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8 ORD ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of Board of Building g Regulations and Standards n ak Massachusetts Stale Building Code, 780 CMR, 7'"edition Building Dept ( Y Building Permit Application To Construct, Repair, Renovate Or Demolish a *bbeftmswa \� One- or T}co-Fami4y Drvelling This Section For Official Use Only q Building Permit Number: Date Applied: • ' ` y0 l l(0, Signature: Building Commissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 1, roperty ddress: 1.2 Assessors Map At Parcel Numbers ei � s+- I.1 a Is this an accepted street'?yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: 5 ,wile 1 mdj Zoning District Proposed Use 1 Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) 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? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check ifyes❑ P P Y SECTION 2: PROPERTY OWNERSHIP' 2.1 wnert of Rec rd: p' / &n/7 ��n f/�O nd H C) C�fGI S'T game(Print) Address for Service: 9 7rr - s>'o Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work: s Q ee SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ L��Q,f/ ©D 1. Building Permit Fee: S Indicate how fee is determined: -3 ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x- 3. . Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) S List: ` (f 5. Mechanical (Fire S Total All Fees:$ Suppression) Check No. _Check Amount: Cash Amount:_ 6.Total Project Cost: S C)t') ❑ Paid in Full ❑Outstanding Balance Due: P � 66 f SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) lel z 2 U` License Number Ex iratio Dale NNgmc of CSL-Helder List CSL Type(see below) �FCSL-Helder ! v-w flfl J List CSL Type(see below) �F Address r• t kDRcsidential Descn tion M stricted u to 1., Cu. g Signature 71) icted I&2 Famil Dwellin 7��`ujq,-N�� n Only I emial Roofin Coverin Telephone ential Window and Siding ential Solid Fuel Burning Appliance Installation Demolition 5.�R7egister m (toCnonrtraclIC ,% e17m 778' HIC Company Name or HIC Registrant Name Registration Number 01 s• lyla s 2-115-110 -B Addre s L u y1,.�/ 'Expirfition Date Signature Telephone-/—,r SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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. Si nature of Owner Date SEC ION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and be n Print Name t 9 0 Signature of Owner or Authorized Agent Dale (Signed under the pains and penalties of perjury) NOTES: I. 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 110.R5, respectively. 2. When substantial work is planned,provide the information below: Total floors 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" ''' " CITY OF SALEM y '1 r � PUBLIC PROPRERTY DEPARTMENT IJ; \1 AMII\i..,IN11!Lfr ♦ \.\11 \I, \L\ iV .. ; 1 . _I'i I I I v'sx-v_-•).841. Construction Debris Disposal Allidavit (required liir all demolition and renovation work) `i In accordance \\ith the sixth edition of the State Building Code, 780 CMR section 1 1 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit N 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 I 11. S 150A. The debris will be transported by: (name of harder) I lie debris will be disposed.of in vnnr,✓�r J Q�,I.S jamo � Inamr of laeility) — � In\ rc�o�ililyl vgnaturo of permit,q)p cant ,r to I CITY OF SALEM PUBLIC PROPRERTY _ DEPARTMENT •I�u'. M'I1' ,AHI• 11 sal w1wM 11. WA41I.MI ION SI.ALL Is S,Ht N.MA%%Aw III ;1 I Is 3197 111. •ps-713-1393 • 1:sax 97x.743 1316 Yorkers' Compensation Insurance tifftdowit: Builders/Contractors/Electricians/Ptutnbers %milicant Information /♦� 1 n Please Print LeCihl Ty Vi11TiC lllu.l i��w((silh�anvatinNlndnulual):tel//17) �JK�• L/- 0,0 r 1,Idi'cia:c�C/� 1/PQe)nQ 57— Ciry,Srtrc.%ip: It .\rc y au an employer:'Check the appropriate box: 'I'y per of project (required): 1,4111 4 lam a general contractor and t :im a employer with�_ ❑ fie C3 New construction cmployces(['oil amllur part-time).