5 SCHOOL ST UNIT 5 - BLDG PERMIT APP B-15-1269 The Commonwealth of Massachusetts
Department of Public Safety
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:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
1 f( S (S<, Sr L)n(4- S � I� M, r1 � 61g70
U r 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 O or check all that apply in the two rows below
I Existing Building❑ Repair Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
I4_ _ 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 Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: /` ��
�1 vt I t ,-�1 J J' y t y .
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): 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 S.USE GROUP(Check as a licab e) - - -
A: Assembly A-1❑ A-2 13Nightclub [3A-3 ❑ A4 ClA-S❑ B: Business ❑ E: Educational ❑
R Facto F-1❑ F2❑ j H: Hi h Hazard Hd 13H-2 13, -H-3 ❑ H-4 13 H-5 E3I: Institutional 1-1❑ 1-2 13I-3 i31-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4 17
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ (B ❑ IIA ❑ IIB ❑ IIIA C3 IIIB ❑ IVO 1 VA 13 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❑
Private O or indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: hazards to Air Navigation: I_�\I li._tgric,i;unnnissiun Itevwt%: Pnm is:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
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:
C11 f�1 l r
LL(2sa
SECTION 9: PROPERTY OWNER AUTHORIZATION 4
Name and Address f Property Owner
S�2 kn,2lr�0.$ S Sar-l'( 5T V� .Sc��� W ✓blA
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
91, -7i6
Title Telephone No.(business) Telephone No. (cell) e-mail address
If. plicabie,the property owner hereby authorizes
j�ober �a jje 3D�i 3o5hw Post Ra L , ylatO o( 77kl
Name Street Address City/To wn 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)- - -
If building is less than 35,17011 cu.ft.of enclosed space and j or not under Construction Control then check here O and ski Section 10.1
100..1 Registered Professional Responsible for Construction Control -
Nam Re utra t) Telepho a o. e-mail address 7 g Registration Number
oil 1o5�at %tf'a >�a dt
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - -
�Cl �lf�bF ion
Com y Name
Name of Person Responsible for Construction License No. and Type if Applicable
YL P*
reet Address City/Town State Zip
%[ - (:It Rq�7q
Telephone No. business Telephone No. cell e-mail address
SECTION 11:WORKERS'CONIPENSAI10N iNSU RANC E AFF'B1AVrr 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 0 No O
SECTION 12--CONSTRUCTION COSTS.AND PERMIT FEE - -
Item Estimated Costs:(Libor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ D0 `" Building Permit Fee—Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3.Plumbing $
d.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ - Enclose check payable to
6.Total Cost $ ( (contact municipality)and write check number here -
SECFI 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
Pleas p hand s g_t/} S�, q�D� t , o Tit e 10, 'LL `fin Telephone o. Date
tyU
Street Address 1 Ciy/To1 State Zip
Municipal Inspector to fill out this section upon application approval•
Mm
Nang Date
Massachusetts-Department of Public Safety
Board of Building Regulations and Standards -
' - - i=ouststitYnn Sune,—.�isnr �. _
License. CS-098666 - -
ROBERT A Y.ABES.
�LE -
304BOSTON Po$P
Wayland MA 01'18
Expiration
Commissioner - 05/09/2017
Ac" CERTIFICATE OF LIABILITY INSURANCE 8/19/15
'THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: if the certificate holder is an ADDITIONAL INSURED,the policKes) must be endorsed. H SUBROGATION IS WAIVED,subject to
the terms and conditions of the policy,certain policies may require an endorsement. A statement on thi s certificate does not confer rights to the
certificate holder in lieu of such endorsenen
PROWLER NAR¢:CONTACT Jennifer Goodfellow
Chisholm Insurance Agency PHONE SOH 358-6111 N : (508) 358-5324
PO Box 399 EM L
ADMESS:
Wayland, MA 01778 INSURIE AFFORDING COVERAGE NAIL
USUREnA:Western World Insurance
INSURED IN$unSa B:Arbella Protection
LaBelle Roofing, Inc. INsuRERc:The Hartford Insurance Co.
