99 WASHINGTON ST - BUILDING INSPECTION (7) Cl,n, O1. S.v_1:m
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7APPLICATION FOR PLAN EXAMINATIONANDBUILDING PERMIT
1DINGS EXCEPT ONE AND 2 FAMILY DWELLINGS
I.MPORTANT: .%pplicants must complete all items un this page
an
SITE' INFORMATION p. - .
,
.. .., W ..<w+
Location Name � Budding '
Property Address
Located in: Conservation Area Y/N Historic district
APPLICATION DATE
Use Groups
(check one)
Group Homes 113_Ra_
Residential (3 or more Units) R2
Type of improvement Residential (hotel/motel) RI _
(check one) Assembly (Theaters) Al _
New Building_ Assembly (restaurants & clubs) A2r_A2nc
Addition Assembly(churches) - Al
Alteration Business B
Repair/ Replacement_ Educational E_
Demolilinn_ Factory (moderate hazard) Fl _
Move/Relocate Factory(low hazard) F2_
Foundation Only High Hazard 11_
Accessory Building Institutional (residential care) Il _
Institutional (incapacitated) 12_
Institutional (restrained) 13
Mercantile Rl_
Storage SI _Mudcralc II:¢ard
Storage S2_Low I lazard
ON'.NE,RSIIIP INFORNIATION(Please type or Print Clearly)
OWNER Name
Address � Jhin/ C Tslel/ S T
Telephone
Signature
DESCRIPTION OF %%ORK TO BE PERFORMED
L11IS74-46 .VI lec-/ 25- XWf
57- 5-,b,5; 2,10 317 f-r
LS I INIA I ED CONS RUC I'ION COST
CON'I'RAC IOR INFOR\IA FIOIN ,,/) p
Name /7 U�lUN C an --
Address �a ,9 4,y Ar ID eI fliv�.+ i79 01 iYS
Telephone 9'R8' 9Zs �/ro a1
Construction Supervisor's Lic #
Home Improvement Contractor# /SP�,9ttzs4
.\RCI11'1'F:CI'/ISNI:INEER INFORMATION
Name
Address
Telephone
Muss. Registration #
PERINIFF FEE CALCULATION
OG
Estimated Cost x $11/$1,000 + $5.00=
CODiNIENTS
The undersigned applicatit does hereby attest that all information stated above is trite to the best of niy kiioivledge
under the perialti of perju
(owner) (agent)
Signed
APPROVED BY :
DATE APPROVED: / !ol 09
CITY OF SALEM
;`. PUBLIC PROPRERTY
DEPARTMENT
\ntstt.
::I V Cr x!.l!1'UxI5Cul.l.
Nt Nn lt 12^.WASHING I0.N S7x LL•l' • S.f tEU,MASSACl n SE rl S 01970
'I'hi.:978-.745-9595 it 17nX:978-740-9S46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Lonlicant Information Please Print Leeiblv
14aMC (13uiinctis/Organiration/Intlividual):
Address:
Cityislateizip: A' r1i .i£rr 114 Mime #: 97J` 77; YS"'C/G
Are you an employer'.' Check the appropriate box: 'Type of project(required):
1 I am a er with employer 4. ❑ 1 am a general contractor and t h
P Y ❑ New construction
employees(full and/or part-torte).• have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner-
listed on the attached sheet. �• ❑ Remodeling
ship:and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
INo 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 I I.❑ Plumbing repairs or additions
myself. LNo workers' comp, c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. LNo workers' 13.❑ Other
comp. insurance required.]
-Any:ippticant that chucks box 01 must also fill out the kctiou bcluw showing their workers'compensation policy infumation. -
'I Wmcuwvers whu xrbnal this affidavit indicating they are doing all work and Then hire outside cooractom must suhmil an.affidavit indicting such.
-Contractors that chuck this box moor attached on additional shsxt showing the name of the subcontractors and their workers'comp.policy information.
/❑ut mr employer that is providing)vorkers'c•ompeasatiorr insurance for cry employees. Below is the po/icy and job site
injonnurion.
Insurance Company Name:
I'olicv 4 or Self--ins. Lie. #: ___._._._ -....._._.._ Expiration Date:
Job Site Address: City/State/Zip:
Attach if copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ol'.N IGL 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 fine
of up to S250.00 a day against dte violator. lie advised that a copy of this slatcment may be forwarded to the Office of
luvcsligatimts ofthe DIA for insurance coverage vcritication.
