3 PLACEEASANT ST - BUILDING INSPECTION The Commonwealth of Massachusetts
h Board of Building Regulations and Standards Town of
�a Massachusetts State Building Code,780 CMR, T"edition Budding Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a *
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: U
Signature:
�' �j 'O�U
Building Com ssioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Pro rtVddr�ess: � � ` 1.2 Assessors Map& Parcel Numbers
1.I a Is this an accepted street?yes-2- no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 0) Frontage(tl)
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 if es❑ P po y
SECTION 2: PROPERTY OWNERSHIP'
2.1 27ner'of Record \ ---) 9, 5X,-Nt� L)
Name(Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKr(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: 5
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
G Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S \� D�� ❑ Paid in Full ❑Outstanding Balance Due:
�� 06k�/�eh�
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
r„ v,�� o_--� 54� License Number Expiration Date
Name of CSL-Helder
�_C)\Y �_, �R J'11n'. List CSL Type(see below)
Address U EDResidential
Description
tricted u to 35,000 Cu. Ft.)
Signature p� cted I&2 Famil Dwellin
n Onl
J Reside Roofin Coverin
Telephone ential Window and Sidin
ential Solid Fuel Bumin Appliance Installation
Demolition
5.2 R!�te\g Home Jlmpcoyemel�nt Contractor(HIC)
PICC panyyNNaame or HIC R is rant Name .l� Registration Number
hh�] �_ �j � Ol
Address b
p
7-)klsy,;)'7 � xpuanonDate
Signature Telephone
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 ..........13 No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I• 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.
Signature of Owner Date
1 SECTION J 7b:COIWNERt OR AUTHORIZED AGENT DECLARATION-
'VK”
ECLARATION
'`t K"" „-e'ri\ ,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
behalf.
W s 1t t hwn S
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I 10.116 and I IO.RS,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"
i
1
CITY OF SALEM
1►l PUBLIC PROPRERTY
-� DEPARTMENT
12: W n sk a sto 10.),LL 1 * Set t wt,M.w xs.0 l It it l rs J l i7J
fcl. VIII • 1:%x 9711-74;: 1346
Workers' Compensation Insurance Iffftdavit: Builders/Contractors/Electricians/Plumbers
%moicant Information Please Print Leeihly
Nitlne lW
ddl ess: aJ,0 F-c
City,Stara Rip O?� ��t�, � Phone
.\rc y ou an employer?Check the appropriate box: 'Type of project(required):
4 1 :un a general contractor and I fie New construction
I. 1 ;un 4 employer with r� ❑ ❑
coplluyces(full 4nd'or pert-urfte).• have hired the suh-contractors
?.❑ 1 am a sole pmpricux or partner- listed on the attached sheet. C1 RanoJeline
ship and have no etnpluyccs These sub-contractors have S. ❑ Demolition
working lir me in any capacity. workers' emnp. Insurance. q. ❑ Building addition
I No workers'comp. insurance 5. ❑ We are a gni poration and its
I rcquircd.) officers 114ve exercised their 10.❑ Electrical repairs or additions
3. ❑ 1 amu homeowner doing 411 work right of cxcntption per hIGL 11.❑ Plumbing repairs or additions
myself. [Ko workers' comp. c. 152, ¢1(4),and we have no 12.❑ Ruuf repairs
insurance required.) r employees. lKo workers' 13.❑ Other
comp. insurance required.)
•waw .,pphonl that checks box 01 must:dw fill cut the section luluw showing dear wurkcvi cunhpenvaiwt lwlwy iolonoa&ium
' I fomeu. mn who sabmif this affidavit indiea111tg am)an Joing all wutk avW Then hire oul u c cwurxron must.uhmit a new a1f.Javi1 inJieafhng.huh.
f onvxurtv thin sheet this box mUar Jawhed an aJdnimal nlhsel.hawing the anew of 1ht sub<onuwton and Ihnr twrken'comp.pahcy mfurmanan
/our an employer that is providing workers'c'uurpenvadon insuraucc for my enrplu3�ecs. Below is the pis/icy and/ob.wirs,
injornturio s.
Innurancc CompanyVame, � �—___._._.__
I'oli:.v a or Sclf-ins. Lic. R: Q�� see s__ Enpiranun Date: ,
lob Silo Address: `0\`�-o`R��__. ""'^a'� Elty;SlataZlp.
attach it copy of the workers'cufnpcnsatiun policy declaration page(showing the polley number and expiration date).
I'allnrC to secure cuwerage as required under Scctiun 25A ul'\IGL c. 152 can lead to the imposition of criminal penalties afa
rine op to$1.51101)0 end/ur ung-year imprisonment,4x hell Js ciw d penalllcs in the Tann of a STOP WORK ORDER and a fine
of 1111 fn 1250.00 a Jay .kguinsl the violator. ❑e advised that a copy of this aidwinctit may be lurw4rded to the O111ce ul
Ino:ai•,aNnb of-'.hc OL\ (or o,osarce .'owcra�v wcnlicJLun.
/i/o herrhy e olio uu,fcrry�111p;1fge�ainx an,d npenalliev ujperjary that the in/urwallon provided ua�bove is true tun!correct.
Ph-,, v 1.
�1�J 0 �� T
[Issuing
flla9u1 u.%e o,dy. DJ/lar Ivrlle 111 llll.x arl'tl, lis be cuorylrlyd by ally ur lolvn o/�icia/. I
tv ur fawn: Per mic/Lieencc Y.ifuthurily (circle life):
hoard of livallh 2. Iludding Ucp.fruncul 1. l:ih.Tuwu Clerk 4. Electrical In.pcctor 5. Plumbing Impeetor
01hernlaa L"r,",. .. _. Phone d:
Information and Instructions
N I.l,s.ldm.;eus(icncral Luws chapter 152 rcquirb a I i employers to provide workers' compensation fi)r their employees.
I'unu.mt w MIS ,nature, an rmplurre is defined as ' esery pclson in die service of another under any Contract of hire,
:\prbs or Implied, ural or wrrnten."
An employer is defined as'an Individual, partnership, .Issociatiou.corporation or other legal entity, or any two or more
a IF.c i,recowg engaged it a point emerpnse, and including the !cgai reprbeuutives of a deceased cmpluycr,or the
fes:elver of trustee of .111 Illdividual,paltilersllip, 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
,Iw:11mg wuse of another who employs persons to do maintenance,cunstruction or repair work on such dwelling house
or ,til the grounds or budding 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 u license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of cumpllance with the insurance coverage required."
AJdinanally, NIGL chapter I52, s25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of puhlic work unit] acceptable evidence ufcunipliance with the insurance
requirements of this dtapter have been presented to the contracting authority."
ppplicalts
Pleasc 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 ccrfificate(s)of
inswance. 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 docs have
cniployees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirlatiun of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be reuirncd 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 arc 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 he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of flit: affidavit for you to fill nut in the event the Office of Investigations has to contact you regarding the applicant,
1'I:asc be sure to fill in the pannitlicense number which will be used as a reference number. In addition,an applicant
that most submit multiple pennio'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)." % 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 dog license or permit to burn leaves etc.)said person is NOT required to comp]cte this affidavit.
I h,r r)hive of Invesri,ations wuuld It" to drank you in adv:uncc fur your cooperation and should you hale :1ny questions,
please du nut hesitate to give us a call.
fhc Dcparnncnt's address, telephone and fax number'
The Commonwealth of Massachusetts
Department of Industrial Accidents
ii of Investigations
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax 0 617-727-7749
www.mass.gov/dia
s CITY OF SALEM
^' PUBLIC PROPRERTY
DEPAR'T'MENT
12, \ . ,Iin�..,��S ryrr r ♦ S.\I i 11. %I\t. v ... i . -I'' -
I I I: '/'S V3.9;9j • I \s::78.'4:- ,.S41.
Construction Debris Disposal Affidavit
(icyuired fiur all demolition and renovation wot'k)
I
In accordance %kith the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL e 40, S 54;
Building Permit d 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 hailer)
The debris will be disposed ofin
(name of facility)
laldress of lariliw) ,J
1P <_cyL
�Iguamrc of permit applicant '.
late
.. 7!77ti. `
Shea Roofing Co.
Salem, MA 01970
(978) 745-7313
PROPOSAL c
SUBMITTED TO:
3 Pleasant St.
Salem, Me.
We hereby submit specifications and estimates for:
To remove old rubber roof and the roof insulation from entire lower
flat roof.
To mechanically install all new half inch fiberboard, using three inch
plates and screws with a minimum of twelve plates per 4x8 board covering
entire lower flat roof.
To install new .060 EPDM rubber roofing membrane fully adhered
covering complete lower roof running field sheet up sidewalls terminating
under new asphalt shingled roof.
edges.To install new heavy custom aluminum drip edge trim along all roof
To re-flash all the skylights according to manufacture's
cnnrifi tion
Insfall new frames raising both sk li h
both according t anufacture s specifications y g nd re-flashing
. (5400.00)
To mec nically install all new half inch fiberboard, using three inch
Plates and screws with a minimum of twelve plates Per 4x8 board covering
entire front porch roof.
To install new .060 EPDM rubber roofing membrane fully adhered
covering entire front porch roof running field sheet up sidewalls
terminating under siding on main building.
roof edges. To install new heavy custom aluminum drip edge trim along all
To pick up and remove all roofing debris from job site. ($2,150.00)
To install new seamless aluminum gutters and new facia boards around
front porch.
To repair and install aluminum cap over left rear roof return. ($550.00)
To install additional downspout systems to improve gutter drainage on
front side of main building.
We propose hereby to furnish material and labor-complet in accordance
-.- with above specifications,for the sum of:
Fourteen Thousand Six Hundred
Payment to be made as follows: �� --dollars (� W
Upon completion. t, )
All material Is guaranteed to be s
standard Practices. Any alteration or deviation from abowork to beveospecifications Plated in a workmanlike manner aelord
only upon written orders,and will become an extra charge hexinvolving extra costs will be executed
strikes,accidents or delays beyond our control- Owner to ca over the estimate. Alla upon
Our workers are fully cove ns fire,tornado and agreements
necessary contingent
Workman's Compensation Insurance,
Acceptance of Proposal-You a '
0 o e work as specified.
Authorized Signature:
Signature:
Date of Acceptance: /