20 BALCOMB ST - BUILDING INSPECTION (3) t �$ f S 4 C K- 3q5$
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR)
n Building Permit Application for any Building other than aOne-or Two-Family Dwelling
. ('Phis Section For Official Use Only)
n ild er 't Number: Date Applied: Building Official:
J` ON 1:LOCATION(Please indicate Block#and Lot If for locations for which a street address is not available '
No.and Street City/Town Zip Code Name of Building(if appliciLAe) '"
I SECTION 2 PROPOSED WORK
I� Edition of MA State Code used If New Construction check here❑or check all that apply in the two robeloi!'' .
l Existing Building❑ Repair❑ 1 Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appe�ix 1)
1111 Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: 49
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? \ i pY s ❑ No ❑
Brief Description of Proposed Work: 5't S; �rc�. --" t�.4w� `D W.7L��—: i
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 5:USE GROUP(Check as applicable)
A. Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E. Educational ❑
F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional I-1❑ I-2❑ I-3❑ I-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S. Storage S-1❑ S-2❑ U. Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
TA TB ❑ IIA ❑ IIB ❑ IHA ❑ HIB ❑ 1 IV ❑ 1 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❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify Zone: or on site system❑ permit is enccll required❑ trench or specify:
osed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ 1 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:
"P-I k-'E�v <'� le"R-to a-p-" 0 e 116
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of operty Owner �- \
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
O _-_-
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
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)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
\s,k 0_ !� K�Ni SNb _—Y\--��
Name(Registrant) elephone No. e-mail address Registration Number
'� fs,� � X\f- o `Alam
Street Address City/Towirj State Zip Discipline Expiration Date
10.2\General Contractor
Compan}\'Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail a dress
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT .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 O No O
SECTION 12•CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ �G`6 Building 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 $ ��5 (contact municipality)and write check number here
SECTION IS.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 the�best f in know dge and understanding.
S `2 o a&0_ y QrK3ha �llI 6/15 �6
Please print an srgn�me Title Telephone No. Date
Street Address City/T wn State Zip /L
Municipal Inspector to fill out this section upon application approval: '9 /!
Name VDate
CITY OF SM Ebi, 1NI.-kS&A CHUSETTS
a
BUI SING DEPARTSIENT
120 WASHINGTON STREET,Sao FLOOR
"ILL (978)745-9595
FAX(978)740-9846
KI\IBFMZY DRISCOLL
MAYORTHOdtAS ST.P[ERR6
DIRECTOR OF PUBLIC PROPERTY/BUR.DLNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Nagle(BusirnssiOrganization/Individual):
Address: , A >,
City/State/Zip: %Q-N1\ 14 -34�N'-- Phone #:
Are you an employer?Cheek the appropriate box: Type of project(required):
1.P 1 am a employer with 4. 0 I am a general contractor and 1
employees(full artd/or part-time).
have hired the sub contractors 6. ❑New construction
2.0 1 am a sole proprietor or partner- listed on the attached sheet: 7. 0 Remodeling
ship and have no employees These sub-contractors have g. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9, 0 Building addition
[No workers'comp. insurance S. 0 We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions
myself.[No workers'comp. c. 132,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.0 Other
comp. insurance required.]
•Any appgeant that chocks box#1 must also fill out the section below showing their workm-oon w..tie.policy information.
t l lemeuwnen who submit this affidavit indicating they are doing all work and then him amide contractors must submit a xv aRulavit indicating such
=Comranon don cheek this box must attached an additional sheet showing the tome of the sdbwvmteatae and thew wohers'comp.policy inrwnmion.
/am an employer that Ls providing workers'compensation lnsarancefor my employees. Below Is the pollay and Jab site
.information.
Insurance Company Name:
Policy#or Self-ins.Lie. Expiration Date: B 1 a-�) mo
r^
Job Site Address: o City/State/Zip, Ja—\QAti. P�,.211 p
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL c. 132 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisorunent,as well as civil penalties in the forth of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certify ands pains d Ines of peryary that the information provided above is true and correct
Sienarure•. �/i�/� !�= Date:
Phone#: — 11
Off elet use only. Do not write in this area,to be completed by city or town offtciaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person:— Phone#•
i CITY OF SAI.Ea"%vi, NL1SSACHLSETTS
• BUILDING DEPARTMENT
130 WASHINGTON STREET, 3' FLoOR
TEL. (978) 745-9595
FAX(978) 740-9846
KiJiBERL EY DRISCOLL
MAYOR THomAs ST.Pwmm
DIRECTOR OF PUBLIC PROPERTY/BU mDING co.%m ISSIONER
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:
Svsl� �-041
,
(name of hau r)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
date
dabri5alLduc
Shea R f' .g .
i
oo mg �Go =i
s 17„/2 ,'o6'ter Street
Salem, IIA01970
(978) �745=7313 - ' _ r1"
PROPOSAL - - May 24,2016
- SUBMI TEDTO: Greg Revill t
50 Balcomb Street
Salem, Ms.
We hereby submit specifications and estimates for
To remove all existing roof shingles from complete-roof,including all
lower extensions and front bay roof
To install ice and water shield covering all lower roof edges and under all
flashing points prior to re-roofing, a
I*� To-install up to`50-linearfeet•of rtiiif boarding as-necessary:
- To install synthetic underlayment paper covering all roof boarding prior
to re-roofing.
To install all new metal drip edge along all roof edges both horizontal and
Vertical.
To install architectural (GAF or Ceftainteed Lifetime) roof shingles
covering complete roof as mentioned above.
To counter flash, re-flash and/or reseal the chimney flashing as able
around firer escape. If lead flashing is too damaged on the chimney we will
grind it out and re-lead at an additional cost of$300.00 per chimney.
To install new roof flanges on roof vent pipes.
To counter flash, re-flash and/or reseal skylight as necessary.
To install new roof vents as necessary.
To clean up and remove all roofing debris from job site.
;A,
We propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of
Thirteen Thousand Eight Hundred and Eighty Five'-Dollars ($13,885.00)
4.,,
Payment to be made as follows; "
One third to start balance upon co_mpl tion
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 a orized to do thetasted.
Authorized Signature:
Signature:
G
Date of Acceptance: rJ/ Z.i"f 11°
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