45 FORT AVE - BUILDING INSPECTION M CrrSt OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
w1 VerntlY trrr.r..
1Lvwt� 12C tlwssawalosrStalgtr•lntssl ltaawa�»s OIsfO
Tu:f7►71S ySeb •Rs::97F7gvW
Worker' Compwsdom Insuratest Afftevit: BdldaWContrwftm'EltxWdanu/Phmbort
>t
VafflCllfuaieewQyrri+otieNlmLvwlv.11: r��0( tld/G:La� ��Lr /v-y / GniY �ilil, -
Add 066,a 262
City/stmevzi . S.4ft/7 V,7U 1'hootN i`'2� 7�r� `v�k156
<,re N an employer?Cheek the appropriew lest
•n'pe otproltsa Nwdr wl
1. 1 am a employer wits�_ A. p 1 tort a general eooteatsw and 1 6 mm
cawkweea(run mumer part-time).• have hired dw stah-cururu'tors 13
2.❑ 1 am a solo proprlosar or partner listd oa the at40ted short t co
7• ❑ RemodalittB
ship and brve no ampiayom Theca saw rL p Danolitim
working for me in my capxity. workaa'eoetp itteYrOMM
INn worker•cen+P insurance S. p we an a corporation ud its °• p Buddim addition
squired) oflleae haw exercised their I0.0
Electrical repairs or addition.
3.❑ I am a hamaowrter doing all work rilllo of esattptim per MGL 1 I.p Plumbind repairs or atktieictta
myself.(No workers'umtp. C. 152.#1(A)and we have no 12.p Ruof aepaia
insurance required J ► cmplayom(A'o workers' 13.p Other
comp, imumax requiroJ.1
Amy.rpse..t ter elydo esa of asset&five fin ma as ma,m twkw Ab"tk*amawe'eusgewetks 7WMq'{.aY.rrioa
'I¢rrtinrn Weis suede"a111rki hgw6y err aw deity dl we*And tee Ww eerrfde eawarrs ntwr wdn(r a nwr amtMil irnNadiy Ywi
l,rrtaaan doraert Yie w swr ateelar/m addMlaY dews.Mwiaa tar nrwe erneAb4possoonasd face waraw'soap.Pdky iwArraenoa
/uw Ye YraaOfoyar/het b provliffn;worAerB•coasprwraalew/rurrreaeijor nsr enrp/oyetrs Bi/otr b NI peBrr rinr/foI a1q
Insurance Company.Non r._Z�ejr7L IA f _ZG
Policy r of Salr--ins. Lie.w. !Zf G 2.A fy,74 ._ .. Eapirattoo Date: .5 11 ld f�
dub Site .atklnss:_ _ '�raroL 'paa V r )117a2'
.\track At cupy of the workers'compensation pulky declaratloa page(showing the policy number and cipiratlua date)
I;ailuro to acute coverage as required under Swim 25A of NGL c. 152 can teed to dN imposition of criminal psnalties of a
r,n.up [is 31-500.00 and/or one-year imprimmncnt,ar well as civil penahivn in the form of a STOP WORK ORDER and a line
a(up to S250.00 a Jay agrinat the violator. 11e adviacd Mat a copy ufthis seat mart may be turwarded to the OlYce of
fac..ngaumr ul'thc DIA ror insurar•.cc:oscndst vuifuattun.
JY hsrt b�r.rli�YY r the pYIRr YYI/KYY/1/re 60086Y17/Aer Me,lYjermadva pre vided YIItN if/erne Yprl ea/rera
Ci•:r h r••
- Date .Z 72�Q�
U/Jkial Yea eel)t A*&Ave rrim/r rA/s err^le M eoaspfrrnttf 1y CA)P ar serve o, A.14d
City or rown: Permit/IJeertse t
laaing Amthurity (circle one): — —
I. Iluard of Ilealth 1. Building Department 1. Civrono Clerk J. Electrical Inspector S. Plumbing Inspector
6 Other
Gouact Person: _ Phone b:
Information and Instructions
.%ta"achwoorm General Laws chapter 132 tequiors all employers to provide wohara' cO111111111insatitm^or
their empkVa&
counam at"
su
purant to this,-:+note.au*o �7'a'r is defined so'...svery Poison is the service of analw Y
eapeess or uspliui.oral or wruaa
carporatift se other kepi carry or any two se meld
.ton pylsytr it dMlnad as na 'Msbdi► ' 'van of a deceased employer,or the
of rho foregoing engaged in a joise catsrprtm and incbk tat dq IN rytesen However toe
nrceivef"ttttsea of mn utdtvtduaL prmersbips adOCed"at tither legal snot.smployiaf es playas '
owner Of Ill dsodit boom bavis f oat mars-ban drier apsraraota and who lea" t tepai►Sir work
ooeto d o uin
dwougs bow"or aaoober who employs parsons a do�OOeO�'CYO1n'te�a repair work on such dwallop boos-
or on gramd or buildfat appoetMant ph_ , dog met baswn Of mob mploymoat be domed to be era aonployer.