304 Boston Post Road INSURERD:Nautilus Insurance c/o CT Unde
Wayland, NA 01778
INSURER E:
INSURER F;
COVERAGES CERTIFICATE NUMBER: REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED. NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
I SR ADDL SUBR POLICY EFF POLICY EXP
LTR TYPE OF INSURANCE INSR WVD POLICY NUMBER MND/Y WMDMYYYI' UMTS
A GENERALUMILDY g NPP8236613 8/1/15 8/1/16 EACH OCCURRENCE S 1,000,000
.q COMMERCIAL GENERALLIABILITY DAMAGE TO RENTEDREMB'S(Eaemrne S 5G 000
CNIN6 MAGE ®OCCUR MEDEXPNMompe ) $ 5 000
PERSONALSADVINJURY S 1,000.000
GENERAL AGGREGATE S 2,000,000
GEN'LAGGREGATE LANITAPPLEiSPER PRODUCTS-COMP/OP AGG S 1 0OO 00O
POLICY PCTLOC $
B AUTOMOBILEUASIUTY 1020008624 8/31/15 8/31/16 COMBIINEEOSINGLELIM $ 1,000,000
ANYAUTO BODILY INJURY(Per pown) $
ALLOWNEDSCHEDULED BODILY INJURY accident) $
AUTOS x
AUTOS
NON-0WNED PROPEmYDAMAGE S
HIRED AUTOS X AUTOS eratcitleN
$
B X UMBRELLA LIARg OCCUR AN019894 8/1/15 8/1/16 EACH OCCURRENCE $ 51000GGG
EXCESS LIA9 CLAIMS-MADE AGGREGATE $ 5,000,000
DED RETENTIONS $
C. WORKERS COMPENSATION 6S60UB-0271N48-9-15 3/22/15 3/22/16 g WC STATU- OTH-
AND EMPLOYERS'UABIUTY
MY PROPRIEM"ARTNERIE)IECUTME YINN/A EL.EACHACODENT $ 100,000
OFFI(ERAAEMBER EXCLLRIED?
(MaMamryin NH) EL.DISEASE-EAEMPLOYE
S 100,000
Dyes,describe under
DESCRIPTION OF OPERATIONS below EL DISEASE-POUCYUMU $ SOG GGG
DESCRIPTIONOFOPERATIONS/LOCATIONS/VIe11CLES (ARach ACORD101,AddlDom]Rermrla Schedule,NmorestemIem dmd)
*The Workers' Comp. certificate will follow from The Hartford. The above is for info only.
CERTIFICATE HOLDER CANCELLATION '..
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED N
ACCORDANCE WITH THE POLICY PROVISIONS.
AMORIZED REPRESENTATIVE
Thomas B. Chisholm
®1988-2010 ACORD CORPORATION. All rights reserved.
ACORD 25(2010/05) The AC ORD lame and logo are registered marks of ACORD
Phone: Fax: E-Mail:
The Commonwealth ofMassachasetts
-Department oflndas ialAccidents
I Congress Street, Suite 100
Boston,MA 0211¢2017
www.massgov/dia.
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/plumbers.
rO BE LED V=THE PERMITTING AVTHORTTY.
A Iitant Information FII - _ Please Print L 'b
Name(Business/Otgenizatiodlndividual): Q I{� b`—I r1
Address: /1 ()q
1 + 1-�,A
City/State/Zip:l � � �r1 nl 7?3 Phone#: .A " 3579 - � ill
Are you an employer?Check theappropriata box: Type of project(required):
L&Ji am a employer with employees(full and/orpartfime).' 7. ❑New construction
2.❑I=a sole proprietor orparmership and have no employees working forme in S. ❑Remodeling
any capacity.[No woo ens'tomo.insurance required]
3. I am a honeovmer do aU woo: 9. ❑Demolition
❑ m myself,(No workers'comp.insurance required]t
C.❑I zm a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition ,
emue that all contractors either have workers'compensation insurance or are sole 11.❑Electrical repairs or additions
ompriemr with no employees.
