7 WEST TER - BUILDING INSPECTION r
/ The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALERevised ar42011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For OffigiaiUse Only
Building Permit Number: Da Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
L l a Is this an accepted street?yes_ no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
&,Aq Stc ..wr rLSn���
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altera[ion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work : 5't r —
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (RVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees: $
4 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ p 0 �') ❑Paid in Full ❑Outstanding Balance Due:
0 A ct44��4t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
0'�
� �\"'--� � License Number Expimtio Dat—e
Name of CSL Holder
-�)'o �� List CSL Type(see below)
No.and Street h Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted M2 Family Dwelling
Citylrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
QW
l' \ cn' S�'�--ti- HIC Registration Number Expir ion Date
HIC Company Nye or HIC Registrant Name
`�O ��
No.agtl StreetkN)Aj { . . ^r ,�.��,� COX��` Email address
City/Town,State,ZIP !• h Telephone
`J
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 .......... ❑ No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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:OWNEW 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 applica ion is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Dat
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.uov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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 May 5,2011
SUBMITTED TO: Rev. Jeffrey Barz-Snell
1 *West Terrace Ave.
Salem, Me
We hereby submit specifications and estimates for:
To remove all existing roof shingles from complete main roof, lower side
roof, rear extension roof and front entranceway .
To install ice and water shield along all roof edges and along all flashing
ffts 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, lower side roof, rear extension roof
and front entranceway.
To install up to 100 linear feet of roof boarding if necessary.
To counter flash, re-flash and/or re-seal all sidewalls as necessary.
To install new roof flanges on roof vent pipes.
To counter flash, re-flash and /or reseal power vent fan on main roof.
To install new roof bathroom vent on main roof
To counter flash and/or reseal the chimney flashings as necessary. If lead
flashing is too damaged on the chimneys we will grind them out and re-
lead at an additional cost of$250.00.
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 $5,685.00
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 contro ner to carTy fire,tornado and other necessary insurance.
Our workers are fully covered by W s 'on surance.
Acceptance of Proposal-You are rk a pacified.
Authorized Signature:
Signature: a
Date of Acceptance:
CITY OF S�UE11, �'Ir1SS��CHL`SETTS
• BUILDING DEPART\IENT
120 WASHINGTON STREET,Sae FLOOR
e� TEL (978)745-9595
FAX(978) 740-9846
iUNfBERI.SY DRISCOLL
NMAYOR THOMAS ST.PIEM
DIRECTOR OF PUBLIC PROPERTY/BUMDING CO\L\aSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben
Applicant Information Please Print Legibly
Van1C(BusirnsaiOrgartiza[ioNlndivitlual): V. \\ "\ 'Grv..
Address: 1,30 �c A-4,—X
City/State/Zip: A rA , JN�)1 'Phone -)"\n-0
Are you an employer?Cheek t _ appropriate box: Type of project(requireM:
1,EJJ am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9, ❑Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its
required,] officers have exercised their IO.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers' 13.❑Other
comp. insurance required.]
•Any applicant that checks box r I mutt also fill out the sectim below stowing their wmiren'tmmpimunim policy infunnation_
♦I lnnsetwneo who submit this aPot6,vit indicating they ate doing all work and than hire outside cwttmcmts must submit a new andavit indicating such.
=Conuncton that cheek this bane must anachod an additional sheet slowing the count of the subsoa mcbo s and their worltws'comp.policy information.
l am an employer that Ir providing workers'compensation Insurance for my employees. Below Is the po/fey and Job site
information.
Insurance Company Name.- OO
Policy H or Self-ins.Lie.H: \tv �D V�1 `� �— Expiration Date: h�nJob Site Address: City/Smte/Zip: Sc,\-ca ,1�r ,A ie..
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 S 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
f do hereby cert6&under the pains and penaldes ojperfury that the information provided above Is true and tarred
sienatil L "1// [)are:
Phone7L•
Official use only. Do not write in this area,to he completed by city or town ocioL
City or Town: Permit/I.1cease#
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.Cilyfl'own Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person• Phone q:
CITY OF S.UXIN1, TNLkSSACHUSETTS
• BUMDL%IG DEPARTNE1UNT
' 120 WASHINGTON STREET,YD FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
K INiBERL.EY DRISCOLL
MAYOR THOLNAS ST.PtEm
DIRECTOR OF PUBLIC PROPEM/BUUMING 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)
(addrIss of facility)
signature of permit applicant
date
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