tM
.%IGL chapter 132.f2x(`)slate stews that"ea07 sea"ar teem ge eldst son"
d"wMhhold don
tast"nas w
a busholum er eo eo stirs t buildings In tM c@mmm*nwssW fast sea
nsewsl serer s Ileac ee pasducson d sparsM svidones er eo"Prsnan wifb eba Issarswoor esysregs rNtsird."
sppliasst wM lose sat produced acceptable the coomenterwitabill,mile MW of its polioeal subdivialow song
>dditisealb•M(R.chapter 152.;24Cf7)etas" work utaWdoor ' aeeeptable avGfsocs ofcaraplitesee with doe itwno"
stun into asy centtsa fl r the performance public s ek uotill AccstdtolitY'
regafrsmemt&of tbis cbmplw bave ban presensod
Appikasa
please all
out der worhsle' eompanssaOA affidavit O0°ploo'h''by chaekmg the bones that apply to your Situation and.if
ems)aame(sL addras(es)and phone numbss(s)along with their certiffeate(a)�doom the
necessary.sspplY L at Limited Liability Pntberrdtips(LLP)with m MPWOM
inauanow Limited Liability Companies lL CI e, if an LLC or LLP does haw
Don not required to carry wotlren Compensationnnsoreoo
members or poAasra. Be advised that this aftWnooft may be submitted to the Dopwunm t of Industrial
cmployeas.a policy is req�6worsnee covmp. Abe be sun n alp and date the afildavM. The sifidavit should
Accidents for confirmation er licensee is being regttaued,oaf the Department of
be returttsd to the city or sown that the application for the the low of if you era required too door s wa rmn'
comp rirl tine policy.
pl a calaau�va anquestions number u�below. Self-i wmW complains should enter their
compensation po8ey."bees
:seder-i,swr.tta Ifeattsa number on the
appro
city or Towa of1kkk
Plcase he sure that de affidavit is.complete and printed logibll•' '17ta Wperaleta hen provided a apnea at else bicam..
of the affidavit for You to rollout in the event the Office of lnvestigatiaaa has to contact you repeating the spPlieare
1'I ass be aura a till in sloe purmivliccnse number which will Ire used as a refers mitber.ora n addition,
an appucang
rag ounant
that must submit multiple pstmialieetw applications in any given year, s Only
write"all locations is_(airy or
policy information(if necessary)and under"lob Site Address door slop
town6"A copy of the affidavit that has been officially stamped or marked by the city or town May be provided to the
applicant Sir Woof that a valid affidavit is on file for fltwn permit&at licensee. A now affidavit•nest be filled Out each
year. Whoa a horns owner or c. . . obtsiniug s lkerws or permit rear related to any business or commercial venture
s i.e. a dog license or permit ro!earn leaves M.)said parses its NOT required to complete this atYldsvit
Vhc Oi ticc of Investigations would "s oo thank you in advance for your cooperation and should you have any questions.
;ease Ju nut hesitate to give us a cal.
The Dcpanment's address, telephone and fat number:
Thor Commonwealth of Mmuhusetts
Depattrl M of DO a W Aaeidents
Omer of Isve dpow
6t70 WasAia�Street
BosM MA 02111
TeL N 617-7274%*en 41%tlr 1-877-MASSAFE
Fall M 617-727-7749
www.nuLa.gov/dill
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTUEM
at.+�• tx r.�s cv::asts.arsr•iva r.fLwut:r *0b:.+.
r
Construction Debris Disim"ti Affidavit
(reyuimd lbr all demolition and nnovatien wetrk)
In madam with du dadt adidas of dw$tars HuU1ng Cods`M aIR seodon 111.E
oebris.and the provisions of NGL a 44!A
13%didlas pan _ is iawtd with the cood[doe dtet dw debris ra ddns dos
this work shall be diaposod of in s pevpw{y Ueansed wawa disposal &dlity as defined by MCHL e
111.2INA.
rho debris will be transported by:
tnotw of had1)
fhe.lcbris will be disposed of in
,r1 -
Page: 9 of 9
j
02/13/2008 11:01 9787408347 SALEM HARBOR MAINT aDoi
A
rofessional Roofing Contractors, Inc.
