35 FLINT - BP 11-100 ;�., ;► ' The Commonwealth of Massachusetts
Department of Public Safety
vw.` ..\Li.,.s,ichusetls Slate Building Code(780 CMR)Seventh Edition
City of Salem
D U Building Permit Application for any Building other than a I- or 2-Family Dwelling
I (This Section For Offictal U.se Only)
Budding Permit Number: Dale Applied: Building Inspector:
SECTION 1: LOCATION (Please indicate Block 11 and Lot 0 for locations for which a street address is not available)
No. and Street Cin• /Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that appl y in the two rows below
Existing Building R,pai,)K I Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No-R—
Is an Independent Structural Engineering Peer Review required? Yes ❑ No-)*
Brief Description of Proposed Work: !ZF,"r,.,,+4 rtf J-1--?7e -9T 2V9/T dr�l.n avd
.SNJ14" ouFt-1 C'ui,p�,sr r ,4" T � �9vrJ 4r "Fs 7-.'4F CFrl4•v7fEo C)E•v%PivJ•¢ r J-GATC
_..1..a F2awT oF- cad .SGA7r wi// !?C 6lFr7e�rd --9-7 rvrkc.j
j::1C uzr SL 47T �}r,..-t RiL+4 icr R"r JC,+Tt fR2 CA
r
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing UseGroup(s): Proposed UseGroup(s): r
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area (sq. ft.)and Tutal Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4 ClA-5❑ e: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5 Cl
I: Institutional 1-1 ❑ 1-2 ❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R- R-3❑ R-4❑
S: Storage S-1 ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ 118 ❑ IIIA ❑ � IV ❑ VA ❑ VB (3
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Waler Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
P ,he ❑ Check if outside flood Zone CI municipal ❑ A trench will not be Lice rise
d Dispas.d Site❑
required❑or trench or ,peciv:
I'n cafe❑ or indentilc Zonr: ur un,rtr sc,trm Cl required
is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation:
\, 1 \ppliatble❑ I,titrniclure tc nth ut Dupont opt.ro.id,arro' In their review conipleted.'
a l ut,cnt to Budd eniLtrd ❑ Yv,0 nr No❑ Yes ❑ No ❑
SECTION 8:CONTENT OF CERTIFICA rE OF OCCUPANCY
L,v Croup(,): rapcof Con,ln,coon: Occupant Lood per l loor:
Ixa•, the budJutp c,uvoin.tn Spnnklgr?c,tcm.': �pca.tl�IipuLwans:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) No.and Street - City/Tower
V Prupvrty Owner Contact Information:
Title R ZC "",I rfw— Telephone No. (business) Telephone No. Icell) e-mail address
If applicable, the property owner hereby atithonzes
t-F,4 l of —
Name Street Address City/Torun State Zip
to act on the +ro perry owner's behalf, in all matters relative h,work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin•is less than 3i,UW Co. Mot enclosed s ac and/ur not under Construction Control then check here O and ski Sevttun ILL 1)
10.1 Registered Professional'Res onsible for Construction Control
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address - City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name: ( 9/
Name of Person Resp,msible fur Construction License No. and Type if Applicable
Street Address City/Town State Zip
7F _97>' tj�a U 57� _�/J (/J ( %W/ ✓JT9i �/7 S 9 Q
Telephone hone No.(business) Telephone No. (cell) e-mail address
SECTION 11:WORKERS'COhII'ENSATION OVSURANCE 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 this application. 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) _$
1C 1. Building $ [[ Mb O 0 Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) S Note:Minimum fee=S (contact municipality)
5. Mechanical (Other) S / Enclose check payable to
�( 6.Total Cult $ �! �� U (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By en Jeri nK 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 to the best of my knowledge and understanding.
9�� 8/s- ! 6 s=iz_16
('le.tae print and sign>name title ieleph, a No. Date
Klrcel Address City/Town - .'a Zip
Municipal Inspector to fill out this section upon application approval: \ �(7
.Name I)ate
III
P'l
7�-
0 WNSM I NCTON STqE A�Z &4_AO4 ss;;3MJJSETa 019I70
z
(97EI)745-9-- F C,� - T.�
X�11 FAX�07_';74o-;)404
A? ?OZIJATEN f
(f Is 1 I cc tif�ed that the Sak ru Historical Com4ission has determined that oic propoge(L
U, lciiom
Altcr:diDn
De n'A 61.rL Para-mg
OtheT l ork
as dc. i ib, I b:-low will be approm3te to the preser+tion of said Historic District, as per the recuircmcrts .ieL
forth rh, 'M ;ta:is Disuk:t'5 Ac (M,1G.L. Ch. 49C.)�Tid the Saiczn Historic F,isjricts Ordinance.