12 Plumbing repairs or additions
5.❑I am a general contractor and I have hired the subcantacmrs listed on the attached sheet
These subcont actors have employees and have worlreas'comp-insurarmt 13._,(Roof rep�a+irls�
6.0 We are a corporation and its omce[s have exercised their right of exemption per VOL e. 14.V Other �J h �t
152,§I(4),and we have no employees.[No workers'comp.h,,,,e req dredj
*Any applicantthat checks box"]must also Moll the section below showing their workers'compensation policy information
t Homeowners wbo submit this affidavit indurating they are doing all wmk and than hue onside contactors must submit a new affidavit indicating surdL
'Contractors that check this box must attached an additional shexshowing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contacGas have employes.1hey must provide their workers'coarp.policy number.
lam an employer that it'providing workers'eompeasadon insarmaee for my employers. Below it rhe policy"and job site
informaliox 4p,f
/. CoInsurance Company Name:
Policy#or Self-ins.Lic. � Sb OVB .
` c7l W a,1 j- -/ Frpitafion Date: 1
Job Site Address: SchDbt St 04l14 5� City/Statesip: VIA 01-1-
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, 625A 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 from of a STOP WORK ORDER and a tine of up to$250.00 a
day against the violator.A copy of this statement may be.forwarded to the Office of Investigations ofthe DIA for insurance
coverage verification.
I do hereby under p ens ps�gf perjury that the information pravideor above is true aced correct b
Sign
(t c J G, Date
s w
Phone#: — 3 V - fo I'I
Official rise only. Do not write ire chis area,to be completed by city or town official
City or Town: Permit/License# -
Tarninag Authority(circle one): '
1.Board of Health 2.Building Department 3.City/Tovm Clerk 4.Electrical Inspector -5.Phrmbmg Inspector
6.Other
Contact Person: Phone#
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..."HOME IMPROVEMEM s'C OIA d IRAC E OR
F 'agisfration: •153054 Type*
` Expiration: 2/5/2017 Private Corporatior
LABELL? ROOPH\IG, INC.
30!j fits; ((N' POSTRID.
Undersecretary
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�. { HOME IMPROVEMENT CONTRACT
Date: (y _I Sold Furnished and Installed by:
JobN �O F LaBelle Roofing,Inc.
i 304 Boston Post Road,Wayland,MA 01778
it Phone:508-358-7663;Fax:508-358-7662
' {{ Federal IDN 20-8350649
MA Home Improvement Contractor Reg.4154084
a Installation Address: yA rt lf �e M A Q Cr�n
1 Qty State Zi
t Porchaxrr ( Work Phone• BomePhone: P
I
Home Address:
a (Ifdifferentfrom lnstallaUon Address) -. _ ,Qty 5� State Zip
Prosect Information:V We/You("Purchaser"),the owners of the property located at the above installation address,offer to contraqt with,
LaBelle Roofing,Inc.,to famish,driilver and arrange for the installation ofall materials as described on the.attached Spec Sheet tk: I
LaBelle Roofing,Inc.reserves the right to cancel this contract if,upon re-inspection of the job,LaBelle Roofing,Inc.determines
that it cannot perform Its obligations due to a structural problem with the home or because work required to complete the job was
not included in the contract t
t
f DEPOSIT PAYMENT OPTIONS
(Subject to fund verification and/or credit approval)
? CONTRACT AMOUNT $ 7, f W I Check,Cashiers Check or US Postal Service Money Order
O� �(ifMade( payable to LaBelle Aoefing,I.e.)
'LESS DEPOSIT $_ Vis' "y�t u` 2. Credit Card* payment options-Circle One Below
1
Visa MasterCard Discover American Express
BALANCE DUE >2...,.. Avers. Pep.Dam:
ON COMPLETION $ 3W
Name as it appears on card
Indicate Payment Method For *By my/our signature below;Vwe agree to allow LaBelle Roofing Inc.to
BALANCE DUE ON COMPLETION: charge the above referenced credit card for the deposit indicated
Cardholder's Signature Detc
I
Purchaser agrees that,immediately upon satisfactory completion of the work,Purchaser will execute a Completion Certificate and pay any
balance due.Purchaser also agrees to be jointly and severally obligated and liable hereunder.
