330 ESSEX ST - BUILDING JACKET RFCE-IVED
:� The Commonwealth of M8WAt s ^
Department of Public Safety W. 3�
hlassachusetts State Building Covis 110 P
Building Permit Application forany Building other than a One-or Two-Family Dwelling
N (This Section For Official Use Only)
Budding Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
,9C, FS -19 r_'e,�
No.and Street City/Town Zip Code Name of Budding(if applicable)
SECTION 2:PROPOSED WORK
Edition of hfA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition 0 (Please fill out and submit Appendix 1)
ChangeofUse ❑ ChangeufOccupancy ❑ 1 Other 0 Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engfncertng P Review required? Yes O No ❑
Brief Description of Proposed Work: 01� t S i•-+—G //��'T�N'yj1
+�a l4 d—
O 1i G
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 CbIR 34) ❑
Existing Use Group(s): I Proposed Use Group(s)-
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
#Factory
loors/Stories(Include basement levels)dr Area Per Fluor(sq. ft.)
Area(sq.ft.)and Total Height(ft.)
SECTIONS:USE GROUP(Check as a licable)
bly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5 0 B: Business ❑ E: Educational ❑
F-1 O F2❑ H: Hi h Hazard H-1 0. H-2❑ H-3 ❑ H-4❑ H-5 0
tional I-1❑ I-2 0 1-3 0 FI❑ M: Mercantile❑ R: Residential R-10 R-20 R-30 R4❑
e S-1 ❑ S-2❑ U: Utility 0 Special Use 0 and please describe below:
se: SECTION 6.CONSTRUCTION TYPE(Check as a licable)1D0 IL10 1160 IIIA ❑ 1fill ❑ IV 0 1 VA VD ❑
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: ur on site system❑ required 0 or trench or specify:
permit is enclosed CO
Railroad right-of-way: Hazards to Air Navigation: �I-\I li=turf,lonmiis6 gi 140v n.,14.x,t+c
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Budd enclosed❑ 1 Yes 0 or No 0 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Gruup(s): Type of Construction: Occupant Load per Fluor:
INVS the building contain an Sprinkler System?: Special Stipulations:
CoA\j •� �1 D ��19
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and dress of Property Owner
LtZ �YL --?cs T S -,nLL- p� df 7b
Name No.and Street City/Town Zip
Property Owner Contact Information:-
7 G/� 3ok �'�1 0 �~
�� �-- —'� Wit,_ t����P>,� ��-,
Title Telephone No.(business) Telephone No. (cell) a-mail address !"
If applicable,the property owner hereby authorizes C y
Out;r 6�IP, l >.vi l 6 l/;- ' _y�T l�'g!� '5
Name Street Address City/Town State - Zip
to act on the property owners 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 thvt 35,0W cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Namre.(Registrant) Telephone No. mail address Registration Numbera
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - -
I�o LO S P //V wo Co>`i r"/1
Company Name 0606eys0 #V(VP CS i IQ D �a
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 address
SECTION 11:WORKEPS'CO&WENSAI'ION INSUItANC1.AFFIDAVIT M.G.L.C.152. 25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with thisapplication. 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 $ 5100 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ -zb appropriate municipal factor)_$
3. Plumbing $ p
d.Mechanical (HVAC) $ Note:Mini f tact municipality)mum fee=$ (con
5. Mechanica4 Other $ �"� x
Enclose check payable to ' ��/
6.Total Cost $ I IL10 (contact mtmicipali )and write check number ej e
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains anti penalties of perjury that all of the information contained in t¢is
application is true anti accurate to the best of my knowledge and understanding.
Y/ovvc•r w� ( e✓I � 7P( _77_
Please print anti sign name �J Title ��I, Telephone No. Date
_1/_ y �T // 18n rSC2/L � K3✓� v '1 /1 ell )
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval•
Name Date
t:-
i
� I -
7 7i 1 y �I
Ace
I 1 _
LL i'
1 i
1 � ,y _•f�1 �T��—�i
4Lt l)VaE IGWAT allo. DESIG4!%AN6 ARE PRWIDED FOII THE£AW GESIcwE6 roRp1 'I 8Y E / �tl_�I. ,G
SIZE OESI9 NATION$, USE VTHE CLIENT OR HI6 AGENT IN 7It¢NS.Z_Y 1-I WIN ` I NO.
