11 GLOVER ST - BUILDING INSPECTION (2) I� 7 1-he Commonwealth of Massachusetts
0 yl"lk Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM
•y, W Revised.I&v 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-FundlY Dwelling
This Section For Official Use Only
Building Permit Number: Date plied:
Building Official(Print Narne) Signature Do�
SECTION 1:SITE INFORMA
1.1 Propert Address: 1.2 Assessors Nlap Parcel Numbers
S^TL
1.1 a 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 It) Frontage(11)
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, §5q) 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 Owner'of Recor
S'rls :. .1 yeeze2 S'g1P,�, , Mass
Nmne(Print) City,Stulc.ZIP
9 /837
No.and Street "telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
t .D a To Q Doorners
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and \laterials) -
1. Building $ �/S'd pCZ) 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/.Town Application Fee
_. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing $ 1. 0 ,pees: $ ��
q. ,,\Icehanical (IIV:1C) S List:�,(�zt* �(.J �
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. C'heck Amount: Cash Amount:
G. Tidal Project Cost: S 0 paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL) `
License Nunther I[v iraliou Date
N:unc of C'SI. I lolder
e - _ nA s List CSL'fr pc(scc below) _
No. aid Street Type Description
�./ CI unrestricted(Buildio gs up to 35,000 Co. It.)
Cif% --/.IV R Restricted 1&2 Fanil Duelling
C'iq/I own.Slate.LIP M M1Euon
ry
RC Routing C'o%erin
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Ielc hone [:mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /4/2 7 y
" T�BIL4 Te �D(1 �lnC r I I IC'LRegistration Number If. pir mn Uutc
III(; upny N:une or I IIC Re�tmnt Name
o. mid Street Email address
Ci /Town, State,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
1, 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 her y attest under the pains and penalties of perjury that all of the information
contained in this application is truZO
accurate to the best of my knowledge and understanding.
b En t (0 1 d�I
Print Ottner's or Authorized Agent's Nance(Electr i Signature) Date
NOTES:
I. An Owner who obtains a building permit to do hisiher 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. 132A.Other important information on the HIC Program can I found at
gry i+ct) Information on the Construction Supervisor License can be found at k% ao� dp;
2. When substantial work is planned, provide the information below:
Total floor area(sq. RJ _(including garage, finished basement'attics,decks or porch)
Gross living area(sq. ft.) _ _ Habitable room count
\umber of fireplaces-__ Number of bedrooms
Nuntherofbathroonts _ _ _ _ ___ Number ofhalfbadis
1'%pe of heating system —_-----__ Number of decks,porches--__- -- -- _ -_
I)pc of cooling systelu _ _ Enclosed --
3. -Fol:d Project Square Footage-may be substituted fix"I'olal Project Cost"
v,v� N
CITY OF 5ALEM
PUBLIC PRUPRERTY
DEPARTMENT
Iw:.XfI Y:IXIK„II
\I%1,rl
• Sit,I.A. JI's7J
I'cl. rla.)ti•ti'IS • f 1.Y 'Nt•7rG'Isali
Workers' Cumpensation Insurance %indavit: Uullders/Contrac torsi E lee trlclans/Plum ber
t tllcant Information
rint Legibly
' �18111�111u•nluvsi Organlrninmindlvuluull:�(/m ��h JSir.r'T •'r� � 7 � T7 �,
\lklress:
Cily,.ScIrc,zip. I'honr il:
