26 FOREST AVE - BUILDING INSPECTION (2) �V
_RECEIVED
r(J � The Commonwealth of Massachusettsr
Departmentu Public Safety 1015 NOV 2 S A U 12
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)
Building Permit Number: Date Applied: _ Building Official: tl 7> f
1 (� SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for whick a street addrHAs not available)
(� No.and Street City/Town Zip Code Name of Building(if applicable)
�y 1 SECTION 2:PROPOSED WORK.
Edition of MA State Code used_ If New Construction check here O or check all that apply in the two rows below
Existing Building❑ 1 Repair❑ I Alteration ❑ 1 Addition❑ I Demolition O (Please fill out and submit Appendix 1)
Chan I Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No O
Brief Description of Proposed Work:
s'os'yT�eA
v
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY -
Check here d an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) O
Existing Use Group(s): IProposed 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 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 O F2❑ H: High
Hazard H-1❑ H-2❑ H-3 O H-4 O H-5❑
1: Institutional 1-1❑ I-2❑ [-3❑ IJI❑ M: Mercantile❑ R: Residential R- R-2❑ R-30 R-4❑
U: utility❑ Special Use O and lease describe below:
S: Storage S-1❑ S-2❑ ty P P
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
U1 ❑ IB O IIA ❑ IIB O IIIA ❑ IfIB ❑ 1 IV ❑ 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 Cl A trench will not be Licensed Disposal Site❑
required O or trench or specify:
Private❑ or indentity Zone; or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: I I. t;ri.Commi sion_Re, ry I ru ys:
Not Applicable Cl Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No O
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 Property Owner t
Y-/ehAqrJ C DI•on o26 �yvlt3� �y S,q/trn pfasS 0PF70 .
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: P
Ddhe— �-' 2Vs a ,
Title Telephone No. (business) Telephone No. (cell) e-mail address
If ap licable, the prop rty owner hereby authorizes
�Yo Abs sv 2- �s,<�y a�� . e N
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) -
f building 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 -
&-a,/ d u22 ler - /5� �2�i /o 6 Lf 6, /
Name(Registr nt) // Telephone No, e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - - - - -
,c. .�( tja
ComyNmeuro's�iO2j 6_s �2, s� rly 6616 / J 73 Z 1T
C/"H,�Q (•"- v""'yi�•
Name of ersoo Resp9nsible(jor Con ruction License No. and ype if Applicable
$t� QGvI d Sl ' sdl 4L
Street Address City/Town State Zip
11 70--5 2-
Tele hone No. business Telephone No. cell e-mail address
SECTION 11: WORKERS'CONIPENSAI'ION INSURANOI Af.FIDAVI'1' M.G.L.c.152.§25C(6))
AWorkers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No D
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE. -`
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Building $ to "ZZ'7 + Budding Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (0 ^p0' 00 (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
application is true and accurate to th st of my knowledge and understand' g.
710-70-1-
Please pr' t ind sig11 nmrie S Tithe Telephone No. Date
Sl l d S�9ZC rAn rqc, of476
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Name
Date
PEGERO ODD Joss
Lynn Mass 01.902
Phone-781 -603-9832
Richard E.Dion
26 Forest Ave. PROPOSAL
Salem Mass 01970 11/18//2015
1-978-604-0142
Dear Sir or Madame,
Based on my visit to your house located at the above address and our discussion,I have prepared the following proposal.
Please review the following outline of the general specifications and the work required in order to complete the Roof Job to
your property at 26 Forest Av.Salem Mass. 01970
The following project/work will be completed in accordance with the building codes set forth
By the Commonwealth of Massachusetts 780 CMR:
Description of the Job
1. Contractor to obtain required building permit(s) from the city/town Salem Mass 01970.
2.Remove off 24sq.the existing old shingles.
3.Install 24 sq. of architect life time warranty. (Timberline Natural Shadow 40MEM Lifetime Shingles.
Or color TBD.
4.Install 15 Felt paper Roof Protection.
5.Install Ice& Water Shield,Roll Roofing Und'erlayment.3 Ft,edge the roof only.
6.Install F8 White Aluminum Open Face Drip Edge.
7.Install Cobra Ridge Vent Low Profile Exhaust Vent. (If needed)
'.Remove 3 and install 3'new 21 in. x 45-3/4 'n.Fresh Air Venting Deck-Mount Skylight with Tempered
LowE3 Glass. � eerk '-{-d (ole, [ ( lux
9. Contractor responsible for the debris does to the construction work.
Total cost of labor and materials: 10500.00. Down Payment of 5250.00 Final payment job completions
5250.00
work could begin within(1)to(2)weeks of acceptance and take approximately(1)to(1/2)weeks to complete,depending on
the weather. Once started, all work would be performed in a timely and professional manner. Please note that any changes to
the above listed specifications would have to be discussed and re-evaluated as expected.
CONTRACT ACCEPTANCE: Signing this proposal means you have accepted the terms and specifications as stated in the
proposal and authorize Pegero Odd Job. To begin work at your property. In addition,the signing of this proposal by both
parties' converts this proposal to a binding contract between the two parties.