GIVEN AtkE SUEfJVCT TG CONVERNOTHE"P ECTAS L6 VMHN REV V {
2° RIT;IpIh1O(,j ON JOJU - TINS COtRPACT.DMGR.N %RER:ABI THE �'
ifE cAsu AEHI}S'.ME.Si[ro INWI'Elm of tans r•NNH axn CAN wor eE �7�w�Ml Mp,ofq .
$ITJOB 4UNbFTAON6. Nn1bIRl lob n&6.m AssalrtYr USED OR wism MRO RHiMI om.
The Commonwealth of Massachusetts
� wn of
Board of Building Regulationssanand d StandLand
ards To
ka Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Ttvo-Faintly Dwelling
( This Section For Official Ap Use Only
Building Permil Numb Date Applied:
i.
i
Signature: 3 y ��
1. Bwl t ssioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property�ddress: ) 1.2 Assessors Map At Parcel Numbers
30 t SS (Got �7
1.1 a Is this an accepted street?yes N_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(fl)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of R cord: 3 36 (FSS
KMn-r ,0cN Zed
Name Pri t) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ T Alteration(s) Cl I Additi n ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify: qA7Su&A-n G
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $ Total All Fees:$
Suppression)
/,rr Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ p2`'f'(1 Q' 13paid in Full ❑Outstanding Balance Due:
L
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Ngme of CSL- Helder
a F
List CSL Type Isee below)
Address VDRcsii'tedemial
Descri Lion
tricted u to 35,000 Cu. Ft.)
Signature cted 1&2 Famil Dwelling
n Onl -
Telephoneential Window and Sidinntial Solid Fuel B Demolition
5.2 Registered Homqq Improvement Contractor(HIC)
HIC Company Nameor H4C Re tg strap Name Registration Number
Address � ^ M /G
/ Expiration Date
Signature Telephone Ca�/ t'7
SECTIO 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 I u e of[he building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZA ON O BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
/I ('
1, , T (V G eJJ , as Owner of the subject property hereby
authorize 9 1 c-010,� to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of wrier Date
SECTION 7b: OWNERt OR`/AUTHORIZED AGENT DECLARATION
1, P) ��"('f�✓ � ��� l ,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.
rc [PA,tLto C.
Print Name
Signature of Owner or Authorized Agent Date 7
(Signed under the pains and penalties of erju
KffrE S:
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 1 10.R5, 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 Footage"may be substituted for"Total Project Cost"
0
Salem Historical Commission
120 WASHINGTON STREET,SALEM, MASSACHUSETTS 01970
(978) 745-9595 EXT.311 FAX(978) 740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that.the proposed:
❑ Construction ❑ Moving
❑ Reconstruction ❑ Alteration
❑ Demolition ❑_ Painting
❑ Signage ^!R'(� Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: 230 Essex Street 41
Name of Record Owner: Catherine Toth Ken Clenzer
Description of Work Proposed:
Cellulose insulation to be blown in to rear and sides of'house through temporarily removed board, to be
returned to existing condition. Cellulose insulation to be blown in to front of house through 1 318" holes, after
which will be filled in and painted to match. Holes to be placed behind shutters wherever possible.
Dated: February 17, 2009 SALEM OMMISSION
By:
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). 'Alf work commenced must be completed within one-year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.
February 12, 2009
Subject: Blown-in Cellulose Insulation
330 Essex Street, 41
Salem, Massachusetts
To Whom It May Concern;
We the undersigned are owners of 330 Essex Street, 42, in Salem. Along with Kent
Glenzer and Catherine Toth (owners of#1), we are members of the Three-Thirty Essex
Street Condominium Association, which governs matters pertaining to the two-unit
condominium at this address.
With this letter, we declare that the application of blown-in cellulose insulation to #1
does not infringe on our privately held property.
