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2 FORT AVENUE -BPA 70-10 ROOFING ys ZO ©og� �. The Com onwealth of Massachusetts 4 Department of Public Safety Massachusetts Slate Building Code(780 CMR)Seventh Edition.,' City of Salem 1 Building Permit Application for any Building other than a 1- or 2-Family Dwelling (This Section For Official Use Only) Building Permit Number: Date Applied: Z B' Building Inspector SECTION 1: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available) CX`tt T?Q No.and Street City /Town Zip Code Name of Building(it a pplicable) 4,471OF' SECTION 2:PROPOSED WORK FTOKC7, If New Construction check here❑ or check all that apply in the two rows below Existing Building ❑ Repair 1211tAlteration ❑ 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 0� , Is an Independent Structural Engineering Peer Review required? Yes ❑ No Cam, Bri Description of PruposWork: SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑ Existing Use Group(s): proposed Use Group(s): Y Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34: 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-2r.❑ A-2nc❑- A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Factory F'1 ❑ F20` '' 'H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5 ❑ I: institutional 1-1 ❑ 1-2 ❑ 1-3❑ 1-4 ❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 ❑ S: Storage S-I ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below: Special Use: - SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill IIA ❑ IIB ❑ ILIA IIIB ❑ 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: Licensed Disposal Site❑b ill w not e Public❑ Check if outside Flood Zone❑ Indicate municipal ❑ A trench _ I'ricote ❑ or indentifv Zone: or on site stti required ❑or trench or spectfv: tem ❑ permit is enclosed ❑ Railroad right-of-way: Hazards to Air Navigation: MA I cc iv..1'rurr..; Not Applicable ❑ Is titruclrne�cithin auport approach area? Is their rep iekc completed.' _ •or C rninent to Build enclosed ❑ ' Yes❑ or No❑ Yes ❑ \u ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY I dition of Code UNe Group(N): Tcpe of Construction: Occupant Load per hour. j Does the building contain an Sprinkler Scstem?: Special Stipulations: SECTION 9: PROPERTY OWNER AUTHORIZATION ' Name and Address of Property Owner �. Name(Print) No.and Street City/Town Zip Proper , Con Information, 611 L M -� Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the properly owner hereby authorizes ' Name Street Address' City/Town State Zip to act on the pro perty owner's behalf, in all matters relative to work authorized by this buildin , permit a plicntiun. SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2) (If bl.lildillg is less than 35,000 cu. ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control _ Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor 0 party Name: Name of Person Responsible uction License No. and Type if Applicable fu nstr Street Address City/Town State Zip Telephone No. (business) Telephone No. (cell) e-mail address SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(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 issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 'Lc C tvrw LST��• _ 4. Mechanical (HVAC) $ Note: Minunihm fee=$ (contact municipality) 5. Mechanical' (Other) $ Enclose check payable to 6. Total Cost $ 0 (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT Be entering my name below, I herebv attest under the pains and penalties of perjury that all of the information contained in this a f lication is true and accurate to e best of my knowl dge and un/de�rstanding. Plaice print and .i};n n.une Title Talephune No. Date Street Address City/Town Zip Municipal Inspector to fill out this section upon application approval: -2 • G..f.�J ime Date i CITY OF S.U-ENis NLvLNSSACHL;SETTS BL:MDLNG DEPAILTNMNT _ .120-W.ISH[IGTON STREEr.3 o,FLOOR "IDS_ (971) 745.959S Ffix(971n 7449&M KImBERIEY DRJSCOL L MAYOR DIRECTOR ST.PlF11ls DIRECTOR OF PL BLIC PROPERTY/BCammG CO%L%asslo%EJL Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers k tIn Ilcant Infnrmadon Please Printe Name igusit OrgantzaliomintbvtduAi): Address: City/StatdZip��- -�eA,5_ "A- I PhoneN: 9ti<2;z-.��-� e Are you to employer'Cheek the appropriate boa: Type of project(required): �m a er with employer _�2— 4. 0 I am a general conbxtm and 1 P Y 6. ❑New construction employees(1411 and/or Part-time).