18 BARNES RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
r Rrrisrr/Jmnnvv
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. :(HAI
One-or rtvu-Fumily Dwelling
This Section For Official Use Only
Building Permit N mbe : Date Applied:
Signature: 1AK4l/�/yy
Builds Cummissioned w of Buildings rats
SECTION I: SITE INFORMATION
1.1 Property 1.2 Assessors Map& Parcel Numbers
/Z Ka InFS A /
I.I a Is this an accepted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Areo(sq 11) Frontage(11)*
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.Jo,§34) 1.7 Flood Zan*Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesCl
SECTION 2: PROPERTY OWNERSHIP'
rNewCons
�qrm / e It �g'Qq f n CA S QC/
) G� Address far Service:
9,V - 746- Od"7'
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check aU that apply)
uction❑ Existing Building❑ Owner-Occupied ❑ Repain(s) ❑ Alteration(s) ❑ AdditioJ(03
Demolition ❑ Accessory Bldg.❑ I Number of Units Other Specify: /Vf:v/ /Qoa
Brief Description of Proposed Work:
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OlRelal Use Only
Labor and Materials
I. Building s d, I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S
❑Standard Ciry/Town Application Fee
❑Total Project Cost (Item 6)x multiplier—x
). Plumbing Is 2. Other Fees: S
4. Mechanical (FIVAC) s List:
s. Mechanical lFirc s
Suppression) Total All Fees:S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S57 'od 0paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /Q 1 z Z U
Wm �QOMn�_ License Number I:v inuun ate
Name of CSI.• I luldet List CSL Type Isec below►
azr Uescri ion
U unrestricted to 75,000 C'u.Ft.
YYw NZG / r' R Restricted 132 Famil lTvellin
Signature M m4sonry Only
-fo �/AA1 RC Residential Routin C'overin
felcplkum WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Horne Improvement Contractor(HIC) /off 77
I IIC rromP Name HIVe t rant N Regimrati n Num er
0.0
A dressB.SRfSC��T Espirarion bald
l d t
Signature telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISi f M(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.
I' Signed Affidavit Attached? Yes .......... 0 No...........0
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.
Signature of Own" Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
iI)a r as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
behalf
Print
Signature of OWIMor Auihjfpzcd Agent vat
(Sigried under the pains andbcnalties 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 99 have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110.146 and I MRS.mpectively.
2. s planned.When substantial work i provide the information below:
h basement/attics decks or porch)
Total floors arca(Sq. Ft.) (including garage, finished Po )
Gross living area(Sq.Ft.) Habitable room count
Number of fireplaces
Number of bedrooms
Number of bathrooms Number of half1baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed ()pen
). "Total Projmt Square Footage"may he substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
All DEPARTMENT
W;K:F1'UxlS(a n.l.
\i.\1'tut I!^.WASitiNl;I O\S Ix ELT • SAILM,MASS.%ci It tit:'I'I s 01970
TH.:978-145.9595 • P.\x.978-71^-9846
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
l yliiant Infonnrtion —rip `{ Please Print Leeibiv
V i11nC tBusilxxs/Orp,anintimt/Indivuluul): �/'YJ / r r� /1U✓I� �J2! `//3 in
F
G !
City starc;/.ip: Af" v S Phone i': 7)n
Are youan employer:' Check the appropriate box: - Type of project(required):
employer 4. Q I am a general contractor and 1 6. New construction
with [ ❑
.tm a ��_
• have hired the sub-contractors
employees(full uml/or part-tinteb _ 7. Remodeling
listed on the attached ahect.
� proprietor or armu-
1 ant a sole r p
�'❑ P P These sub-contractors have 8. Q Demolition
ship and have no employees
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
P I No workers'cum . insurance 5. ❑ 10.❑We are a corporation and its Electrical repairs or additions
required.] officers have exercised their
' per MGL I l.Q Plumbing repairs or additions
3.El om a homeowner doing all work right of exemption p
myself. Lisa workers' comp. c. 152,g 1(4),and we have no 12.Q Roof repairs
insurance rcyuired.J t anployces. Eno work 13.0 Other
comp.
ors'
insurance required.]
•Ally applicunt thus checks box dl must atsu till out am secrian trulow showing their workas'cumpenwtiuo pulicy inlinmutiuw
' I lomcuwnen whu submit this affidavit indicating they are doing all work and then him outside coturaeton must vuhmii a new al'ndavit indieubng such.
wfontrxiors[hat check this box must attached on additional sheet showing the name of the sub<ontrxtors and their wurkens'comp.polity informariun.
/anf un ,:ntpioyer tltut is providing rvurkers'cotnpen.cnt/oa insuranee jar my employees. Belon,is the policy unit)ob site
information
Insurance Company Name: ....__.---....__---------
7 e
Policy is or Seir-ins. Li�e./#:/�n`�04� ��� � Z/�w Expiration Date:
.Job Site Address: le /[Jq 1 ✓1[cxS �r:✓ .__..- City,Stute/Zip:.
