8 BURNSIDE ST - BPA-16-600 0 The Commonwealth of Massachusetts .agr��EGT{9s�AL $ RV4 5
Board of Building Regulations and Standards ` CITY OF
Massachusetts State Building Code,780 CMR S EM
Idisar2011
( Building Permit Application To Construct,Repair,Renovate r emolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied:
fBuilding Official(Print Name) Signature Da
SECTION 1: SITE INFORMATION
1.1 Propprs�,rty Address: 1.2 Assessors Map&Parcel Numbers -
8 /SGrHS/7J6 STiccGT
Lla Is this an accepted street?yes no Map Nmnber 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.�OwC.n r�f 7cor�/S'L.
Name(Print) V City,State,ZIP
—Si4/-
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(,) ❑ 1 Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify: X"F
Brief Description of Proposed Work2:
t W-0 L r
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 $ El Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount Cash Amount:
6. Total Project Cost: $ I O Sob - ❑Paid in Full ❑Outstanding Balance Due:
V ts/aI-- ?
I --I q21
SENC) 76 FA•o P sir b �3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) D 996,S�9 2-- Z2- �(p
D N 4 / /�Lt License Number Expiration Date
Name of CSL Hold r
R T15i�a( V19 List CSL Type(see below) R-C
No.and Street Type Description
UA-5 9 t&A �ll O 306a U Unrestricted(Buildings u to 35,000 cu.ft.
`t R Restricted 1&2 Family Dwelling
City/Ibwn,State,ZIP M Masonry
® Roofing Covering
7 ]f Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/S'7'0/7 /o -Z-Zo/7
6(1) SC4QM.. HIC Registration Number Expiration Date
HIC Comp y Name or HIC a is t Name
297iflle�n in�oGo/ds��a�gra� p
No.and Site Email address
CheldtS'1--ord PA Olgzy 97,V-Z57-7663
Ci /Town,State,ZER - Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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
1,as Owner of the subject property,hereby authorize 4A46 ny /a-&
to act on my behalf,in all matters relative to work authorized by this building permit application.
'nt Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By ente my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain ' this application is true and accurate to the best of my knowledge and understanding.
S /y /4
Print O er's r Authorized Agent's Name(Electronic Signature) ate
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hues an unregistered contractor
(not registered in the Home Improvement Contractor(MC)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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
2. When substantial work is planned,provide the information below:
Total floor area(sq.fl.) (including garage,finished basementlattics,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"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORIAN.
Applicant Information Please Print Legibly
Business/Organization Narne: nLT] SC46b_ 6AOu p l MC=
Address:
City/State/Zip:CkJt4Sr-v►-c2, f4"' 6 / Phone#: 978-Z S1-7610
Are y an employer?Check the appropriate box: Business Type(required):
1.U I am a employer with�_employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.❑ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] 8. Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152,§1(4),and we have 1011 Manufacturing
no employees. [No workers'comp.insurance required]* 11.❑Health Care
4.❑ We are a non-profit organization,staffed by volunteers,
with no employees. [No workers'comp.insurance regj 12.❑Other
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is requited and such an
organization should check box#I.
am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name:
Insurer's Address:
City/State/Zip:
Policy#or Self-ins.Lic.# Expiration Date:
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 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of N DIA for insurance coverage verification.
l do hereby ce under the pains and penalties ofperjury that the information provided above is true and correct.