* have hired the subcontractors 2.0 1 am a sole proprietor ar partner- listed on the attached sheet. : 7. Remodeling :hip and have no employees Thew sub-contractors have B. 0 Demolition Workingfor me in an capacity. -+vorkera'comp.insurance. - Y P tY• 9. �Building addition I No workers' comp. insurance 5. 0 We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions ).❑ 1 am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions myself.(No workers'comp. c. 152.f 1(4),and we have no 12.0 Roof repairs insurance requited.) r employees.INo workers' 13.0 Other comp. insurance nequired.J -Any applicars dui shacks boa Of mttm alwa no WA the twolas belay showing tbide wvrkaa'remiss nedtm puliey infurmaloa s I hmma wi as who suMtit ride anldwk indicating they are doing all work soft this hit*ouside canin fors tntsm stthanil a are a 9dwit indicting iock. <r.mtm"n thin chwk this box mum arlwhd an addniad shay.hawing the tsame of the aukswtatwctar s and their workae'ramp.pmicy iafamotitm. l arse a a employer that b providfnB trorkers'compensarbn Insurance for say employees. Below to/h4 pel4y and Job slat informutian. Insurance Company Name: Policy M or Self-ins. Lie. p: Expiration Date: Job Site Address: City/State/Zip: ,attack a copy of the workers'comp ingsdoo poBcy dethtrsabn pegs(showing the polk y number and expiration date). Failure to secure coverage as requited under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a rime up to 51,500.00 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 ul ainsf the violator. Ile advised that a copy of this statement maybe forwarded to the Olfice of Invcangatiuna ul'the DIA for insurance coverage verification. Ida hereby e It under the ins and penalties of perjury that the informodoa provided above is true aid earreca P�nre A O friml we duly. Da mat write in this area, to be suntpleted by dry or town a/f rial City or ruwn: - eermit/I.Icense M Issuintl Authunly (circle tine): i I. Ituard of llrallh 2. Huddling Department 1. Ciiytrown Clerk J. Electrical ln}pector 5. Plumbing Inspector 6. 0Iher !.,,nisei Pcrson: Phone . _..__ . ._. L hcsrf,+,...rsio., JifL. 978-815-3032 Estimate Salem Park & Recreation Dept. March 12, 2009 5 Broad Street Salem, MA 01970 Attention: Doug Bollen RE: Re-roof sun house @ Salem Willows Park Large House *Strip off roofing and all sheathing *Remove rotted rafters and replace with new(approx 6-8) *Install new roof deck; secure with 2 '/z ring shank framing nails (options below) *Cover roof with 15 Ib roofing felt *Install aluminum drip edge *Cover with 30-year architectural shingle *Cap hips with cap shingles **Clean and remove all roofing debris **Regular plywood not the best option because of exposure to elements from beneath. Ledger board or pressure treated (with H-clips) better way to go. Labor& Material: Large House $11,250- 1/2" pressure treated plywood $10,260-5/8" CDX plywood $10,540- 1"x 8" Ledger board Workers'compensation and liability insurance available upon request.All materials,parts and equipment are warraned by the manufacturers or suppliers written warranties only.All labor performed by O'Keefe Brothers Construction Inc.Is warranted for five years or as otherwise indicated in writing. All work to be completed in a professional manner according to standard roofing practices. Any alterations or deviations from above'specifications involving extra costs will be executed only upon written orders,and will become an extra charge over and above this estimate.All agreements contingent upon strikes,accidents,weather and other delays beyond our control.This estimate is for completing the job above and is based on our evaluation and does not include material price increases or additional labor and materials,which may be required should unforeseen problems arise after work has been started. Respectfully, , 4 Eddie O'Keefe Y CITY OF SALLM PUBLIC: PROPRERTY ^. �,,.,. . DEPARTMENT .I ,. . , __ I:: U +,•r•. . • . ..all • �Vi u, \I+..+ . .I + Construction Debris Disposal Allidasit octluired Ibr all dentulit it)n and renuca0un work) In accurdauce 11 ith the sixth edition of the Slate Building Code, 7S0 CAIR sec lion 11 1 5 Debris, and the provisions of N1GL c 40, S 54; Building Permit M is issued with the condition that the dcbris resulting from this work shall he disposed of in a pruperly licensed waste disposal Ihcility as defined by ,MGL c I11. S 150A. The debris will he transported by: Inamc of hauler) I he debris will be disposed of in (name of Iacilily) 1.iJdre.. of I�aluvl .ipialmc nt p:nnrt .q+p is q ,late