64 FORRESTER ST - BUILDING INSPECTION (2) � 3ro3
CK02 bILf0
The Common $�`4cliusetts
p - De of Public Safety
l mg� I Massachusetts State Buildi�Ig e(-tSW31R)
Lr Building Permit Application for an l �t� y g
e than aOne-or Two-Family Dwelling
(This.Section For Official Use Only)
(\J\ Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block#and lot#for locations for which a street address is not available)
1 9 / rras P.t S7 roD/euL p1470 Sr /jjeAolns
1� No.and Street City/Town Zip Code Name of Building(if applicable)
�- - SECTION 2:PROPOSED WORK
1 Edition of MA State Code used if New Construction check here❑or check all that apply in the two rows below
Existing Building q I Repair�, Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 1 Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No GE
Is an Independent Structural Engineering Peer Review required? Yes ❑ No M -
Brief Description of Proposed Work:
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2a 1°nrr F'taSd r� Rro N.L C. PU igS
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 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
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 Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional I-t❑ 1-2❑ I-3❑ 1-4❑ 1 M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IHA ❑ IIIB ❑ IV ❑ 1 VA ❑ VB ❑
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 O Check if outside Flood Zone❑ Indicate municipal 09 A trench will not be Licensed Disposal Site
required k or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Revicw Process:
Not Applicable, is Structure within airport approach area? Is their reviser completed?
or Consent to Build enclosed❑ Yes❑ or No X Yes❑ No
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
STti.ttlnln3 6.c� Forres7er Si SAfemc yyr4 01974)
Name(Print) No.and Sti cet City/Town Zip
Property Owner Contact Information:
-
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owner's 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 than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here and skip Section 10.1)
10.1Registered Professional Responsible 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
_S' TnN z9 fo l2Fx
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
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Street Address City/Town State Zip
9?8 1,576 74 Sfj 975E' 4/z3 97u6 Atae4 — J"TwN 60 S7-- PV)a ygeor 9 CB
Telephone No. (business) Telephone No. (cell) e-mail address
.SECTION 11:WORKERS'COMPENSATION INSL'RANCF AFFIDAVI"r(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? Yes44 No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$Jj2 ",O, Dd
1.Building $ Building Permit Fee=Total Construction Cost x — Insert here
2.Electrical $ appropriate municipal factor)
3.Plumbing $
4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ Enclose check payable to Da
6.Total Cost $ 3"2 _ S o (contact Municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I hereby attest under the pains and penalties of perjury that Al of the information contained in this
application is true and accurate to the best of my knowledge and understanding.
Please print and sign name Title Telephone No. Date
Street Address City/Town - lA ,State Zip tQ
Municipal Inspector to fill out this section upon application approval: v
Name Date
ROOFING COMPANY INC.
42 Mitchell Rd. * Ipswich, MA 01938
(978) 356-7958 * (978) 356-1499 fax
(A Veteran Owned Business)
Proposal
Submitted To: St.Nicholas Orthodox Church June 24,2015
64 Forrester Street 978-998-1994
Salem,MA 01970
Attn: Chuck
Re: St.Nicholas Orthodox Church -
Chuck:
We hereby propose to furnish material and labor—complete in accordance with,specifications below for the sum of:
$32,550.00(Thirty Two Thousand Five Hundred Fifty Dollars).
A. 2 Dome's Forrester St.Side:
I. Remove slate and copper around base of domes saving slate for reuse.
2. Furnish and install ice and water shield.
3. Furnish and install 16oz.copper step flashing and cricket.
4. Reinstall saved slate.
5, Repair or replace rotted siding.
B. Main Dome: -
1. Remove slate and copper around base of domes saving slate for reuse.
2. Furnish and install ice and water shield.
3. Furnish and install 16oz.copper step flashing and cricket.
4. Reinstall saved slate.
5. Repair or replace rotted siding.
C. Sm Chimney:
1. Remove slate and copper around base of domes saving slate for reuse.
2. Furnish and install ice and water shield.
3. Furnish and install 16oz.capper step flashing and cricket.
4. Reinstall saved slate.
D. Ridge:
1. Furnish and install 16oz.ridge cap.
E. Front Gutter:
I. Repair seam in wood gutter center.
F. Repair or replace broke or missing slate on main church roof.
G. Inspect center cupola for leaks around windows.
All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices.
Any alteration or deviation from specifications below involving extra cost will be executed only upon written orders and will
become an extra charge over and above the estimate. All agreements contingent upon strike, accidents or delays beyond our
control. Owner to carry fire,tomad6 and other necessary insurance.
Our workers are fully covered by Workmen's Compensation Insurance and General Liability Insurance. Certificates of
Insurance are available upon request.
Respectfully,
Stanley Roofing Company,Inc.
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S+•A; '�c -31PIP�y Michael Doane
This proposal may be withdrawn from us if not accepted within 30 days.Acceptance of Proposal �J /J
Date: 7• Z - ! Signature: e. �/F �-Z1W LZ: /1
Payam...... s:Payment is dire upon complmiwr Jjo8.25%irneren bcharged on accwurrs more Thou 30 dayr weNne;md.•• rher anmrgemnru are mode.Concel nwr:the mvrmr har
Three baslnessdays ro mote/this conrracr.
Nome Inrprawrmenr License k/23089-Gpires 1214116.Cannacrw's Soper ieors License 9 066263-&pires 21310.
STANLEY ROOFING COMPANY,INC. 026740
City of Salem 08/21/2015 $363.00 Control #26740
Permit-St Nicholas Church Invoice Payment
Invoice Date Description Amount Discount Amount Vendor Inv
08212015 08/21/2015 City of Salem $363.00 $363.00
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Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block # and Lot # for locations for which a street address is not
available)
64' rdrreS7ea s r' S41e Cl 1970 S!, /Vi
No. and Street City /Town Zip Name of Building (if applicable)
For the above described property the following action was taken:
Water Shut Off? Yes ❑ No M Provider notified and Release obtained? Yes ❑ No ❑
Gas Shut Off? Yes ❑ No M Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No M Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No fib, Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this. The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark"x"where applicable
No. Item Submitted Incomplete Not Required
1 Architectural
2 Foundation
3 Structural
4 Fire Suppression
5 Fire Alarm (may require repeaters)
6 HVAC
7 Electrical
8 Plumbing include local connections
9 Gas(Natural,Propane,Medical or other)
10 Surveyed Site Plan Utilities,Wetland,etc.
11 Specifications
12 Structural Peer Review
13 Structural Tests&inspections Program
14 Fire Protection Narrative Report
15 Existing Building Survey/investigation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(Specify)
2"1 Other S ecif
22 1 Other S ecif
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction. Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/"Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
Registration Number
Name(Registrant) Telephone No. e-mail address
Discipline Expiration Date
Street Address City/Town State Zip