I thank you for your business and look forward to helping you add value of your property.
Sincerely,
Pegero Construction
502 Easter Ave.
Lynn Mass 01950
781-603--9831 JJ
Date accepted: Signature of property owner:
e
Date accepted: Signature of contractor ki
Page 1 oft
IL
The CommonweaM of Massachusetts
Depazonerlt ofbidttstrialAe dents
I CongressSWw4 Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit Builders/Contractors/Etechicfans/Plumbers.
TO BE MAD WITH THE PR RbIIWMG AUTHORITY.
Applicant hbMation PkA=PEW,
Name(Basioess!Or&amzation%1ndividml): GL W QS Co rt-S � .
address:_
City/State/zip: s/! wi ._ x-14 5 Phone#: �Sr(-?/S _ 3 2-
Are you as empbyeYPtled[tae appreprWe Of ro ecl .
Type P J (re9nirod):
employer wffi 2 prem(tate aaw rpw.tmx).� 7• Q New conabnctiun
2Q1am a,sok ptopvae or,orparaysldp have no.empbypm wo44ns !"me in $; ORemodeling
aa,'rayaattY (No awrlms''comy.foaamro requked) -
3.p lam a homeow�dq®g sa wadcmyseu:(No worker'emry:koiamtae t .,)� 9: O DemoMibn' .
10 p Buiildmg'sddi`6'on.
a.p Iain a eomeowaeraoa tell be trviog ooimacrma b eeodtat an we*on my pmpetty. 1 war -
eoaeethat atl eowaama arawhave makers'enmpemation iaa u mm sole 11.0 Electrical repairs or additions
weprimmacormao 12.13 Plumbing epiksoraddNow
5.O lama gmne]ccmmnaand ltirvehim!ds sub4aebactm tiaad on the said"sheet: 13. Roof
7bm wbo-c Mwtmhaveemployeoaodbawwc&m'oomP msur�o�t- Q: . reps- .
6.E]we ere a cerporaii®sod its o}5ceisheve exached di*dshta ®ptionpe MGl,c. 14'00th
Mf](41 and am hninb iorytgxes:pro wIwkeis' mpmaeeV Mgaeed.I ' -
MnyappHoMfhetcheeb66af]&mt afro 68 oIDtbe,eu to bebwahewingPodrwolkeas a atim pohrylo ' .
t Homeow9es afio aubrnit dis affidartt tndiee�gtbeY medoing as wrnk and mtanhe oubrde amore mea sabmi nnewaffidavR IDdrmmig aaeti:
tCmunamthat check"tied mbar stashed anadditional&COADWhIs the nam ofine sub-whCpoims and sate*hcdw ernm dim c=W Lave .
employaac Ifae b-c�.hm aM 1.0Ya4Weymustpmvidemr6.wmk-':e mA Pahcy
Iain an , that ar
employer prowlding sMrh�=,4!0
mp0*
agvn uuyraoeelor my emplvyses. Below it thepatiryaadfab
Insurance Company Name:
Policy#or Self-ns.Lic.# f�SL'✓i✓ �/O 6Gd/ !S� EgjQ on Date:
Job Site Addross: OZ(o dAOS A U[, • Ca mat zip: �LD �•
Attach a copy of the workers,compensation pollcy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required Tinder MGL c. 152,§25A is a criminal violation punishable by a Sue up to$1,500.00
and/or ono-year imprisomoeat,as well as civil penalties io the form ofa STOP WORK ORDER and a fine of uP;to$230.00 e
day against the violator.A copy oft stateirimt may he torwa-dad to$e Office oflovestigaticns of the DIA for ianiraace
coverage venficatiau.
Ido hereby eertifygader a ains and ojperfrrry that the information provided oboes m true and eomd
Phone . 32.5 I—
O,(/icia/an only. Do not write in this area,to be Mosplelad by Cary or sown oflcw
City or Town: Permlt/IAeense p.
Issuing Authority(circle one):
1.Board of Health I Building Department 3.City/fawn Clerk 4.Electrical hospector 5.Plumbing Inspector
6.Other
Contact Person: Phone ti:
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 ofhire,
express or implied,oral or writtgn"
An employer is defined as"an individuals 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 in individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resider 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 requircd."
Additionally,MGL chapter 152,§25C(7)states"Neither the cornamonwealth 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 shustion and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with thea certificates)of
insurance. Limited Liability Conn aures(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]me.
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 a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given yea,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.a dqg 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
I Congress Street,Suite 100
Boston,MA 02114-2017,
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/die
CITY OF SALEA MASSACHLBEnS
BEnDiwDErARTzxr
120 WASfEiCMNSTREET,3IDRC+OR
TkL(978)745.9595.
FAX(978)740-9896
Rit.4nRRi nYDRISQ7LL
MAYOR TMAM STAEM
DntECTC9tOFPMUCPROP MIIIIAi MCDMWM I�M
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
CLJ V '1Sr)Q, acv
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signaiure of applicant
Date