Endre AnreeaeutL This agreement"it its attachments,including any financing:agreement,contain the complete agreement between the
parties and cannot be amended or modified unless in writing in a separate agreement signed by both patties.
f
INOTICE TO PURCHASER
your not sign Dothicot sign my re you read IL You are entitled to a completely filled-in copy of the contract at the time you sign.Keep It to protect
your rights,Da not sign soy completion Certificmc or agreement stating that you arc satisfied with the entire project before this project is
complete.Law prohibits home repair contractors from requesting or accepting a Completion Certificate signed by the owner prior to the actual
completion of the work to be pertormed;under the contract.
i
You may cancel this transaction at any time prior to midnight of the third business day after the date of this commit.See Notice of Cancellation
for an explanation of this right There wbl 6e n service charge equal to 24%of the contract amount if the job is cancelled by Purchaser AFTER.
the.third business day.
«
BY MY/OUR SIGNATURE BELOW, r AGF.EE TO BE BOUND BY:THE TERMS OF THIS CONTRACT.IM'8 ACKNOWLEDGE RECEIPT 1
OF A COPY OF THIS CONT Cr T O COMPLETED eOPIESOf THE NOTICE OF CANCELLATION.DO NOT SIGN THIS
CONTRACT IF THERE ANY .SPACES
SUBMITTED BY: ' Date f 6
al C m '
ACCEPTED BY; Date
Date
H wncr 4
NOTICE:ADDITIONAL TERMS,CONDITIONS AND WARRANTIES ARE STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT.
i `{White-Omce Yellow-CnuamQ Piak-Sties Consultant
3 i
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-OWNER ACrrunnizATION
3
job #_ 1 ( 6 f
1
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TO BE COMPLETED WHEN OWNER'S AGENT OR
CONTRACTOR APPLIES FOR A BUILDING PERMIT
. k
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as owner of the
r
subject property. S c71 S+ Un 4-
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hereby authorize LaBelle Roofing to act on my behalf in all
matters relative to work relating to this building permit
application, and all permitted work
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f is o us er ate
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CITY OF SALEM MASSACHLEE M
BIziDmDEPAR7MENf
120 WA9MC7MS7REET,3IDFiooR
UL(978)7459595.
PAX(978)740-9846
B7M8ERLEYDRISQ'�LL
MAYOR THMAS STYMM
DntEcPORcFPI78LrcpxcaRTr/DuaLD ceammoi E=
Construction Debris Disposa/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: vJ P-
(name of hauler)
The debris will be disposed of in:
G)C�-sk VVI t
(name of facility)
(address of facility)
Signature of applicant
Date
A
Mike
Subject: Salem Condo Approval
---------- Forwarded message ----------
From: Sharon Bonner<vaeirlinmassna,comcast.net>
Date: Fri, Nov 13, 2015 at 10:58 AM
Subject: Re: Building permits
To: Kathleen Cyr<kathy@labelleroofing com>
Cc: Kathleen Dailey <kdaileyonel@verizon.net>
To Whom it May Concern,
As a trustee for Cogswell Condos, I give my approval for the issuance of a building permit for the installation of
new skylights in four units of the condo building. Thank you very much.
Sharon Bonner
Trustee
Cogswell Condos
5 School St
Salem MA
Sent from Sharon's iPad
On Nov 13, 2015, at 10:29 AM, Kathleen Cyr <kathy@,labelleroofing com> wrote:
Hi,
Thanks for getting back to me so quickly!
I just spoke to the Building Department again, and a typed signature from any Trustee is fine.
Thank you.
Kathy
On Fri, Nov 13, 2015 at 10:14 AM, Sharon Bonner<vaeirlinmass n,comcast.net> wrote:
Kathleen,
Does the letter need a physical signature or can I write the letter and sign it with just my typed
name? Does it need more than one signature? We are a self managed building and all of us
1 getting the new skylights are trustees of the association. I'll be happy to do the letter, it will just
I be a tad more complicated if a physical signature or more than one signature is required.
Sharon Bonner
Cogswell Condos
1 Sent from Sharon's iPad
t
f > On Nov 13, 2015, at 10:04 AM, Kathleen Cyr<kathyglabelleroofingcom>wrote:
>
>Dear Sharon,
r
i
>I just spoke to the Salem Building Department, and they said that when applying for
>building permits for condos, a letter from the Condo Association giving its approval for
>the project is required.
I >
> Would you please e-mail a copy of the letter from the Condo Association to me at your
> earliest convenience. You could also fax me the letter at 978-443-7662.Please let me know if
fyou have any questions.
� >
> Thank you.
c >
!C
>Kathy Cyr
>LaBelle Roofing
2