I da hereby L'frr under the in.V mt nlfics ujprrjury that the information provided ubu�'s f5w and correct.
S I L L at t l I C: Date: /
Ph"re ii.
Official use ugly. Do riot irrite in this area,to be completed by city or town ojjic•iat
City or Town: __.. ._. Permit/Liecnsc _-
Issuing Authority (circle one):
I. Board orIiealih 2. Building Department .3.Cityffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Ofher
Contact Person: ._.. . _ - _..-- Phonc#:
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empfgree is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
re"Lver or trustee of all individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
of .n he PP
- 1 r .,,rounds or buildingappurtenant thereto shall not because of such employment be deemed to be an employer."
%1GL chapter 152, §25C(6) also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
isi
.additionally, NIGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomuance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors) name(s), address(es)and phone number(s) along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for continuation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pennittlicense number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address" the applicant should write "all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must 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. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he Off ice of Investigations would like to thank you in advance fur your cooperation and should you have any questions,
Please du not hesitate to give us a call
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office 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 PROPRERTY
DEPART?�1ENT
rd .i,q: L� u A;I II� ..,N$I!t hl'i • ti.\I I'�7, �,.�.;\ :li :i l :I'I
Construction Debris Disposal Affidavit
(required fior all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CNIR section 1 1 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l t 1. S 150A.
The debris will be transported by:
(name of harder)
I he debris will be disposed of in
(name ut I'aalny)
(address of facility)
signature o(penui[applicant
(late _--
Nov 06 2008 1 : 28PM LesleyManagement 1-978-374-4853 1
4 Aulson Roofing, Inc,
OO 49 Danton Drive " I
� U Methuen,Massachusetts 01944
(978)975-4500 Fast (978)975-9987 A
pro osar v
Iprppvevi svbmined iv: phone - Doro
Lesley Management Fax: (978)374-4852 11/5/2008
ttmr Jvb NOW C.vmoci 7�armn
P.O.Box 946 Kim
aoq swe and tip Coda Job A.vvatfon
Marblehead,MA 01945 199 Washlo . Street,Salem,10A
We propose to fmrmkh and install a new&P.A.M. roofing syuens to R.P.,/rnanuJite wren.
speerlmdons in lbefolioudeeg manner:
• This cstimatc covers the following areas: lower flat roof on Este Street side
* Prepare the existing roof to install the new roof directly over it by removing loose gravel.
" Mechanically fasten 1/2 fiberboard with 3"insulation plates and coated screws.
* The.060 EPDM membrane will be fully adhered to the insulation.
The roof edges will have installed new.032 mill finished aluminum edge metal
and 5" EPDM cover strip.
• Vent pipes to have new preformed pipe boot installed up to 6 inches.
Properly flash all drains
* Walls to be vertically flashed and properly terminated.
Provide standard Aulson Roofing two year workmanship guarantee.
• Remove all outside job related debris.
CONTRACT NOTE:
Wcpnrpwe be►eby rolup 6eh aiaMede■ad mom,"opwa im ns ov A met"a above 4WORCedox.f"ehe ON=UP f1,95ade
One Thousand Nine Hundred Fifty Dollars and no cents.
Terms and Conditionet
1. Payment-Payment terms arc as follows:
" Deposit of 1/3,balance upon substantial completion
2. All monies due and payable shall accrue interest from the date such,payment may be due
at a rate equal to 1 1/2%per month.
3. Permits,Fees, and Notices-Aulson will secure building permits and other permits.The
customer is responsible for the coat of said building permits and other permits,at well
as governmental fees, licenses and inspections.
4. Preparation-The customer shall be responsible for preparation and cleaning of interior
ofthe building,specifically the attic as small particles may fall into the attic from the roof.
t
Pape 1
Nov 06 2008 1 : 28PM LesletlManagement 1 -976-374-4853 P. 1
Aulson Roofing, Inc.
49 Danton Drive
Methuen, Massachusetts 01944
(978)975-4500 .Fax: (978)975-9987 n D C1
Proposal K
Propam/sab,einedto: rhane Dab
Lesley Manneernent Fax: (978)374-4852 11/5/2008
Smrnf ,bb NOW Conmd Pff M
P.O.Box 946 Kim
Cao,Stan and 24v Cob !ab 4owNon
Marblehead MA 01945 99 Wasbington Street,Salem,Iv LA
We propose to jarnlrh and install a New E-P.P-11/.reelm9 system to R.P..I re►anaJieta►s►s
specolcartions in thejollowMR aranae►.
