65 COLUMBUS AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
1� Revised Junuury
Building Permit Application To Construct,Repair, Renovate Or Demolish a l• 'nr�x
n or Two-Family Dwelling
is Section For Official Use Only
Building Permit Numb: / Date Applied: '263 1 10
Signature: 11
Buildin ummissioner/ pector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property A ddress
��)�
: 1.2 Assessors Map& Parcel Numbers
_ 6�
I.l 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 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if esO Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: p
A,
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': -�V — t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S _ I. Building Permit Fee:S Indicate how tee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cast (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
G Check No._Check Amount: Cash Amount:
6. Total Project Cost: S Ll %r,, ',,P ❑Paid in Full ❑Outstanding Balance Due:—_
�' r �'VCiC, "V 1. V•�'.�V v��.
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
5�-k, License Number iiGspimuon Uate
c
Name ol'CSL-I lulder
List C•SL'rype(see below)
.Address Description
Unrestricted u l0 35,000 Ca Ft.
e Restricted 182 Family Dwellin
Signawro M Masonry Only
RC Residential Rooting Coverin
telephone WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 RegbtFrgd Home Improvement Contractor(HIC)
I IIC Company Name ur FIIC R—egistram Name Registration Number
Add s
I—S�()')1� Exptm on Date —�
Signature 'relephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.to 152.5 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..........1w No...........O
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.
Signature of Owner Dale
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
I, t-, S���. ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. i tt ,'
Print Name 3 /13S n ^ J
Signature of Own�rAuthorized Agent Date � I�
(Signed under the pains and penalties of 'u
NOTES:
I. 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 ny_(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 780 CMR Regulations I IO.R6 and 110.115•respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 Foolage"may be substituted for"Total Project Cost"
�S CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MIF,
M`.,,,a I:C tt'.NIII\b;JV S114UT •SA I M,
1'rl 97S.740-1t846
construction Debris Disposal Affidavit
(required fur all demolition mhd renovation work)
In accurdimce 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will be transported by:
� CGS
(tame of hauler)
T,h1e debris will be disposed of in
(OAme Ur aGl ply)
, 4 s PC-
Address of racilily)
signature of permit applicant
date
CITY OF SM-E.`Ip NLASSACHUSETTS
BUMD0I43,DEPARTtE`iT
120 WASHINGTON STREZT. r FtoOR
TPA. (978) 74S059S
F.ex(978) 740-95W
KINBEA ..F D(USCOLL THO&W ST.PlIERRt
MAYOR DIRECTOR Of PLaLIC PROPERTY/8L'QDNO CO%L%nsstO'%
Workers' Compensation Insurance ARidavit: guilders/Contractor/Electriclan%iPtumbers
+ Ileant Infnrmatlos Ptesse Print Legibly
Valne Itltouw+rOryarraliotvlrtJavtduall: ����� G.. ` �,
Address: Its,
p�
Kvtll�C�
City/SatdZip: �
\re yoe as employe'Cheek the appropriate be-: Type of project(required$
I:�S I am s employe with _ 4. ❑ I am a priced contracur and 1 6 ❑New construction
anployse(full and/or pan-time)-0 have hired the s&erauraetors
2.Q 1 am a solo proprietor tar pmuter-
listed an the attached sheet t 7. Remodeling❑
,hip and have no employee These sh,Comp.
ins rs have e. ❑Demolition
twrkers'comp inwrsaoe
working for me is any capacity. 9. Q DuiWing addition
INo workers'comp insurance S. Q We are a corporation and its 10.❑Electrical repairs or additions
nquirmLJ ofters have esereiaed their
).Q 1 am a homeowner doing all wort right of exemption per MOL 11.Q Plumbing repairs or additions
myself.(No workers'comp. c. 152.f 1(41 and we have no 12.Q Roof repairs
nsurshtee required J r c su (ifts w r I2.Q OOte
comp.
insurance required.]
•Any appgar tNs ehmo boa at rental alwfi no uta dw fiacrise below asswig shelf -0 tee'cmnpwedtm rdhr i,%mh dos
'I t.wrewnm who submit this afteri indicating thq no Joins fill work and thm him rush rvsoecfiefie itnr ratme a new amJwi indicairy souk
: 'MMIme tM A wk IW bra treat anxlyd so aldihitwl show dwwity Jos tmee fir the w►serrnson ad their wwhwa'rm7.Policy intwmWen.
I am as awp/ayer that h providins workers'cos k"Amr/ea/Nsumare fer t4 taspleysws eeMe tr ere paHey eaI/o1 r/br
in "we"
Insurance Company Name:
Policy Nor Self•ins. Lie. G C6 �,h Expiration Dab: R
Job Site Adfibh:rs:
7 \ � � City/Slaw/Zip:
,%ttacb a copy of the workers'compensuh a policy deetwdtlss pop pbowing the policy number and espi thta dab►.
Failure to secure coverage as required under Section 23A otMOL a 152 can lad to the imposition of criminal penalties of
fine-up to S 1.300.00 and/or one-year imprisonment,as well as civil penalties is the form of a STOP WORK ORDER and a fleas
Of up to S25o.00 a day ryainsi the violator. Ile advi.al that copy of this statement may be furwarded to the OtTlee of
Invv,htaatiuns of the MA for insurance cowrose wrifleaticim
/do hereby certify wrier the i !and ytNelu a/perjury that the informetloa provided above is true and correct
.. Data• ����� V
0/lclal aaa an/y, Oo nee write ie this firm,if 6a surnp/irrd by riry or tewa n/fh rrL
I
'City or ruwn: Ycrmit/LlcenstM__. __ __
Nsuinfl Aulhurrty (circle fine):
1. tluard of Ileallh 1. Ruildinu Witirimcnt ). Citytrown Clerk J. Electrical In+pectar S. Plumbing Impactor
6.Other
l„nracl Pcnon: _ . _ Phone e:
Shea Roofing Co.
17 % Foster Street
Salem, NA 01970
(978) 745-7313
PROPOSAL March 9,2010
SUBMITTED TO: Steve Pe'r,^r &
65 Columbus Ave.
Salem, Ms.
We hereby submit specifications and estimates for.
To install architectural(30-year windseal) roof shingles covering
complete of main roof and front porch.
To install Ice and water shield covering (3) feet up from all roof edges
and along all flashing points prior to re-roofing.
To install ail new metal drip edge along all roof edges, both horizontal
and vertical.
To Install new roof flange on roof vent pipe.
To counter flash, re-flash and/or reseal flashing points along all
sidewalls as necessary.
To clean up and remove all roofing debris from job site. `
The new roof is guaranteed for five years against any problems created
by faulty workmanship.
We propose hereby to fumish material and labor—complete in accordance with above specifications,for the sum of:
Four Thousand Nine Hundred,and Eighty Five- ------Dollars ($4,985.00)
Payment to be made as follows:
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 overthe 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 authorizedto do the-work a specified:
Authorized Signature: k11.4k—
Signature:. r�
Date of Acceptance: .