182 FEDERAL ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
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 Num Date Applied: I
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Properly Ad(�ress. 1.2 Assessors Map&Parcel Numbers
rii aL �-t>���\ S�
l.la 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 R) 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'
2.1 Ow�ne`r'of Record:
iName(Print)` City,State, P
I%'}- ! �&k SION Im CAP—\
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work: +[ _ h' '-N
W ` ti 'n rnr \, N O
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ f6 1. 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 (RVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
0.Total Project Cost: $7f ❑paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
S�-2c� License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) \l\
No.and Street Type Description
Unrestricted(Buildings up to 35,000 cu.R
R Restricted 1&2Famil Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
t� SF I Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ��,��
5 V--11 "`���� , h t HIC Registration Number E pi
HICj m17n sine or HI�-4 >-Registrant Name
N .and Street Email address
City/Town,State, [P 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 ..........M 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 \J� , W, 5
to act on my behalf,in all matters re ive,to work autho ized by this building permit application.
int Owner's Name(Ele, tronic Sigr ur - D to
SECTION 7b:OWNER' 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 a curate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic 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.gov/dps
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 halfibaths
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"
Shea Roofing Co.
17 % Foster Street
Salem, MA 01970
(978) 745-7313
PROPOSAL - October 31,2013
SUBMITTEOTO: 182 Federal Street Condominiums
182 Federal Street
Salem, Ma. 01970
We hereby submit specifications and estimates for:
To nail down any raised or curled shingles and replace any missing
shingles on complete top roof to provide for a smooth surface prior to re-
roofing.
To install all new metal drip edge along all roof edges, both horizontal
and vertical.
To install standard three tab GAF roof shingles covering complete top
roof.
To install up to 100 linear feet of roof boarding if necessary.
To install new roof flanges on roof vent pipes.
To install new roof air vents replacing all existing vents.
To counter flash and/or reseal the chimney flashings as necessary. If lead
flashing is too damaged on the chimney we will grind it out and re-lead at
an additional cost of$350.00 per chimney.
To install new flat roof on front entranceway roof.
To clean up and remove all roofing debris from job site.
We propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
Eight Thousand Eight Hundred and Eighty Five--------Dollars ($8,885.00)
Payment to be made as follows;
One third ($2,900.00) to start balance upon completion
I
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 over the 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.
s
Acceptance of Proposal-You are author' ed +dot ork as specified.
Authorized Signature:
Signature:
Date of Acceptance: 1I
CITY OF &U.&N4 !MASSACHUSETTS
BL'IIDING DEPARTMENT
• a• 120 WASHINGTON STREET,San FLOOR
0'f TEL (978)745-9595
FAX(978)740-9846
Kl\iBERLEY DRISCOLL
MAYOR THOMAS ST.PWJ=
DIRECTOR OF PUBLIC PROPERTY/BL'IL.DLNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben
Applicant Information Please Print Legibly
Name(Busim-ssiorgunizatiorvindividual):
Address: ',aO
City/State/Zip: Phone H: !�' S —
Aie you in employer?Check the appropriate box: Type or project(requitred):
I'PJ am a employer with 1') 4. ❑ 1 am a general contractor and I
employees(full and/or part-timo).
• have hired the sub-contractors 6. ❑New construction
2.El am a sole proprietor or partner- listed on the attached sheet 1 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical airs of additions
required.] officers have exercised they
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'cramp. c. 152,§44),and we have no ME]Roof repairs
insurance required.]t employees.[No workers'
comp.insurance required.] ME]Other
•Any applicant that checks box N I must also fill out the section bciow slowing their workos'compensation policy information.
1 tomeowmas who submit this affidavit indicating they are doing all wok and than him outside eommeno, must submit stunt,affidavit indicating such.
:Corumcwts that check this box most anached an additional shmi showing the name of the ab�commcua s and their work='comp,policy infmmmion,
l am an employer that Is providing workers'compensadon lnsurancefor my employees. Below is the pulley and Jab site
Information.
pp �
Insurance Company Name:_
Policy li dr Self-ins.Lic.tt: A�1 C�10���C��l �� Expiration Date: 'r3/6�r I L
Job Site Address City/State/Zip:53\(".
Attach a copy of the workers'cempensattoa policy declaration page(showing the policy number and espiradon 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 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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certo under the pains and penaId of. Vary that the h!rarmallon provided above Is true and correc&
Sienature a Date I t I
Phone$: :"\ �'l5,o—
Official use only. Do aot write in this area,to be completed by city or town afflciaL
City or Town: Permit(License q
Issuing Authority(circle one):
L Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone q:
CITY OF S.U.&M, TNI.kSS.ACHUSETTS
• BUILDING DEP kRnEENT
130 WASHINGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAX(978) 740-91W
KIJIBERLEY DRISCOLL
LIAYOR T HomAs ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%WISSIONER
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)
�Jw er D g c-� &
(address of facility)
signature of permit applicant
II � ►y �I -
date
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