Inc
jaines +V. Shea, ,President
P.O.' YQX 26" 45 DE ARBDRN S'TR ;F;T
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P:TON' T'. [57111 744diFAIA FAX(074) 74-4-?g1
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PROPOSAL
April 29, 70 1.6
Mr. George Vea7tet
Vernet Propel-ties
70 Washington St.
Sallem, MA. 01970
RE: Flat Roof— 70 o v ast ington St., Salem, MA.
To re-roofrear flat roof with the following steps:
1, Set Up perimeter«tarring lives per O.S.H.A. requirements.
2. Remove loose gravel from roof,
3. Apply 2" polviso roof insulekm to entire roof.
4 Apply 2",wood.nailertoptairneteroft•ovt.
5. Apply Carlisle 060 fully adhered EPIDNA Design 'A" roof system.
6. Install Carlisle inss strip detail on all vents and walls.
7. Re-flash all penetrations per Carlisle roof details, �f�fr
4. Install 040 bronze color aluminum i-oof edge flashing.
9. Install two new ron-Cdrains.
10. Remove all roofing materials.
11.. This proposal does not Cover and in no case sbali PyofCHPional. hoofing Contractor8, Inc. be
liable for•the removal or darnace to l .VAC unitis, conduits_ gas titres, water lines and
electrical lines whether located above, below or in roof system.
TOTAL COST..........................................Sk9,800.00
ACCEPTANCE OFPROPOSAL.............................................
TERMS OF PAYWNT.........................................................
Options:
1. Provide Carlisle 15 year labor and material warranty....................Sp75.09
2, dn,5tnl(teew 1,6 oz. copper roof edge Plashing with stainless steel exposed screws.
(:nst.......................... ......
The Commonwealth of Massachusetts
a Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
\'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name (Business/Organization/Individual): )Gull i /lG_CY1 r�)tf}CLIGY1 l
Address: f%` & ' Jv ik o-t.
City/state/Zip:. U 61f� v Phone #: f Z6'— 7yY-0/
Are you an employer?Check the appropriate box: - - Type of project(required):
1.®I am a employer with zi employees(full and/orpart-time).• 7. ❑New construction
2.❑1 am a sole proprietor or partnership and have no employees working for me in g. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.O 1 am a homeowner doing all work myself.[No workers comp.insurance required.]r
10 Q Building addition
4.❑1 am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole I IQ Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.r'l 1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.®Roof repairs
These sub-contractors have employees and have workers'comp.insurance.' ICy
6.r—1 We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
I Homeowners who subtrut this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: (f,o
Policy#or Self-ins.Lic.#: 6 yZ V d LJIfS(1 /t/[J —L /S" Expiration Date: $ l//Z 7
Job Site Address:_1) f kr#/14 ,A*L.Z`Il City/State/Zip:
Attach a copy of the workers' comp nsation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$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$250.00 a
day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties of perjury that„'tee.-nformatien provided above is true and correct.
Signature: �ik"G'J = /'9✓�J/ gr..� Date: G�O fir,
Phone -.
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
9PROF02 OP ID: DP
DNYM
CERTIFICATE OF LIABILITY INSURANCE DAM
06103120 6
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: If the certificate holder is an ADDITIONAL INSURED,the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on this certificate does not corder rights to the
certificate holder in lieu of such endomemen s.
PRODUCER CNAINE CT John J.Walsh Ins.A cy.,Inc.
John J Walsh Ins Agency,Inc PHONE g78-7453300 FAX No:
P O Box 4407 AIc Na Ea : 978-745-9557
Salem,MA 01970-W7 EMAIL
John J.Walsh Ins.Agcy.,Inc. ADDRESS:
INSURE Si AFFORDING COVERAGE NAIC 1t
wsURERA:AdmiralInsurance
INSURED Professional Roofing INSURIER132urich
Contractors Inc.