• have hired the sub-contractors ?. ❑ 1 inn a sale proprietor or panner- listed on the attached shcet. ❑ Remodeling ship and have no umploycus These subcontractors have S. ❑ Demolition working lin Inc in any capacity. workers' comp. insurance. g, ❑ Building adddiun I No workers'comp, insurance 5. ❑ We are a crnporation and its I required.] officers have exercised their 10.❑ Electrical repairs or additions 3. ❑ I am a homeowner doing all work right ofcxcinption per MCL I I.❑ plumbing repairs or additions myself. (No workers' comp. c. 152, j 1(3),and we have no 12.❑ Ruuf rupairs insurance required.] r employees. tNo workers' 13,C] Other Allau-) pe ode_ comp. insurance required] •way ..pphcani dint cheeks box AI muwl alao till con the,•dims Iwluw allowing ihosr workus'cumpcnsWiun lwliuy ndinnlatoan. -' 11„muuwncn whu,ubntil this affidavit indiejung thew are doing all work mW then hire ou4We cwurxrurx must.uhmil a new alGdavil indi"mg"I'l, 4,msrxwry Ihal,heck this box mitt unxh,d an addoimal..Ixat.howmit raw name of tho sub<osnrxton and their wurken'compry,hcy intonation /our an employer that i.r providing rvurAers'rmnpatcarion insurance jar ury enrplayees, Below is the policy and job wife hrforinution. Ir..urancc Company Name:A_;2 - -- _ ---------- 1'oliev it ur Self.ins.QLic. Ir: 619 -.. . Enpirunun Date: J / 0 lob Site Address: X. t�R9 S� _.S9 l-' . ..ineo Cuy;Slate/ZIp: .\each it copy of the workers' compensation policy declaration pale(showing the policy nuosber and expiration date). I dlluic to teethe cu\era Se as required under Seltiun 25A JI M61. e. 152 can lead to the imposition of criminal penalties ofa tine up to$1.5110.00 and/ur une-year imprisonment, as well as civil penalties in the Rsrm of a STOP WORK ORDER and a fine of up to i250.00 it Jay,Iguinst the violamr. Ilc adviicd that a copy of the wtalument may be Iurw arded to the Office of :Ix tit ut-Iiv I)IA :Or in.ut arse .axeraga wrilicacon. /du herrby ter larder the paitiv andireitulticy of perjury that the iufunnut/on provided �ue,#true surd correct. sl fficiul sue mdy. Da ant Ivrite in this arra, to be t ompleted by.ny ur town r,1jiridz ( iw lv or ton: Per mitiLiccncc 0 iw.uins Aulhurity (circle one): L Ill.ard of llu-ilih !. Mudding, Mpartincnt .1. Gilt.-foou Clerk 4. Electrical lu;peclor 5. Plumbing Inspector 6. Other _ Cw,nucl l'cnun: .. .- Phone r: Information and Instructions N l.t�s.,chusens Genesi Laws chapter I72 require!all Cnlplo)ers to provide workers' Compensation for their employees. f'urnumI to this statute,an emphriee is defined as- e+cry pec son in Ilie service of anuttier under.tiny contract of hire, e,pre»or implied, oral or written." \n employer is detined as"an Individual,partnership,association,corporation or tither legal entity,or any two or more Ir the loreeomg engaged .n a pont enterprise. and including the Icgal representatives of a deceased empio)cr,or the rccervrr or trustee of.or mdtvrdual,piumcr>hlp,association or other legal entity,cmpiuying emplo)ces. However the owner ofa dwelling house having not more than three apartments and who resides therein, or the occupant of the ,t.velhng house of another who employs persons to do mairnenunce,construction or repair work on such dwelling house or,on the grou»dl;or building appurtenant thereto shall not because of such employment be deemed to be on employer." NIGL chapter 152, .25C(6)also states that ..every state or local licensing;agency shall withhold the issuance or renewal of it license or permit to operate a holiness or to construct buildings in the commonwealth for any applicant wino has not produced acceptable evidence of cumpltance with the insurance coverage required." Udimonally, bIGL chapter I52, 4. 