•tre t an ealployar:'Chvelt the apprllprlate but;
:lot a employer with _ ' urpro/act(rail
ulrrJ):❑ mgcnenl caulrxtor and 1
?.❑ enlpluyaes(full Jnd/ur paranoia).• huve hired the.sub•cuntrxwrs 6. ❑New cunstructiun
1 am sole pro ricutr or an P partner. listed on the anach , v 7,
c I.h'et. ' Rem❑ odelin
ship and have no mnpluyees These subcontractors have
at 11• Demoliri titr me in any capacity, worker' comp, insurance. ❑ on
IKn workers'comp. insursnq J. ❑ We�rs n enlpontinn and its 9' ❑ DlriWind addition
3.0rcyuirud) ottteen Nava elereis.yl their I O.Q Electrical repair or additions
1 am a holrteuwner doing all work right ofeaemption per VIOL I I.Q Plumbing repairs Of additional Myself.(No workers'camp• C. 132,Q 1(i).am1 we
hltvd no
insurance rcyuirad.) t cmployeas. (Ko workers' Ii•❑ Ruufrepuirs
comp insursncv nyuind.I 1 J�Other ACp�
•not.,q+hca,Y tlIW chefs boa�I muq alw rill uW the,Yaban lwbw
•I IYnv,I1W4 11.Iw„1 nnoon,$this erlldsvh iIX11eJIilq Illey Jq saint JI aurk And Issue AW"Side eu,Xrnenre mXw'r.Y'Iw,Ynew Jlnaeen IIYIiuYip Yw•Y,
d,Xlln.on IAp vMcY qis boost muM JnahM.Is xldiltuyl.hwt.An,eina IIMI nanw o/rlr,u►canrr sewn and Iheir uuAen'cony,pulwy Inrbrrrlanw
/mn un ernpleyp that/r prvvid►nX Ivurbnr'rutnpenrn/ion Lrramnea jar my emp/uyaar. Br/ero h Me pu/4y and/u�,r/Ie
iujunnullus\
In.vurauc,r Company Vame:_MaLLI .
I'ulicy 4 ur Sulf•int. Lic.M: EL22767 7
EApirullon Date: L
Job Site .Address:,/ '
C1ly'slatcalp:
�uacA n enpy ur Ila workore'cumpensatlon pullay daelsrallun page(showing the policy nuntbur and ciplratlun date),
PJduru to viceure euveraye as required uodur Scctiun 251%ul•SIGL e. 132 eau lead to rite imposition o/•eriminal penalties of a
Gne up n,S 15110.011 Jnd/ur uoe•year imprismuncnr, Js ,full Js Ovd pcnalnes in the lurm of STOP WORK ORDER and a ring
06lp In i2st)On is dJy Jdi1111at Ille vu)1a1111" Ike advised thut a alpy ufthis.vta7amuill may be lurwJrded to the Utl)ee„C
Ill% ;M1."Jimils at ills I \ for III„IfJnee G,if cfJyL' \CrIIII JI{Un.
/Ile hereby,crrijy ru /u 1,
the print and parrdNcr u/per/cry/hut the iujurinYNen prvrided ub fe it tr a and eorrert
I17//Icial ilia wily. pu nor nvira in Ndr arru, lu he cumyteled by city up to logo n1JIciui
( ilY of I'gwT.
PennittL(eenfa I
I,vuing.\Whurily (eirela nna);
iI. IL,.rrJ III IleJlrb !. IIud,Gn� Ilcp.lnua•nt 1. (:ill.'I'w,it C'Icrk J. Cluclrical Ioyluctur 3. Phnn(lind In,yceror �'
. - 11hune 1:
I
information and Instructions
�Lusadhn:ens Gcnenl for their 0111110)'"s-
Laws:hapter 132 rcywre%all eVeployaion ,n the Ss to prov it
e l
of another iulern,ry cJntmct of hire
I`unu.rtt to tills %Wutr, in rmplut'ra Is defined as -.e ry pc '..
.press or ,"pricd. Oral of written." oration of Other legal entity,or ally two or more
�n.•rnpfuyw is Jctincd w"an individual, purtnenhip,.lssoeiauoo,carp
he
a the f.,legomg en W g' woos of Other legal entity,ernploymg cntPloyeee. However the
r.J m a joint enterprise- and inciuding the Icdal represuuatives of a deceased employer,or t
ecerver or Irustce ul'.to iudivlJual, patmerShrp, asaoe
occupant of the
runs to do maintenance,cunatrucuon or repair work on such)welling house
Jwner of a dwelling house having not Inare has three apamnents and who resides therein,or this n
,Iwellrng house of another who employ. P+
or On rho grounds or building appurtenant thereto shall not because of such employment be deem
eJ to be an employer.'