Signature: Date: lN�L
Phone#
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
Massachusetts Department of Public Safety
lugBoard of Building Regulations and Standards
License: CSSL-099649
Construction Supervisor Specialty 3
ANTHONY N DOWD J
9 DIGITAL DR#202
NASHUA NH 03062
CA—_ Expiration:
Commissioner 02128/2018
V/te tponwrzwrrne¢ co. crtuec rralelld
MA
Office of Consume;Affairs&Business Regulation .License or registration valid for mdividul use only
OME IMPROVEMENT CONTRACTOR ! before the expiration date. If found return to:
egrstration .157447 - Type Office of Consumer Affairs and Business Regulation--
Expiration 10/2/201 7 Private Corperat 1 - 10 Park Playa-Suite 5170 -
_ Boston,MA 02116
OLD SCHOOL GROUP INC y
ANTHONY DOWD _
tl
297 LITTLETON AD
_
GHELMSFORD,MA 01624'--- Undersecretaryt Not valid without signature
Massachusetts Contractor License #15 744 7
CONTMUI LY TRAINED AND CERTIFIED BY AMERICA'S LARGEST ROOFING MANI A T IRERS
Thank you for considering Old School Roofing and giving us the opportunity to provide you with a no worry,quality
roofing system. At Old School Roofing,we are committed to customer service and satisfaction and prompt response to
your needs or concerns. We would be honored to welcome you to the Old School Roofing family.
Residence May 14, 2016
8-10 Burnside Street
Salem, MA 01970
Lulu11375(awahoo.com 'S+%llenSe _Yaticw. com
1. Strip existing roof area to decking. (2-3 layers)
2. Inspect decking replacing any damaged or rotted decking—additional cost may apply.
3. Install new lin insulation ISO board to entire roof deck to areas to be roofed with rubber.
4. Insulation will be mechanically fastened using specialty coated plates and screws.
S. Apply a bonding adhesive to the entire decking surface.
6. Install .060 EPDM rubber membrane to the entire decking.
7. Re-flash all protrusions with a field wrap or flashing boots, chimneys will be counter flashed with new lead.
8. Wash all lap and splice areas with splice cleaner.
9. Old School Roofing will obtain any permits pertaining to the job.
10. We will warranty all our work for 10 years.
Job Cost: $10,800.00
If there is tar and gravel at the base and additional cost will apply for disposal.
"Decking will be replaced at$60 00 Per sheet for CDX Plywood and $3 00 per lineal foot for deck boards."
Includes full clean-uP and disposal of all debris.
Payments will be made as follows: 1/3 Deposit and balance upon completion.
SIGNING BELOW INDICATES ACCEPTANCE OF THE PRICES AND SPECIFICATIONS SET FORTH HEREIN AND
ACCEPTANCE OF THE TERMS AND CONDITIIONS OF THIS CONTRACT.
Auth ri Contractor
I
o
blassachasetts t onti-actorLiceitse #157447
CONTtNjIALLY TRAINED AND CERTIFIED BY AMF ICA'S LARGEST ROOFING MANiIFACTIIRERs
Thank you for considering Old School Roofing and giving us the opportunity to provide you with a no worry,quality
roofing system. At Old School Roofing,we are committed to customer service and satisfaction and prompt response to
your needs or concerns. We would be honored to welcome you to the OW School Roofing family.
Residence May 14, 2016
8-10 Burnside Street
Salem. MA 01970
UN11375navahoo.com ��r�lEhSeGSiaj+ou. CoM
1. Strip existing roof area to decking.(2-3 layers)
2. Inspect decking replacing any damaged or rotted decking—additional cost may apply.
3. Install new lin insulation ISO board to entire roof deck to areas to be roofed with rubber.
4. Insulation will be mechanically fastened using specialty coated plates and screws.
S. Apply a bonding,adhesive to the entire decking surface.
6. Install .060 EPDM rubber membrane to the entire decking.
7. Re-flash all protrusions with a field wrap or flashing boots, chimneys will be counter flashed with new lead.
8. Wash all lap and splice areas with splice cleaner.
9. Old School Roofing will obtain any permits pertaining to the job.
10. We will warranty all our work for 10 years.
Job Cost: $10,800.00
If there is tar and gravel at the base and additional cost will apply for disposal.
**Deckine will be replaced at$60 00 per sheet for CDX plywood and $3 00 per lineal foot for deck boards."
Includes full clean-up and disposal of all debris.
Payments will be made as follows: 113 Deposit and balance upon completion.
SIGNING BELOW INDICATES ACCEPTANCE OF THE PRICES AND SPECIFICATIONS SET FORTH HEREIN AND
ACCEPTANCE OF THE TERMS AND CONDITIONS OF THIS CONTRACT.
Auth ri Contractor dlq
1