Distr M,1ndjw__
AJdr c: Pr(pc zu-
I r
!'epic "4 it r f e,.-isfing slojs re.w,.'shingfes on TVcvfs;dp pfhippeo roo on the 3-story n o 1.Ildin
f y purric the .11
771 If -1:abriCTfV be CO'CUT I'S101C oSrhO11 in.Ej.Trx GrIdam
9al p 1 "4 CS 0 Are,Sg"vfzgn)so,r to be used for rCpzir5 to slate roofing on remaining 3 xides,
of qclv copper u(C!C arfhc m7arr,h C'Xivif"g,
f _Z p I Q
SALEWrffT TOFUC.,�,L. COMMMS1,ON
By
I.he DpM,0 33.; icl comwienzE"he�-'r m cs�s It Kcia s to Iesooring an outiscarfdkir,
I.A +'I't -kt y--ar fivai this da"e unIm-ai'a_rw z
TI-LIS N )T A.731171,131NG PER Z\41T, Please be 3u tr)obtair,t )c upprWrial,; permits from the Nspector of
is ny other necessary )CT"its of approval
prior To U,mmco6ng Work
CITY OF S.U.E.`Ip NLkSSACHUSEM
�w/BLUMLNG DEPAXT.%MNT
I'_0 �w.k-441TIGTON STREET. Ya FLOOR
TEL (971) 745-9S95
F.%X(978) 740.9&M
IV,.,®Faf t=Y DRlSCOLL
NAYOII THO&L%S ST•PIERM
DtRECTOR OF PL BLIC PROPERTY/gL'DDLVG CO%L%nSSIO%ER,
Workers' Compensatlon Insurance ARldavit: Builders/Contractors/ElectrielansiPlumbers
Allnllcant Infnrmatloe /n� Please Print Legibly
Name (auaira'vs.Ortaetrsnon lnsbvtdual): a V LS 6/i kC rJ Fill g
Address: �—q ct
NI�Fery� ✓ 6ldi/Y
City/StatdZip: �9 PhoneN: g7e 97S— y`wi'Q �
,%re you to employer!Cheek the appropriate boa: Type of project(required):
1 1 am a un to with 6• ❑ 1 am a gene al contractor and I ❑
p Yc► 6. Nowconstruciioo
cmployros(full and/or pan-time).• have hired the subcarrracmrs
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 7. ❑Remodeling
.hip and have no employee Then sub-contraetoea have 5. ❑Demolition
workin rot me in am capacity. lvorkers'comp.inaunact
g y Oos ry' 3. ❑ We are a corporation and its q ❑Building addition
[No workers'tomµ insurance officers have exercised their 10.0 Electrical repairs or additions
required.]
3.❑ 1 am a horricum ter doing ail work right of exemption per MOL I I.❑Plumbing repairs or additions
myself.(Na workers'comp. c. 152,f 10),and we have no 12�aof repairs
insurance required.]► employees.LNe workers'
tomµ insurance required.) 13.❑Other—
comp.
-Any app4caat this chocas tqa el mug ator rig ad tlss oehee below rarwie{fbdr teerkwe'coepwwadoe puhcy infrrrrtwloa
'114wneuwea who subowt this aMdsvil itdlelina they ant china all Walk ate dm hit aalid#eaerrecsoa noes submit a new aMbvil indiorina suck.
-.rats>Ytn thin cMsk this ton msae anachod an ad ounial Anse sharing dw oar of dw wA4wrecswe teal the worYwe'ceap-policy infixi raron
/one an earpkyer that b previdfnR workers'coepenerdon onserrnceJor ey eaaph yers Mean Is tAe pdiey andm soar
information. lQ t�
In.urunce Company Name: c�' 1 C6 C y
Policy N or Self-ins. Lie.M J ,S L E 1 726 100 d Expiration Date: /U `7
fob Site Address: _2c F� r-�T ST City/State/Zip: 'rye V7
attach a copy of the workers'compeasadon polley deelaralloa pap(showing the polky number and eaplradon dab).