25C(7)states"Neither the commonwealth nor any of its political subdivisions shall cnmr 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 Gil out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if necessary,supply sub-contractor(s) name(s), addresses)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 lccidents for conHmation of insurance coverage. Also be sure to sign and dale the affidavit. The atlidavit should be returned to the city or town that the application for the permit or license is being requested, not the Chpartment of i ndustriai 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 ap ropriate line. City or Town Officials Please be arc that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of rhe affidavit fur you to fill not in the cvem the Office of Investigations has to contact you regarding the applicant. ('!.cane be sure to till in the permit/license number which wit)be used;I.s 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 t if necessary)and under"lob Silt Address"the applicant should write"all locations in (city or town)."A copy of the affidavit that has been officially stamped or narked 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 tilted out each i year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture i i.e. a dug license or permit to burn heaves cte.)said person is NOT required to complete this affidavit. I h,: 1 Mice ort Iilvestigatlons would It" to thank )'ou in add;ucc for your cooperation and should you hale.any questions, picise do not hesitate to give us a call. fhc Department's address,telephone and fax number The Commonwealth of Massachusetts Department of Industrial Accidents Omce of investigations 600 Washington Street Boston, MA 02111 Tel. N 617-7274900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 .u' www.mass.gov/dia ' Page No. of Pages ,-�-- - �' wf ng rcr osttt TrslM. TRAHANT !R. CONSTRUCTION, INC. 4TH GENERATION ROOFING 215 Verona Street LYNN, MASSACHUSETTS 01904 (781)844.4551 FAX: (781) 581.0855 H.1, LIC. #141778 PROPOSAL SUBMITILD TO PHONE GATE Y On 1`1`e 53a — 3 Z -r0 STREET JOB NAME CIN,STATE and ZIP CODE JOB LOCATION We hereby submit specifications and estimates for: We hereby submit specifications and estimates for, SHINGLE ROOF FLAT/RUBBER ROOF Strip entire roof 0 Sweep entire roof clean 'Replace any bad boards up to 100 linear feet 0 Strip entire roof 'install ice and water barrier first three feet up roof 0 Mechanically fasten down ISO board insulation install ice and water barrier in all valleys and along dormers ❑ Install 060 Rubber Roofing on entire roof Install 151b felt paper on remainder of roof 0 Install metal flashing around perimeter of building _ .._ ------------ Install eight Inch drip edge 0 Flash chimney(s), pipe(s)and wall(s) Install ridge vent 0 Edge caulk all seams 'UfFlash flash ehimney(s} copper 0 Install new center drain - or re _ 'Ainsta!I new pipe flanges 0 Other: Install 30 year shingle 0 other 0 Clean up all debris 0 Install gutters and downspouts 0 Labor and materials guaranteed 1OOOA for five years 0 Instal}trim coil 0 Install new fascia boards 0 Install new rake boards 0 Install sky light(s) 0 Other: Clean up all debris Labor and materials guaranteed 100% for five years ___-._ --.__ _ _ _._ - ______ ___.. II shingle roofs are nailed by hand. lie I,tTruprrsc hereby to furnish material and labor — complete in accordance with above specifications, for the fsum �of: ---- —. Total Price($ "C)O ' `✓y ). IF YOU ARE HAVING YOUR ROOF STRIPPED, PLEASE COVER ALL VALUABLES IN ATTIC, AS WE HAVE NO CONTROL OVER DEBRIS THAT MAY FALL THROUGH ROOF BOARDS. —4 m material is guaranteed a be as specified. It work to be completed in a above specMke ie manner according a sled to practices.Any alteration wore or deviationcompleted from above workmanlike thea- Authorized tions involving extra costs will be executed only upon written orders, and will become an Signature. extra charge over and above the estimate. All agreements contingent upon strikes, insurance. eO delays beyond our central.Owner ro carry fire,tornado,and other necessary insurance.Our workers are Fully covered by Workman's Compensation Insurance, I A � .r-L� Litt.JBFt<'111rPrltl .lgfiZtj—Theaboveprices, specifications q—, — and conditions are satisfactory and are hereby accepted.You are authorized to Signature do the work as specified.Payment will be made as outlined above. i l Date of.Acceptance_ Signature �„—