19 UNION ST - BUILDING INSPECTION v C-r- 3`Fg- z-
The Commonwealth of Massachusetts
Board of Building Regulations and Standards SALEM
y nW Massachusetts State Building Code, 780 CMR yR Sem°
Up�b SEn' Building Permit Application To Construct, Repair,Renovate Or Demolish a
Y One-or Two-Family Dwelling
0 This Section For Official Use Only
Building Permit Number: Date Ap Ited: '
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1. Property Address: \D� 1.2 Assessors Map&Parcel Numbers
1.1 a is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. nen ofRecord:
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Propos d Wo '
fir n 0% A
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All.Fees: $ e
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ \�3rj 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
V.i•`�� c,�...,� S License Number Expiratio Date
Name of CSL Holder
List CSL Type(see below)
No.and Street`-f vy Type Description
Unrestricted(Buildings up to 35,000 cu.ti.
R Restricted 1&2 Family Dwelling
City/town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
i I Insulation
Telephone Email add}ess D Demolition
5.22 Registerej Home Improvement Contractor(HIC)�611
W HICbRegistration Number Expimio Date
HIC Cpany-Name r HIC egi trt Name
No.and Street anx3 Email address
Ci /Town,State,ZIP 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 ......... - 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
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
Abest of my knowledge and understandding.n L
Print Owner's or Authorized Ag nt's Name(Electronic Signature) Date
NOTES:
1. An Owner who obtains a building permit to do his/her owfFwork,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 MC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at LA .mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"
.m. , o i ` l
Shea Roofing Co: fig.
17 '/Z Foster Street' s
,Salem.ltMA. 0:1970 . .
(978) 745=7313 : , r _
PROPOSAL -... "`' September 19,2016
`suslinrcTw-Tov.-Peter La Chapelle
19 Union St
Salem, Ma.
We hereby submit speclflcations and estimates for.
To remove all existing slab roof shingles from complete roof Including all
mansards and dormers. '
To install ice and water shield completely covering top flatter section and ,
all lower roof edges of roof mention above prior to re-roofing.
To install up to 50 linear feet of roof boarding as necessary.
To install all new metal drip edge along all roof edges both horizontal and
vertical
To install GAF Siateline style roof shingles covering complete roof as
mentioned above.
To install new roof flanges on roof vent pipes.
To counter flash, re-flash and/or reseal all sidewalis as necessary.
To replace skylight with new Velux skylight on top roof, labor only,
homeowner to pay cost of skylight Interior window well finish work not
provided.
To re-flash, counter-flash and/or reseal chimney flashing on both
chimneys as necessary.
To install new 060 rubber roofing membrane on flat rear roof in
accordance to manufacture's specifications.
To clean up and remove all roofing debris from job site.
We propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
Ten Thousand Three Hundred and Fifty------------- ---- ($70,350.00)
Payment to be made as follows;
One half to start balance upon completion
All material is guaranteed to be specified. All work to be completed in a workmanlike manner according to
standard practices. Any alteration or deviation from above specifications Involving extra costs will be executed
only upon written orders,and will become an extra charge over the estimate. All agreements contingent upon
strikes,accidents or delays beyond our control. Owner to carry fire,tornado and other necessary Insurance.
Our workers are fully covered by Workman's Compensation Insurance.
Acceptance of Proposal—You are authorized to do the work as spe 'fico.
Authorized Signature:
Signature:
Date of Acceptance:
i CITY OF SALEM, INWSACHUSETTS
• BUELD4TIG DEPARTMENT
130 WASHIINGTON STREET,3"D FLOOR
TIAL (978) 745-9595
FAX(978) 740-9846
IQ�($FRi.EY DRISCOLL
MAYOR
Il[OMAS ST.P[ERR6
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\L\fISSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by: x
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
date
debrmf doc
CITY OF S.1I. Ab N NSSACHUSETTS
• BUILDING DEPAEIT$iENT
a 120 WASHINGTON STREET,3an FLOOR
TEL. (9715)745-9595
FAX(978) 740q W
KIJIBERLEY DRISCOLL
'I
MAYOR ftonfAs ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BCQDING COMMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansfPlumbers
Applicant Information Please Print Leeibly
Name (BusirhssiOrganira[ioNlndivitival):
Address:
City/State/Zip: Phone II:
Are you an employer?Check the appropriate box: Type or project(requiref:
1 J!hl am a employer with _ 4. ❑ 1 am a general contractor and I 6. El New construction
employees(full and/or part-time).* have hired the sub-contractors
2_❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3111 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself,[No workers'comp. C. 152,§1(4),and we have no 11tE!iRoof repairs
insurance required.)t employees.[Neo workers' 13.[]Other
comp.insurance required.]
Any applicant that checks box#I most also rill out the section below showing their workers'compensation policy initt madon.
*I lnmeownms who submit this affidavit indicating they are doing all work and then hire outside contriteness must wbit a new affidavit indicating such
:Contratton that check this box most attached an additional shoes showing the name of the a tt�conuaetors and their wotltms'comp,policy intermation.
1 am an employer that is providing workers'compensation Insurancefor my employeex Below is the policy and Job site
information. t� _
Insurance Company Name:
Policy#or Self--ins.Lic.#: `^SL- —�\'�0c��0��D Expiration Date: p
Job Site Address: City/State/Zip: 5.
1
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date)..
Failure to=ore coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fix
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Off ice of
Investigations of the DIA for insurance coverage verification.
I do hereby certo under thepains and t
/penalties ofperjury that the information provided above is true and correct.
Signature: n,/-,7 o' A Date: ql I I
riot
OJTciai use aety. Do not write in this area,to be completed by city or town official,
City or Town: Permit/f.lcense#
Issuing Authority(circle one):
I.hoard of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other.
Contact Person:— Phone#: