3 BARR ST - BPA-12-505 ROOF o The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
1 Massachusetts State Building Code, 780 CMR SALEM
d, Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Dat Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 P _ perty Al ss: 1.2 Assessors Map&Parcel Numbers
3 CCCC nn
Lis 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 It) Frontage(R)
1.5 Building Setbacks(it)
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'
22.11 wner of Recor
.
I ' t Vo-- { 1 4 l l2-�--�-
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORRZ(check all that apply)
New Construction❑ Existing Building❑__ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory BI g❑ Number of Units_ Other )7 Specify:
B 'ef Descri lion of Proposed ork�.
S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building Lo 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Cityaown Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: 4V4��—)
5.Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: 0 Paid in Full 0 Outstanding Balance Due:
ons ruc tton��upervtsor License )
Y n Dt' 1 � -- 16 e/ License Number Expo alti� ni-o Date
Name o C L Holder `
�t,rn�QrS�' List CSL Type(see below) I{
No.and Street Type Description
U Unrestricted uildin s u 35,000 cu.ft.
/ City/Town,State,ZIP' ' a R Restricted 1&2 Famil Dwelellin
M Maso
RC Roofin Coverin
WS Window and Sidin
p—�C. —'t SF Solid Fuel Burning Appliances
` ' n /) "zsi ndo I Insulation
Telephone Email address - (" D Demolition
5.2 Registered Home Improvement Contractor(HIC)
" -A r 6� HIC Registration Number Iftirlition Date
HIC CL mpAny Name or HIC I trant 11ame
Izr �J f
o._andStreet "�_ �Q r I ss
�(2�1V� , 1� t A D l�2 �11j'11-3$l �i V Sri Email dress
City/Town,State,ZIP Tele hone ��
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. SFailure
(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. o provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..........�k 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 Signatum) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized gents Name(Electronic Signature) ate
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 can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.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"
SECTIONS: CONSTRUCTION SERVICES
t
CITY OF S�u.EM, NIASSACHUSETTS
• BUILDING DEPARTNMNT
A 130 WASHINGTON STREET,3m FLOOR
°j TEL (978)745-9595
FAX(978)740-9846
M BERLEY DRISCOLL
MAYOR TrIOMAs ST.P[ERRE
DIRECTOR OF PUBLIC PROPERTY/11CUMING COMMSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anulicant Information (l Please Print Legibly
Name(Business+Organiratiotvindividual):
Address: ' 2� O J o
City/State/Zip:�rY-x J X . t)2k S c n 1,117-11 Phone#: 9 7�i Q -7 7—S,�i ]
Are you an employer?Check the appropriate box:
Type of project(required):
I.P,1 am a employer with�_ 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
ship and have no employees These subcontractors have S. ❑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
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,g 1(4),and we have no 12.aRoof repairs
insurance required.]t employees.[No workers' 13.❑OtherS�r.
comp.insurance required.]
;Any applicant that checks box#1 must also rill out the section below showing their workm'compensation policy infunnuion.
lrateowreta who submit this affidavit indicating they are doing all work and then hire outside contractors tent submit a new affidavit indicating such
=Connoamr,that check this box most anachsd an additional sluct showing the name of the sub-contractors,and their wodten'comp,policy infonwtiou
t am an employer that Is providing workers'compensation insurance for my employeex Below is the pulley and jab site
information. 1 _
Insurance Company Name.--At z r \
Policy#or Self--ins.22Lice #: rl� 2ZC- 7 �� Expiration Date: 2
Job Site Address: \l �CU r � cd p b✓I City/State/Zip- G
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 2SA 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 fine
of up to S250.00 a day against the violator. Be advised that a ropy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
i do hereby certify under the pains said penalties of perjury that the information provided above Is true and comet.
mtere Dow t
7
Official use only. Do not write in this area,to be compkied by city or town official
City or Town: PermittLicense#
Issuing Authority(circle one):
1.Board of Ifeallh 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person• Phone#:
CITY OF SALE:M, TAXSSACHUSETTS
BUE DLNG DEP.9,RT\ILNT
130 WASHNGTON STREET,3'FLOOR
ZEL- (978) 745-9595
FAX(978) 740-9846
KIN(BERL.EY DRISCOLL
MAYOR Tmmu ST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BuumiNG CONMUSSIONER
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 wi Il be transported by:
I )t t m n-[-LI I C,
T (name of hauler)
The debris will be disposed of in :
(name of facility)
Il IX'.P MCk C C
(address of facility)
sign a of permi
t date
debris IT.4m
NORTH SHORE ROOFING
281 Andover St. Danvers, MA 01923
(978)977-3816 Fax: (978)762-4667
Mrs. Davis 10/13/11
3 Barr St.
Salem, MA.
(703) 627-0596
The following is a proposal to apply new asphalt shingle roofs on all of the roofs at the above
address, excluding the garage roof.
1) Remove the existing asphalt roof shingles down to the bare roof decking and legally dispose of the
debris .
2)Replace any deteriorated or damaged roof decking if and where needed .
3) Apply 6-ft. of ice and water shield around the entire perimeter of the roofs as well as around all
penetrations and flashings .
4) Remaining exposed roof decking will be covered with 15-lb. asphalt roof paper.
5) Apply new aluminum pipe flanges on all vent pipes .
6)Apply a fibered roof cement on the bases of the two chimneys.
7) Apply 8-in. aluminum drip-edge flashing around the entire perimeter of the roofs .
8)Apply a Lifetime High Definition architectural asphalt roof shingle , color and manufacturer to be
chosen by the home owner .
9) All roof related debris will be legally disposed of by North Shore Roofing .
10)Exterior siding and shrubbery will be protected as best as possible with tarps during construction .
11) All debris will be packed on a daily basis,gutters will be cleaned upon completion of project,
grounds will be swept for nails and screws on a daily basis with a magnetic broom .
12)Five year warranty on tabor, manufacturers limited lifetime warranty on asphalt roof shingles .
14) Quote includes a roof permit .
TOTAL PRICE : $9,400.00
-5%ANGIE'S LIST DISCOUNT: $470.00
NEW TOTAL PRICE: $8,930.00
PAYMENT TERMS
1/3 DEPOSIT REQUIRED: $2,900.00
BALANCE DUE UPON COMPLETION: $6,030.00
Acceptance of Proposal -By signing this proposal you have accepted all of the terms as stated above .
Date of Acceptance �� l3 �d 11 Home own
N.S.R.
✓" Peter iller
*Voted "Best of Boston -North 2010" by Boston Magazine*
*North Shore Roofing carries liability insurance as well as workmen compensation*
*Mass. Construction Supervisor License 499622* *Mass. Reg.#128691*
+- Massachusetts- Depamnent of Public Safer
Board of Buildin-g Rc_ulatinns and Standard
• Construction Supervisor Specialty License
License: CS SL 99M
Restricted to: RF t'ii0iq'f
PETER MILLER
281 ANDOVER STREET
DANVERS, MA 01923
Expiration: 9/6/2013
t'.nunisi„urr Tr—,: 1267 f
Otfice o onsume'r`. a"s` °stness e u a 4& e License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR - before the expiration date. If found return to:
Registration: ;_t28691 - Type: Office of Consumer Affairs and Business Regulation
5/5/2013 DBA 10 Park Plaza-Suite 5170
Expiration:
WHORE
Boston,MA 02116
ROOFING
i.