• This estimate covers the following areas: lower flat roof on Este Skeet side.
* Prepare the existing roof to trunall the new roof directly over it by removing loose gravel.
Mechanically fasten 1/2 fiberboard with 3"insulation plates and coated screws.
• The .06o EPDM membrane will be fully adhered to the insulation.
+ The roof edges will bave installed new.032 mill finished aluminum edge metal
and 5" EPDM cover strip.
• Vent pipes to have new pndbrmad pipe boot installed up to 6 inches.
Properly flesh all drams
+ Walls to be vertically flashed and properly terminated.
• Provide standard Aulson Roofing two year workmanship guar tutee.
Remove all outside job related debris.
CONTRACT NOTE: ixt�ff
Wepnpaee eeKeY atJhrxW n owtde and laser,eowpWr to aaeordmae wee eaaoe 4WWcwfom4 Jfr of W.ap S 1,950L 00
One Thousand Nine Huadrad Fift Dollars and no cents.
Terms and Conditionat
l. Payment-Payment terms are as follows:
+ Deposit of 1/3,balance upon substantial completion
2. All monies due and payable shall acenz interest fiom the date such payment may be due
at a rate equal to 1 1/2%per month.
3. Permits,Fees, and Notices-Aulson will secure building permits and other permits. 71 e
customer is responsible for the cost of said building permits and other partite,as well
as governmental fees,, licensee:and inspections.
4. Preparation•The customer shall be responsible for preparation and cleaning of. interior
of the building,specifically the attic as small particles may fail into the attic from the roof.
Pepe 1
Boar o u1 mngW/eggu1a,'Mons a`�nod Stan
One Ashburton Place - Room 1301
Boston, Mass chusetts 02108
Home Improvemenjtractor Registration
Registration: 111969
__,----- Type: Supplement Card
z — _
r Expiration: 2/2/2009
4
M .
AULSON ROOFING, INC. °
Bruce Tinkham
49 DANTON DRIVE `
4
METHUEN, MA 01844 Y C% — y�e Update Address and return card.Mark reason for change.
[] Address ❑ Renewal Employment Lost Card
DMCAI i3 5OM-07/07-PC8490 .- - -
- v. -�- �/e �oovrxmuaealb� o�✓l/muc/rueelta
�\ Board of Building Regulations and Standards License or registration valid for individul use only
Vp
HOME IMPROVEMENT CONTRACTOR before the•expiration date. If found return to: _
Board Building Regulations and Standards ,
Registratigrl}�111969 One Ashburton Place Run 1301
�E�P1f ,-n—'-l.' I2009 Boston,Ma.02108
r{ ypg—SugplementCaM
AULSON ROOFIFi7.G
Bruce Tinkham
49 DANTON DRIV � ���e�.` 1110
METHUEN,MA 01844 `� Administrator . Not valid without signature
+�- \la.>achuxctlx - Dcparl merit n' Public �afcn
Hfuld of Buildin_ Kc-ul:uiun+ ;uul �'Ia ItIald.
Construction Supervisor Specialty License
License: CS SL 99977 }
Restricted to: RF,WS
BRUCE TINKHAM
20 BALDWIN STREET
PEABODY, MA 01960
aQ
c'xpirauon: 8/13/2011
t .uuid.�hu,r T,=. 99977
-,llcoRD CERTIFICATE OF LIABI ITY INSURANCE °°M��
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THIS CERTIFICATE 5 LISUED A,q
i �Sanct" insurance ]! A MATTER OF NFORMATION
qcy, Inc. ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
36 Cunm Trgg park HOLDER.THI3 CERnFrcATE DOES NOT AMENI Ir EXTEND OR
W)hL'rn NA 01801 ALTER THE COVEHAGE AFFORDED 9YTHEF'CLICIESBELOW
The ne: 761-935-8480 Fax:781-933-5645 '
Ri xjFeo INSURERS AFFORDING COVERAGE NAIL#
NSURER A: -----ea Oe,e FLaA I I Asucenoe co_
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Methuen MI. 01844 INSURER D; `----
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