Failure to secure coverage as required under Section 23A of MGL a 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment as wall as civil penalties in the form of a STOP WORK ORDER and a floe
of up to S230.00 a day against the violator. Ile advj.*W that a copy of this statement maybe forwarded to the Office of
Inv.augmiune of-the DIA for insurance tovtmge veriticalion
1,10 hereby 4-0 rjy under the pins d pe aAier ojper/ury that the in/brmadow provided above is true rod corr►ca
Dote: lU-/7— /6
Phone a: 7 3 6
O/f$iao Due only: Do nor write Al This area,to be Completed by city or town gflridd
I
City or ruwn: _ YrrmiUhlccnseM__. _ I
lauing.\whunly (circle )ne): i
1. Ituard of Ilrallh 2. Ruilding Department J. Cityirown Clerk J. Electrical Impector S. Plumbing Invpeelor
6.01 her
L,nttact Person: _ ._ _.. Phone l/•
CITY OF SALEM
PUBLIC PROPRERTY
I' DEPARTMENT
.I111S MI�1 "Mlv I'•11
I_Q�•.�+111.�1...IV 5111t:rr •5.111\I. �1.\+�.\I I II J I .•.1'r':
Construction Debris Disposal Af ldavit
(required 1'ur all denwlition:ufd rcnovatiun work)
In accurdauce with the sixth edition of the State Building Code, 780 CMR scctiun 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p is issued with the condition that the dcbris resulting from
in r properly licensed waste disposal facility as defined by MGL c
this work shall he disposed of
I11. 5 150A.
The debris will be transportcd by:
n. . I c dn/ @rS r f
pame of hauler)
The
/debris will be disposed of in
Cih/-�f �J'C UCk7r5't / 2vClc�N'i
(name ul aci uy
�a,�iJa-J D�rH "fF/
taddma all minty)
+ignature of lh:rnm.Ipplicant
�Z 2
date
Aulson Roofing, Inc. I D at(a
49 Danton Drive (7, ruzd
Methuen. Massachusetts 01844 C
(978)976-4500 Fax: (978) 685-0753 EMAIL ONLY
Proposal richardiloufcotacomcast.net
Ytnrynol.whwinrAtn: Phone: Dow
Richard J. Louf&Company 3/1 7120 1 0
.WeV l b Isanr. C.w�r Pcrmm
P.O. Box 2012.
(ligt.6urr.Zip l6r/e .hb Laanion -
Salem, MA 35 Flint Street, Salem
We hereby propose to f rrnish labor and materials to install new.shingle roof to manufactures
sptcifscations by the following:
• This estimate covers the following shingle roof areas: rear hip& dorm and front valleys
• Remove the existing(1)layer of shingles and felt down to the wood deck.
• Inspect for and replace any loose or rotted wood.
Any wood deck replacement would be an additional $5.00 per linear foot.
We would match die existing decking as close as possible.
• Install ice and water shield 3 feet along the edge of roof and in valleys.
" Cover remainder of roof with 151b felt paper.
* All valleys to be copper.
• The shingles will be installed by using roofing nails.
• The shingles that will be used are CertainTecd Centennial Slate.
• Your choice of color: black' an iP S,,VJJ� Cv MYJ
• Reuse and seal the existing sidewall and chimney flashing.
• Reuse and seal the existing cap flashing.
" Install 8 inch bronze aluminum drip edge along all eaves and rakes.
• Clean and remove all outside job-related debris.
• Provide standard limited lifetime shingle manufacturer's guarantee.
• Provide standard Aulson Roofing, Inc. 2 year workmanship guarantee.
• Carry all necessary workers'compensation and liability insurance
• Permits will be an additional cost to the customer if above the normal $150.00 @$14.00
per$1,000 on building permit.
• Contract Option: This included removal of both front valleys and installing new copper and
installing slate from rear.
We prayam kerebr b futmhh mnterich wd labor,eomp4te In aecordmer tei&aboee.sped/f o wnom.for rbe sum of:. Sll,/10.00
Eleven Thousand One Hundred Ten Dollars and no cents
Terms and Conditions:
1. Payment- Payment terms are as follows:
• Deposit of 1/3, 113 when half done; balance upon completion
2. All monies due and payable shall accrue interest from the date such payment may be ducat a rate
equal to 1 1/2%per month.
AGORA CERTIFICATE OF LIABILI OF 'INSURANCE OP IDAUL z �ii o 09
PRODUCER 'H i CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION
Y AND CONFERS NO RIGHTS UPON THE CERTIFICATE
DeSanctis Insurance Agcy, Inc. HOLDER.THIS CERTIFICATE DOES NOT AMEND.EXTEND OR
36 Cummings Park ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW.
Woburn !A 01801
Phone: 781-935-8480 Fax:781-933-5645 INSURERS AFFORDING COVERAGE NAIC/
INSURED INSURER A: Star Surplus Lines Ins Cc
Aulson Roofing, Inc INSURER B. 0a -Y
Aulson Industrial Services Inc INSURER mm ft9 rty A l mualty Tee Co
49 Denton
en Drive INSURER D:
MethINSURER E:
CUVERAGEI
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT.TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCU EM WITH RESPECT TO WHICH THIS CERTIFICATE WAY BE ISSUED OR
MAY PERTAIN.THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS.EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAD CLAIMS.
