60 WINTHROP ST - BUILDING INSPECTION The Commonwealth of Massachusetts v
n� Department of Public Safety 2014 AUG _3 A 3 3
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
C Building Permit Number: Date Applied: Building Official:
n SECTION 1:LOCATION(Please indicate Block#and Lot*for locations for which a street address is not available)
0 � JJnITft�oP S� S &k031 0-07a
00 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
IExisting Building"' Repairk Alteration ❑ Addition❑ Demolition (Please fill out mid 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 Engineerm Peer Revieyi re uired? I Yes ❑ No '
B ief Description of Proposed Work: V -/ N
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): I 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)
FA: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑F-1❑ F2❑ H: Hi h Hazud H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑
utional I-1 ❑ 1-2❑ 1-3❑ I-1❑ M: Mercantile❑ 'R: esidential -I❑ R-2❑ R-3 R-4❑
ge S-1 ❑ S-2❑ U: Utility❑ pecial Use❑and please describe below:
Use:
SECTION 6-.CONSTRUCTION TYPE(Check as applicable)
1B ❑ IIA ❑ ❑B fly 1 ILIA ❑ Hill ❑ 1 IV ❑ 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 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❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed ❑
Railroad right-of-way: Tol
Hazards to Air Navigation: NIA i I. t ,_ic C,_nnniksi>n k .��w i,nx- s:
Not Applicable❑ tructure within airport approach area? Is their review completed?
or Consent to Bold enclosedYes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Flour:
Dues the building contain an Sprinkler System?: Special Stipulations:
,eL S 1 $
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner I
rif? (31N!4 81Wb 60 rvN)X;YJZn P sr MetS;7" 1"A oig�
Name(Print) No.and Street City/Town Zip
Property Owner C6nta,a Information:
``,,
Title phone ele T o. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Naune Street Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this budding 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 Hkip Section 10.1
10.1 Registered Professional Responsible for Construction Control -
Name(Registrant) Telephone No. eidress Registry ion Number_
:16ae. �o ao'ay MA 6/5'Gt�
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
A5 S. .R�7T�NCo!!dz"� ��N .� C
So
ompany Name
�J l/�SrROE-7TEWC6, C a7 ��
-Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
7TeIephoneNo. business Tele hone No. cell a-mail address
SECTION 11:W01ZKFRS'C064PFNSn fR,N INSURAN .1i M-FIDAVIf M.G.L.e.152 25C 6kers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
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? Yesk No ❑
SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$ // D , op
1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
4.hledianical (HVAC) $ Note: Minimum fee=$ (contact municipality
5. Mechanical Other $ /
Enclose check payable to
6.Total Cost $ / 6plo, ( (contact municipality)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
❑p I' atio isaryl ace ate to[he best of my knowledge and understanding.
SS ' cr
ase pruit and sign name Title Tele hone No. Date
�S L uyaec De 1&!V/ t21$
Street Address City/Town State Zip
pp
Municipal Inspector to fill out this section upon application approval: 0/� b/g
Name Date
The Commonwealth of Massachusetts
Department oflndustrialAccfdents
I Congress Street, Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Organimdon/Individual):
Address:,,1.0 g�S a U l p—e -D le
City/State/Zip: O 196g2 Phone#: -_�j '7
Are you an employer?Check the appropriate box:
Type of project(required):
1.�am a employer with____employees(full and/or pan-time).'
7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in g, Remodeling any capacity.[Nombrkers'comp.insurance required.] tr❑7 g
3. I am a homeowner doing all work 9• I�1 Demolition
❑ 8 myself[No workers'comp.insurance required.]t
4.❑I am a homeowner and will be hiring contractors to conduct all work on m 10❑Building addition
Y Property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am.a general contractor and I have hired the sub-cormacmrs listed on the attached sheet. -
Thew sub-contractors have employees and have workers'comp.fi so som: 13.❑Roof repairs
t
6.❑we are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑OtherA&AW,L(�
152,§1(4),and we have no employees.[No workers'comp.insurance required.] B� '
'Any applicant that checks box#I must also fill out the section below showing their workers'compensation polity information.
t Homeowners who submit this affidavit indicating they we doing all work and then hire outside contractors must submit a new affidavit indicating such.
tCormactors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employces,they most 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 tti( L( _ MAVE ''7— r,-&XE n T?) y 0 V
Policy#or Self-ins.Lic.#: Expiration Date: `''
Job Site Address: 64/ lznQ - City/State/Zip: p1,760
Attach a copy of the workers'compensation policy declaration page(showing the policy number and a piration 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 fore 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 c ; ut d the pains and p/e acW eeesss off perjury that the information provideed..above is true
>and
correct.
Suture: t ( �A/oir,+ /t��(i/// — Date•
PhoneM:
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#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees. '
Pursuant to this statute,an employee 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
receiver or trustee of an 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
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL 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."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance 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-contractor(s)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 confirmation 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as reference number. In addition,an applicant
that must submit multiple perinn/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 pernut not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
A.S.Bettencourt Construction Company
Where Quality is a Priority
20 Esquire Dr. Peabody, Ma. 01960
1-978-532-0787
Proposal Submitted To: Phone: 978-745-4882 Date:7/29/16
Mr& Mrs Bordonaro
60 Winthrop St
Salem, Ma Job Name Repair Porches
Job Location: Same
Proposal:
151 Floor: Provide and stall two 8"round fiberglass columns and one 4"X4" pressure
treated post with sleeve. Cover ceiling with soffits with center vent. Wrap any other
wood with aluminum. Provide and install three 6 foot rail sections. Provide and install
one 11 foot gutter with accessories .Wrought iron to be attached to the fiberglass.
2"d Floor: Provide and install four 6 foot sections of rail and balusters. Provide and
install five 4"X 4" posts with sleeves with caps and base. Provide and install fiberboard
in order to do a rubber roof. Rubber roof will go up the wall and we will cut a groove in
the brick to be flush. Install piece of aluminum over the rubber in the groove to flush.
We hereby propose to furnish labor and materials complete in accordance with the above
specifications, for the sum of: $11,500.00 (Eleven Thousand Five Hundred Dollars)
Payment Schedule: (1/3 upon start, 1/3 upon request, 1/3 upon completion).
All material is guaranteed to be as specified. All work to be completed in a workman like
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 and above the estimate. All agreements contingent upon
strikes, accidents or delays beyond our control. Owner to carry fire, tornado and other
necessary insurance. O orke are fully covere by Workmen's Compensation
Insurance
Authorized Signature
Note: This proposal m e withdrawn by us if not accepted in Sixty days.
Acceptance of Proposal
The above prices, specifications and conditions are satisfactory and hereby accepted.
You are authorized to do the work as specified. Payment will be made as outlined above.
Accepte Signature:
Date: y/No/NYC, l Gfl�� (y(® Signature: � /
CITY SALEA4MASSAMBET'P'
BULUMDerAXmaW
M tWAMCIMSnr,31"Fi oaa
1>a.(478)7�149846
7*5-9995
BIAm .
Fair ERIEYDL
MAYOR 9EisSST. MM
�scn��� r/st�aa�
Construction Debris Disposo/Affidavit
(required forall demolition andrenovation worki
In accordance with the soM edition of the State Building Code, 780 CMIt, Secdon 111.5 Debra
and the provisions of MGL oW,S 54; Building Permit fi Is issued with the
condition that the debris resulting from this work shelf be disposed of in a pr*erly licensed
waste deposit fadlity as defined by MGL c ill, S 156A.
The debris will be transported by:
(name of hauler)
The ebrls will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
l✓