P. O. Box 262 INSURER G:
Salem,MA 01970 INSURERD:
INSURER E:
INSURER F:
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
POUCYOFILSSR TYPEOFINSURANCE POLICY NUMBER M orfyF MM YEXP umM
A X COMMERCIALGENERALLU1aIUTY EACH OCCURRENCE $ 1,000,00
CLAIMS-MADE XOCCUR CA000020865-02 02/17/2016 0211 7/2017 PREMI FEff
RE 60,00
PREMISES EaO ee $
MED EXP(Any one Person) $ 5,00
PERSONAL B ADV INJURY S 1,000,0001
GENL AGGREGATE LIMIT APPLIES PER: GENERAL AGGREGATE $ 2,000,00
POLICY❑JET LOG PRODUCTS-COMP/OP AGO $ 2,000,00
OTHER $
AUTOMOBILE LIABILITY COMBINED SINGLE LIMIT $
Ea accdent
ANY AUTO BODILY INJURY(Per person) S
ALL OWNED SCHEDULED BODILY INJURY(Per accident) $
AUTOS AUTOS
NON OWNED PROPERTY DAMAGE $
HIRED AUTOS AUTOS Per accident
a
UMBRELLA Me OCCUR EACH OCCURRENCE $
EXCESS LAB CLAIMS-MADE AGGREGATE $
DEO I I RETENTION$ $
WORKERS COMPENSATION PER OTH-
MOEMPLOYEWUABILHY STATl/TE ER
B ANY PROPRIETOR/PARTNERIEXECUTIVE Y❑ 6ZZUB-0450NOB-6-16 05/01/2016 05/01/2017 E.L.EACH ACCIDENT $ 500,00
MI OFFICEREMBER EXCLUDED? MIA
(Mardatory in NN) E.L.DISEASE-EA EMPLOYEE $ 500,00
If yes,describe under
DESCRIPTION OF OPERATIONS Wev, EL DISEASE-POLICY LIMIT $ 500,00
n T
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES (AWRD 101,Addiaonat Remarks Sehadule,may Ce anaehed a more sPaen is required)
CERTIFICATE HOLDER CANCELLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION
NOTICE WILL BE DELIVERED IN
City of Salem ACCORDANCE WITH THE POLICY PROVISIONS.
Inspectional Services
120 Washington St 3rd Floor
Salem, MA 01970 John J. REPRESENTATIVE
John J.Walsh Ins.Agcy.,Inc.
01988-2014 ACORD CORPORATION. All rights reserved.
ACORD 26(2014101) The ACORD name and logo are registered Marks of ACORD
6e _ POME
Officeof Consumer Affairs&Business Regulation IMPROVEMENT CONTRACTOR9istration: 162766 TYPe:piration: 4/6/2017 Private Corporatio.(
PROFESSIONAL ROOFING CONTRACTING INC
JAMES SHEA -
;.41,.45 DEARBORN ST
- +, •SALEM,MA 01970 Undersecretary
r. C
L„K
Massachusetts Department of Public Safety
Y�r Board of Bui loing Regulations and Standards
-' License: CS-019729
i
Construction Supervisor t `,
v =
. 4&r. JAMES W SHEA „
45 DEARBORN ST
r. SALEM MA 0197-0
z,
Expiration:
Commissioner 1 011 512 01 7
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\ *!Comm ONWEALTH OF M%�SSAC IitJSE ,S
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.'A" .J30AR_D'0Fr fi.i
SHEET METAL WORKERS
ISSUES THE FOLLOWING LlCt tOkE;AS A
. 4MASTER UNRESTRICTED t rc
I" JAME3 W SHEA ,.,,
A50EARBQRN-93'
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SALEMp MA-1 04970 2429
.3823 `•421112017 6082
-COMM ONINEALTH'OF M3SACHUSE77S=" z
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` PLUMBERSANb`GASFITTERS K;t
ISSUES THE FOLLOWING LlCEiSE
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G£NSED AS ANLTD ULP I' `
JAMES W SHEA` S' �',. a I
dS DEARBORh1$7 �D jV
`< �SALEM. MyA 019702429�'"�
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