Attach a copy of ilia workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section'_5A ul'.NIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 31.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up it, S250.00;t day against the violator. Ile advised that a copy of this siutement may be forwarded to the 011ice of
I1lvc,t1,,a1iuns ul' i DIA for insurance coverage verification.
:do 7h,,er,,byTcrfiverrthe pains and perudtics o erjuty that the injunnadon provided above is tom curd c'orrcc&
Official use wily. Do not write in this area, to be cumpleted by city or town o/Jicial.
Citv or'l'own: _- -. Permit/l.ictome
Issuim.,iLuihurily (circle one):
I. Board of lleallli 2. Ituildin"' D,:paruueul .l. Ciryi 1-ow n Clerk 4. Electrical Inspector 5. Plumbing; Inspector
6. Other
Coulact Person: _ . .__. Phone Y:
Information and Instructions
Massachusew;General Laws chapter 152 requires all employers to provide workers' compensation for their @niployees.
Pursuant to bits itatute, an emphByee is defined as"...every person in the service of another under any contact of hire,
express or implied, oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer, or the
receiver or trustee of :n individual,partnership,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
dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building 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 compliance with the insurance coverage required."
.additionally, bIGL chapter 152, a2547(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance w ith the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s) namc(s),address(es)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
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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 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 appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill nut in the event the Office of Investigations has to contact you regarding the applicant.
Please be surc to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pcnnit/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)."A 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 complete this affidavit.
I he 01)icc of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please Jo nut hesitate to give us a call. -
rhe Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 of 1-877-MASSAFE
KcviseJ 5-26-05 Fax #617-727-7749
www.mass.gov/dia
; > CITY OF SALEM
L
S
PUBLIC PROPRERTY
DEPARTMENT
r • N.,I I \I. \L�..,, _I•I
74.'4}9,i L.
Construction Debris Disposal Affidavit
(reoluired lilr all demolition and renovation work)
In accordance ill, the sixth edition of the State Building Code, 780 CMR section 1 1 L5
Debris, and the provisions of'v1GL c 40, S 54;
Building Permit h is issued"with the condition that the debris resulting lion
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
�i1y►1 ��4 ��(- sari c
(name:(1 hauler)
I he debris will be disposed of in
L v/
(u Inc of facility)
L AW
(addr rss ut facility)[
� V
'I_Ilatun: ut permit.yiphcanl
date
Page No. of Pages ,
Roofing xoposat
WM. TRAHANT JR. CONSTRUCTION, INC.
4TH GENERATION ROOFING
215 Verona Street
LYNN, MASSACHUSETTS 01904 H.I. LIC. #141778
(781) 599-1211 • (781) 844-4551 • FAX: (781) 581-0855
PROPOSAL SUBMITTED t;oo��++ I - PHONE �. ✓ i ,� DATE
STREET ^�4 I JOB NAME
CITY.STATE and ZIP CODE (-'t JOB LOCATION
Y"i I FA G 1i16
We hereby submit specifications and estimates for: We hereby submit specifications and estimates for:
SHINGLE ROOF FLAT/RUBBER ROOF
Strip entire roof ❑ Sweep entire roof clean
El'Replac a any bad boards up to 100 linear feet ❑ Strip entire roof J
— -
Err�6stall ice and water barrier first three feet up roof ❑ Mechanically fasten down ISO board insulation
21nstall ice and water barrier in all valleys and along dormers ❑ Install 060 Rubber Roofing on entire roof
12'�nstall 151b. felt paper on remainder of roof ❑ Install metal flashing around perimeter of building
®1nstall eight Inch drip edge �) +-}-a_ ❑ Flash chlmney(s), pipe(s) and wall(sI
- -
-- _
p-Install ridge vent ❑ Edge caulk all seams
❑ Flash or re-flash chimney(s) ❑ Install new copper center or
(2'fnstall new pipe flanges �'� t" �' ❑ Other:
f Jin .,vt ve .j .._ . _- - - - -
S246stall 30 year shingle ❑ otherf v�a 13/iZ2 tU<Y ❑ Clean up all debris
--
❑ Install gutters and downspouts El Labor and materials guaranteed 100%for five years
-- _- _
❑ Install trim cod
_ -
ElInstall new fascia boardsJ _i 1, h_
-- -
❑ Install new rake boards
❑ Install sky light(s)
F�r&ther: -f�It .Vzh�` < t-
n
p Clean up all debris F tQI van I��rAlr ��r�r�s,-h«+t"..._�l l/
'001!abor and materials guaranteed 100%for five years tia .7T: 1 6 i
O shingle roofs are nailed by hand.
g1e jUropose hereby to furnish material and labor — complete in accordance with above specifications, for the sum of:
/- Total Price($ S
'*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.
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifi Authorized
ca- �`'<
lions 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, v � x
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.
i.
FEofAcceptance:
lll'e Of JCOl TSZ1I —Theabove prices, specificationss are satisfactory and are hereby accepted.You are authorized to Signature /s specified. Payment will be made as outlined above. iA ,(ptance: ; Signature copy to above address,