L POL�EXPIRATION
TR M'Sa TYPE OF INSURANCE POLICY NUMBER DATE Y DATE(UMMMM LIMITS
QF OEM LL48HAY 131,000,000
A X COMMERCIAL GENERAL LA EACH OCCURRENCE
LIABILITY SISLEIL72010009 10/31/09 10/31/10 PREMISES(Ea OmrerlCe s50 000
CLAWS MADE ®OCCUR MEDEXP(AnY Penes) S5 000
X Lead i Asbestos W/ POLLUTION 6 IUD PERSONALBADVINJURY s1,000 000
Abatement Liab. GENERAL ADORE is2,000,000
GENT.AGGREGATE LIMIT APPLIES PER: PRODUCTS-COMPOP AGO s2 OOO OOO
POLICY R JJEECT LOC
AUTOMOBILE LIABILITY
B ANY AUTO 09MWYY1459 10/31/09 10/31/10 (Ea accideEDMSINGLELMIT s11000,000
ALL OWNED AUTOS
BODILY INJURY s
X SCHEDULED AUTOS (Per Peron)
X HIREDAUTOS
BODILY INJURY s
X NON4)NHED AUTOS (ParavJOent)
PROPERTY DAMAGE s
(Pa eraJeM)
GARAGE LABBSY AUTO ONLY-EA ACCIDENT $
ANY AUTO
OTHER THAN EA ACC S
AUTO ONLY: AGO s
EXCESSWORELLA LABILITY EACH OCCURRENCE s3,000,000
IL X OCCUR CLAWSMADE SZSl 3010009 GL/CPL/XL 10/31/09 10/31/10 AGGREGATE s3,000,000
GL/CPL s
DEDUCTIBLE 6 EL s
X RETENTION $10 000 s
WORKERS COMPENSATION AND R TORY LIMITS ER
EYPLOYERS'LIAmlliY ANY PROPRIETOPRARTNERIEXECIRNE C45817155 10/31/09 10/31/10 E.L.EACH ACCIDENT sl 000 000'
OFFICERBiEMBER EXCLUDED? MA, ME,NH E.L.DISEASE-EA EMPLOYEE $1 00O 000
tl)yeA MseaiEeuMx
- SPECULL PROVISIONS bIor E.L.DISEASE-POLICY LIMIT fl 000 QQO
OTHER
SCRNPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT/SPECIAL PROVISIONS
VIDENCE OF COVERAGE
:R7IFlCATE HOLDER CANCELLATION
PEABO-2 SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 30 DAYS W WTTEN
City of Peabody NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO 00 SO SHALL
City Hall IMPOSE NO OBLIGATION OR LUUMIJTY OF ANY KIND UPON THE INSUHER.ITS AGENTS OR
24 Lowell Street
Peabody NA 01960 REPRESENTATIVES.
AUTHORIZED REPRESENTA
ORD 25(2001108) - - O ACORD CORPORATION 1988
Boar o uildmg OegulaVonss/am�tandards
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement o tractor Registration
RaptalraAon: 11190
Type: Srpplamenl Card
i r I Expiration: , 212J2011
J
AULSON ROOFING, INC.
Bruce Tinkham -
48 DANTON DRIVE
METHUEN, MA D1844 -_...._.__. __._...
Update Address and ratorn card.hark reason for tianp.
oracbr o smroatoe�ororeswosmre ❑ Address Renewal Employment F] Lost Card
Board otAdNigRgaladona and Standards UnmeorroalondonYeAd for indivldulononly
HOME AdPPMENT CONTRACTOR before the espiradoa date. If found return to:
R#&b4QN 111959 Dowd ofBWtft Retutettom and Standards
E On*Ashburton Pisee But 1301
011 Card _ Dog".Ma.rd108
LL
AULSON ROOfI�I >+ .
Bruce Tirddsro
40 DANTON OR1VE'r,�•._.,:.; '�`�""`'L -!/
METHUEt4
Administrator - Not vtGd without JiQaature
Massachusetts- Dcpal1mcnt of Public S:dct%
Board of Builllim_ Rc2ulaliuns and Stand;u•ds
Construction Supervisor Specialty License
License: CS SL 99977
Restricted to: RF,WS,IC
BRUCE TINKHAM
20 BALDWIN STREET
PEABODY, MA 01960
Ezpiralion: 8113l2011
1 unnniwi,nu•r
Trtt: 99M