Kathleen Harvey
Robert Harvey
330 Essex Street#2
Salem, Massachusetts
,�ti � oa 01001
4-
,0 /40907 2S CA',-- s,� Z
VEU
'f The Commonwealth of Massachusetts IDCPV�is,411
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMS
,.. � F
Building Permit Application To Construct, Repair, Renovate O
One-or Tivo-Farnily Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) signature '�Utue
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map Br Parcel Numbers
3 0 55eX { <_ u� _
I.I a Is this an accepted street?yes no k1ap Number Parcel Number
1.3 Z,miag Information: 1.4 Property Dimensions:
%Doing District Proposed Use Lot Area(sq 11) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided RequiredP:E,,�dcl
1.6 Water Supply: (iM.QI,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private Cl Zone: _ Outside Flood hone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSFIIP'
2.1 0"er1 of Recor L p
m Na I -fiL�- Li -70
( ) City, State,ZIP
33 Lsse�c 5�, s78s-.p 7 �lz�
No.and Strect Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Rcpairs(s) ❑ Alteration(s) Cl Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units I Other ❑ Spacily:_
Brief Description of Proposed Work'':_ —. T K" / ky
Lvv�__W-F� -/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
L Building $ I. Building Permit Fee: $ Indicate how fee is determined:
o. Electrical $ ❑Standard Citvfrown Application Fee
❑"total Projec[Cost'(Item 6)s multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (I IVAC) $ List:
5. Mechanical (Fire —
Su ression) $ Total All Fees: $_
Check No. Check Amount Cash Amount:
-
6. Total Pro ect Cost: $j i
�S ❑ paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5A Construction Supervisor license(CSL) t
_ r
It,. ,rsa; License Number Expiration Date
;Name of CSLfloldcr'A'A •^
- ' ' t,• List CSL Type(see below)
No.and Street 'type Description
U Unrestricted(Buildings tip to 35.000 cu. tI.)
Cityll'own,State,ZIP R Restricted 1&2 Fanily Dwelling
M klasonry
RC lioufin Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2�RReegistered Home Improvement Contractor(HIC)
` yeu r HIC Registration Number Expiration Date
HIC Company Name or I1IC Regis ant Name
LN lam,I--) S ,
No,yid StZ 9 (/ >&-S3S-Sa35-
Email address
/o oiP6a
Ci[ /Town, St46,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.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
I,as Owner of the subject properly,hereby authorize r�tJf I.L rg br— jP>er,-f-
to act on my behalf, mail matters relative to work authorized by this building permit application.
1 4k a DeQv Z nice -4-
I b�l
Print Owner's Name(Glee tonic Signature) �atc'
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this applicatlo i
true and accurate to the best of my knowledge and understanding.
Prim Owner's or Aulhorrsd Agent's N:une(F.ectronic Signature) I at/ e
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 not have access to the arbitration
program or guaranty fund tinder NLG.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/dos
2. When substantial work is planned, provide the information below:
Total Floor area(sq. R.) (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____ _Ope❑ -
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth of MassachusettsRCVEO` - CITY OF
Board of Building Regulations and StanECT10NAL SER ALEM
WMassachusetts State Building Code, 780 CMR ICESS
.Revzsed Mar 2011
Building Permit Application To Construct, Repair, RernoyM
5l
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I Date plied:
O
•�� Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
—� 1.1 Property Address• 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/�•1 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'
22.1 Owner'of Record• p -p
.1 di Fs=3¢1xC y� T� 5
Name(Print) City,State,
IF-IS 5
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ FExisting Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Prop
t �
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:
❑Standard City/Town Application Fee
2.Electrical $ s ?
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5. Mechanical (Fire Su $ Total All Fees: $
Suppression)
G Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ O /`b�� ❑Paid in Full ❑Outstanding Balance Due:
rnad-')) 6 MkkL_e-® I s
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C5—M5%0 I
License Number Expiration Date
Name of CSL Holder
List CSL'1'ype(see below)
No.and Street Type Description
Unrestricted(Buildings up to 35,000 cu.ft.
Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Buming Appliances
1 Insala,on
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ,�� ���
N�� a 5 �-y�._ HIC Registration Number Expiration Date
HIC�CompT N\e or HdC R�egtrant Name
�y g
Np.,and Street \ '� Email address
City/Town,State, Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.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
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 Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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 t the best of my knowledge and understanding.
W' W,c..�. Ste= E 3
Print Owner's or Authorized Agent's Name(E ectronic Signature) Date
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.gov/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"may be substituted for"Total Project Cost"
CITY OF S�UE2 1�L3SSACHUSETTS
• BuILDIZNG DEPARTNEERNT
' 120 WASHINGTON STREET, Va FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KiN[BE.RL.EY DRISCOLL
MAYOR T Hows ST.PIERRE
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 will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
'date
dcbrimffdoc
CITY OF SM ENI[, NMASSACHL'SETTS
• BUILDING DEPARTJtENT
120 WASHINGTON STREET,Yo FLOOR
TEL 978)745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOII
THOMAS ST.PDeRRs
MAYOR
DIRECCOR O II
F4LBLICPROPEATY PROPERTY/BUILDING CO\MUSSIONFR
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Analicant Information Please Print Leeibly
c \
Tattle(BusinssiftanizatioNlmfividual):
Address:
City/Statc/Zip: Phone i/: c\-\'-6 �YY�-O
Are you an employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with 4. ❑ 1 am a general contractor and I
employees(full and/or part-time)." have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 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 S. ❑ We are a corporation and its
required,] officers have exercised their 10.0 Electrical repairs or additions
3.❑ i am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp, C. 152,§1(4),and we have no 12.[]Roof repairs
insurance required.)t employees. [No workers' 13.❑Otha
comp.insurance required.]