CSC 6 also states that"every state or local llcenslog agency shall withhold the Issuance or
\lGL chapter license e Othe required."
renewal of a Ilaaase of perntlt to Operate•buslneu or to eosuYOe,with the overagelregor say
applicant wlro has not produced sae+p
table evidence of comp of iv olitical subdivisions shall
\Jditionally, SIGL chapter I S=, a?SCI1►states"Neither the conunonwbig a not any
enter into any contract for the pertormanca Of public work until acceptable evidence
of wnlpliancge with the inwranca
requirements of Ihis chapter have been pr"rited to the contracting Author't
Applicants checking the l to our situation alto if
nsation affidavit completely.to nuber(%)along wi A her c4flificate(s)Of
Plc:tmr rill out the workers' cumpe tley and p LLP with no employees Other than the
necessary.supply sub-contractors)name(e).adtkees( have
workers' compansauon insoronce. If an LLC or LLP floss
nsurance. Limited Liability Companies(LLC)or Limited Liability Partnerships
members or partners' are not require)w carry
employees,u policy is required. 9e advised that this affidavit may be%ubmirced to the Depurtmertt ar Industrial
application for the permit or license is being requested, not the Dr p rtmeat of
mployee rite for policy
i requ re insurarteo eovcrsg I Also be sun to%Ills Itad Jute the ufllJn, n The stlidavit shoo
ha Icittmed to the city or town that the ODD uestioos regarding the luw ar if you are required to obtain
should enter their
Inda%trtul,\ccidents. Should you have any q
compensation policy,please call the Deparvnest at the number listed blow. Self•ina comp
self-insurance license number on the s wropriate lino.
City or Town Officials
Please he sure that the affidavit is complete ;Ord p tinted legibly. The Department has provided u space at thetau 1�anr.
„i the aifiJrvit r'or you to till out in the anent the Olfice of Investigation ationa has to contact You regarding DP
Nets year,need only submit one affidavit indicating c`Irrcur
1'Ieasa 11 sari to till in the 11 out in
the a number which will bit used as a reference number. In addition,an app Icant
that must submit multiple pennio'and tinder
applicationsbSte A any s Ye rovidcd to this
policy information lit necessary)and under"Job Site Address"the applicant shnuW write"Al" locations in.(city
town►.",\copy"It.tile ulYldavit that has bean officially stamp%: or marked by the city or town tray P
entry not related to any business or commercial venture
applicant as proof that a valid at"0" is on rile for future permits or licensaa. A now atflJuvit must be tilled nut sae
year. 90tre a humo owner or citizen is obtaining a licen%a or p
t i.e. a dug licenw or permit to burn leaves eta.)sail person is V0T required to complete this alfida ulha%v.Jay yuesuons,
I he 1)11ke „t luve.rigatiuns hwuld Itee to thank you in advoaclt for your cooperation anJ shuulJ y
Please du nut hesitate to dive us a call.
fhc U:paruncnt's adjress, telephone and fail number:The Commwealth Of[htassachusens
Depacanent of Industrial Accidents
o[Aee of[avasdgadons
600 Washington Street
Boston, MA 02111
f el, p 617.727E 00 Cxt617406 72 of 1.817-MASSAFE
d s.'a.us www.mau.gov/dia
CITY OF S'U.E.Nt, NWSACHUSETTS
BCt mt; DEPARTNONT
110 WASHLNGTON STRM, 3iD FLOOR
TEL (978) 74S.959S
FAX(978) 740-9846
Kll®ER1EY DRWOLL
,bUYOR IHo.+w ST.PtuRs
DfttEcroROFPt:aLICPROPERTY/8E MLNGCOMMISSIONER
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 1 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al 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:
{,,nt Z F ,< ✓t/`
(rArne of hauler)
The debris will be disposed of in
L{"-r)�j�2 -ri�ek-
(name of facility)
n 1 � n
(Iresi of facility)
signature of permit applicant
(0Ar 1 ,
Jate
�Ch/I a.11(tK
V0/Z!/ZU1.1. 1.t:UJ P.AA ylntb(z'FUe t¢J Ul1Z/UUZ .