PETER MILLER \1> - -
281 ANDOVER ST
DANVERS, A 01
_t_
M923 '.,�' -
..,�.<� Undersecretary �- . Not va�ithoutignature
ACOW- CERTIFICATE OF LIABILITY INSURANCE DATEDAAYODAYM
PRODUCER (976) 745-6464 10 17 2011
THIS CERTIFICATE IS 193UED AS A MATTER OF INFORMATION
Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
66 Loring Avenue HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
P.O. Box 958 LTER TH ,COVERAGE AFFORDED 8Y THE OLICIES BEL
Salem MA 01970-
INSURED . INSURERS AFFORDING COVERAGE NAIL a
North Shore Roofing INSUR RA:Nautilus Ins, CO
INSURERD:Hartford
INSU14ERC:
Danvers MA 01923- SURER O:
COVERAGES INSURF•R
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO 1NE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITNSTANbING ANV
REQUIREMENT,TERM OR CONDITION OF ANY CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAYBE ISSUED OR MAV PERTAIN.
THE INSURANCE AFFORDED BY 1HE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS. EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.
AGGREGATE LIMITS SHOWN MAY HAVE BEEN NSR REDVCED BY PAID CLAIMS,
I ADO
L NBR TYPE OFINSURANCE POLICY NUMBER POLICY EE CTNE POLO Y IRATHON A DATE MMI DATE MM1� GENERAL LIABII.RV LIMITS
- X COMMERCIAL GENE ABILITY / / EACH OCCURRENCE 0 500,000
X CLAOMBMADE GENERAL OCCUR NHO24478 05/29/201.1 05/20/2012 PAL ISF.ao a 0Ar0A 0 300,000
MED EXP IAm eM pelew p 5,000
PER$ Net.A ADV INJURY 0 500,000
GEN'I.AGGRCOATE L~PER; / / / / CC AL AGGREGATE a 1,000,000 .
POL CY LOC P DOUC S• OMPA)PAG 0 11000,000
AUTOMOBILE LIABILITY
ANY AUTO / / / / COM31NED SINGLE LIMIT
ALL OWNW AUTOS Me nca4erll) 0
I I I I BODILY INJURY
SCHEWLED AUTOS
NIRF•DAUTOS (Per perenn) 0
NON•OWNBDAUTOS / / / / BODILYINJURY
(Pp.vcmenl) 0
PROPPRTYDAMAGE
GARAGE UA&tffy (PC accMFnD 0
ANY AUTO / / / / AUTO ONLY•EA ACCIDENT A
OTHER THAN EAR ACC 0
EXCESSIU ARELLA LIABILITY AUTO ONLY;
AGG A
OCCUR CLAIMS MADE / / / / _EArHO. C RENC 0
AO RENTS 0
DEDUCTIBLE / / / / 0
RETENTION
1
WOAKER8 EMPLOY R&LIABILITY NAND 5422CO24G7 07/25/2011 07/2572012
ANY PRO RB'UABIVTY
ANY PROPRILTORmARTNERIEXECImvE �0�•�IM
OPPICERRAEMBER EXGLUOEDT .LEA HACGDENT 0 100000
11 M-0LPROVI9de EL.DISEASE•EA6 OYEE0 100000
OTHER E.L DI9Pr;. .POLICY LIMIT 0 5000D0
IESCMPTION OFOPERAWONSAOCATNNISNEMCLEWERCWSN)NS ADDED BY ENOORSEMENnSPECIaL PROVISIONS
:ER FICA It MOLDER
978) 762-4667 NCELLATION
( ) — 9HOIN,O ANY OF THE AB°VE OESCRISP•D POLICIES BE CANCELLED BSipRE THE
EXPIRATION DATE THEREOP, THE ISSUING INSURER VALL ENDEAVOR TO MAIL
M• DAVIS 30 DAYS WRITTEN NOTICE TO THE CERTFICATE HOLDER NAMED TO THE LEFT,BUT
T� FAILURE T'O 0SB SHALL IMPOSE NO GEUGA""OR UABIUTY OP my nN0 Vno4+ n,
3 Bw ITUPT INSURER ITS AGENTS OR REPRESENTATNpa,
SALEM, MA 01970 ALIT REPRESENTATIVE n
CORD 25(2007/OS) n� ®ACORO CORPORATION 19M
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