;Any applicam ohm checks bm g l must also fin out the section below showing thew workers'compensation policy infermanon.
I I fnmeowncts who submit this affidavit indicating they ate doing all work and then hire outside eommcbms mast submit a new affidavit indic ring such
:Commxon that check this boa must anachrd an a"liorcd sheet showing the trouts of the subconuaetors and their wmkda'comp,policy inf@mmtion.
l am an employer(hat Is providing workers'compensation hisarattce for my employem Below Is the policy and job site
information. (�
Insurance Company Name:
Policy 4 or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/Zip: Y]\2J-1 C t �6\�o
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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
i do hereby certify under the pains and penalties oofpOerjury that fire information provided above is true and correct
Signal ire: Date' I 13
Phone#•
Official use only. Do not write in this area,to be completed by city or Iowa ofcialt
City or Town: PermitfLicense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Persoa: Phone#:
r Sh9a Roofing Co.
17 % Foster Street
Salem, MA 01970=
` (978) 745-7313
OPOSAL - November 12,2014
93Pg6MITTED TO:
330 Essex St. Condominium Assoc.
330 Essex St.
Salem, Ma.
We hereby submit specifications and estimates for.
To remove all existing slate toofing from lower left front section of main
roof which his existing skylight
To install ice and water shield covering lower roof edge and under all i
,> flashing points prior to re-roofing.
To install% tthetic underlayment paper covering all roof boarding prior to
re-roofing.
To install all new metal drip edge along all roof edges.
To install GAF Slateline Antique Slate roof shingles covering complete
roof as mentioned above.
To install up to 50 linear feet of roof boarding-if necessary additional
boarding installed at a rate of$3.50 per foot
To install new Solar powered Velux venting skylight, replacing existing
skylight on same section of roof.
Cost$5,700.00
To completely grind out and re-lead both oversized chimneys on same
section of roof.
To re-flash, younter-flash and/or reseal sidewall as necessary.
To refasten existing crown molding prior to rr 400fing, if molding is too
damage we will replace rear section on a time plus materials basis.
To install new custom manufactured metal ridge cap on same section of
roof.
To install new downspout system and repair gutter above same roof as
mentioned above.
To clean up and remove all roofing debris from job site.
Cost$3,185.00
We propose hereby to furnish material and labor-.complete ih accordance with above specifications,for the sum of:
It.
Eight Thousand Eight Hundred and Eighty Five--m=------Dollars ($8,885.00)
Payment to be made as follows; -
One third to start balahce upon completion /
All material is guaranteed to be spec(fu:d. All work to be completed idd workmanlike manner according to
standard practices. Any alteration or deviation from above specificatkns involving extra costs will be executed
only upon written orders,and will become an extra charge over the q#itimate. All agreements contingent upon
strikes,accidents or delays beyond qur'control. Owner to carry fire,tornado and other necessary insurance.
,w Ourorkers are fully covered by Vllorkman's Compensation Insurance.
rAcceptance of Proposal-You a " uttioril?e t do the wog s spec$ed.
��/�Authorized Signature:
I /
Signatures• 7
Date of Acceptance:
Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978) 740-0404
CERTIFICATE OF APPROPRIATENESS
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction W Alteration
❑ Demolition ❑ Painting
❑ Signage ❑ Other work
as described below will be appropriate to the reservation of said Historic District, as per the requirements set
P
forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance.
District: McIntire
Address of Property• 990 Essex Street
Name of Record Owner: Hugh & Diane Pyle Melanie Griffin & Benjamin Larrabbee
Description of Work Proposed:
Replace the existing slate roof along the western roofline, closest to Essex Street, with Slateline 3-tab shingles,
in the color Antique Slate or English Gray. A metal ridge cap will be installed
The remaining slate roofs to be repaired in-kind.
Dated: October 20, 2014 SA�LE/M HISTORICAL COMMISSION
By.
The homeowner has the option not to commence the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.