)am.es W. Shea,President
P.O.BOX 262 45 DEARBORN STREET
SAI..EM, MASSAC HUSETTS 01970
PHONE(978) 744-6888 FAX (978) 744-8814 -
PROPOSAL
Feb. 11, zoos
Mr. Peter Therlault
Dominion Harbor Station
24 Fort Avenue
Salem, Mass. 01970
RE: Roof Repairs — Human Resource Roof.
To reroof one flat roof with the following steps:
1. To jack up roof top unit and remove masonry pavers under roof top unit.
2. To install Carlisle 060 roof membrane over the existing roof.
3. To install Carlisle membrane under existing wall flashing.
4. To install termination bar on concrete deck at end of roof.
5'. To flash all comers and penetrations with Carlisle rubber flashing.
TOTAL COST:.......... $4,500.Q0
ACCEPTANCE OF PROPOSAL:
TERMS OF PAYMENT:
rpm �va,�i
rwsnt p
t
CnF t Q td•9d•gp GCT 9f1t1A
The Commonwealth of Massachusetts
3 "b Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR. 7"'edition NIUNIc'll':�LI"fl'
U J I
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Junuurr
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Num r: Date Applied:
Signature: J 4,xd,
Building Commissione /Inspector of Buildings Date
SECTION 1: SITE INFORMATION
Ll Property Address: // 1.2 Assessors Nlap & Parcel Numbers
'7S �y/T /4t/fr
I.la Is this an accepted street'? yes_ no_ Map Number Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage (lt)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L a 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private ❑ Zone: _ Outside Flood Zone?
Check iryes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O ert of Record: W,41
/ / / / � � / 4 L / /W
Name(Print) Address for Service:
Signature 'felcphone
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed W E e
/ .v ✓c D 'p
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1. Building $ -rr�G. _ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
3. Plumbing
❑Total Project Cost" (Item 6) x multiplier x
$
I. Other Fees: .$
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su ression) S Total All Fees: $
(I. Total Project Cost: $ 7 ��//j! _ Check No. Check Amount: Cash Amount:
1 ❑ Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL) �/1ls72CI zo /-r G f
tS j C 4rn
License Number Expiration Date
Nome otCSL- Holder (' l' �� List CSI_Type (see below)
9nz. '��ru V ,,,)•j/ T e Ucscri tiun
---r
4ddre:
U Unrestncicd(Lip to 3>A00 Cu. Ft
R Restricted I&? Family Dss'cllin
.rgnaturc YI :soasonr Onl
RC Residential Routine Cove nn
J VVS Residential AViudo�v and Sidon"
Telephone/�r i /'.�9` /�L.
\ sr /Gv,:,il SF Residential Solid Fuel l3urnine \>>Lanrc luscdlauon
Y D Residential Demolition
--------------
5.2 Registered Home Improvement Conto�(111C)
Registration Number
-417
FIIC Company Name or HIC Registrant Name
Address Expiration Date
Signature
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 it) provide
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes ..._..... L� No ....._....
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as 9wner of the subject property hereby
1• to act on my behalf. in all matters
authorize _
relative to work authorized by this building permit application.
Date Z Z r/J"
Si ore of O 11 w/--
SECTION 7b: OWNER' OK AUTHORIZED AGENT DECLARATION
(.✓ f�r c
as
t�wfter orr
Authorized Agent hereby declare
that the statements and information on the foregoing application are true an✓ndd accurate, to the best of my knowledge and
behalf.
7.rrr+/ W S Za /
Print Name
Si ore of Owner or Authorized Agent
Date
: tied under the eams and penalties of eQut- ) NOTES:
1. An Owner who obtains a building permit to do his/her own work, or:m owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
IC Program and
program or guaranty Fund under M.G.L. c. 142A. Other important information on the H
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations I I0.R6 and I I0.R5, respectively.
�. hen substantial work is planned, provide the information below:
W (including garage, finished base mendattics• decks or porch)
Total Floors area(Sq. Ft.)
Habitable room count
Gross living area(Sq. Ft.) Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms
'type of heatingstem Number of decks/ porches
'system Enclosed Open
Type of cooling system
e" be substituted for "Total Project Cost"
3. "Total Project Square Footag may