o
NLUIta F011 1a1/9Neft LWo-IM-Wl7 - For. ." mwlnr
.y.e Page No. of Pages
II�txt xLt JJ'Stt.�
WM. TRAHANT JR. CONSTRUCTION, INC.
4TH GENERATION ROOFING
215 Verona Street
LYNN, MASSACHUSETTS 01904
(781) 599-1211 to(781) 844.4551 a FAX: (781) 581-085S H.I. LIC, e141778
rllfllF / 9V3setTEa To - PHOW mT¢
51kSar1 Q7$ - S-17- is37
tl CA0,ja - S4. Four Q7` _ '%Ce? - at400
crrr•STAR one all Oats JOB LOCATION
Sa\mr1
we hereby sub rdt saeciecafions and estimates for- We hereby submit spZ-Gtiorts and estimates for
I
SHIN(j;LE ROOF
O Strip entire roof 0 Sweep entire roof clean
❑ Replace any bad boards up to 100 linear feet Strip WWe roof d� QprmaM 01%%,v - -
Q Install fee and water barrier first three feet up roof �Mechanlcally fasten down ISO board Insulation
❑ Install ice and water barrier in all valleys and along dormers tab install 060 Rubber Roofing on ernirg roof
Ell Install 1 Sib. felt paper on remainder of roof I4Install metal flashing around perimeter of Witting
Q Install eight inch drip edge GYFiash chlmney(s), pipe(s)and wall(s)
❑ Install ridge vent Q�Edge caulk all seams
❑ Flash or reflash chimney(s) ❑Install new copper center draln
._.....----. -.--
LI Install new pipe flanges ❑Other.
0 Install 30 year shingle ❑ other Clean up all debris
W Install gutters and downspouts dLabor and materials guaranteed 100%for five years
U Install trim coil ---P A�Q....G0.11 �l_.4►i��tilv"1--- .-
❑Install new fascia boards
❑ Install new fake boards
❑ Install sky light(s)
171 Other:
❑Clean up all debris
C3labor and materials guaranteed 100%for five year __._.._, .-._._.......,..._.. _ -'-- -.. ..
0 A 1 shingle rOOfS are naired by hand-
?Mar TFroposo hereby to furnish material and labor — complete in accordance with above specifications,-for the sum of:
Tomi Price(e...
eetF You ARE HAVING YOUR ROOF STRIPPED, PLEASE COVER ALL VALUABLES IN ATTIC, AS
WE NAVE NO CONTROL OVER DEBRIS THAT MAY FALL THROUGH ROOF BOARDS.'',
AM me[nid le aThandeM M be w we~Aa we.a b tor cuTleMd in•wMnsdho
,never,ar..' a a m svndord practices.Aq agratloo or dowil aon gone&boa wwdatw Authorized
goof slyokby ems cities we be executed ore,loon w rowl ardor , ad wit bRlaa on SA{naYura �✓ aeaewea� -
ytl chores"or a/d lbey! the eatlTele AM ","Monte eonanaent mom so"%.
a"W"or u0sys beyond our me Owner he oar,,are,ttrnodo,and other resuooery
Insurance.UIr marewre Are,hilly Ctwaod by weAmo's C—We s oa mwrawce
L
ongleM,amwerouthorizoori�to�z era sakarac and as hmeby accepted.You are alAllpized to sigrmbra e work as specified.Payment warm be made as outlined above-OrAGCeptaneW to Sl ennhJrema rn+.ebeu