25 GREEN ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
I / Massachusetts State Building Code, 780 CMR SALEM
Building Permit Application To Construct, Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Fanti elling
This Sectio or Official Use Only
Building Permit Number: Pate A lie
D�
Building Official(Print Name) SllnlleDate
SECTION 1:SITE INFO ION
1.1 Property Address: `1 1.2 Assessors Map&Parcel Numbers
L 1 a Is this an accepted street?yes J no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
4 Zoning District Proposed Use Lot Area(sq ft) 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 Owner`of Record:(�
��� SF.��.cr
Name(Print) s City,State,ZIP
"J.--S
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2:
r� oo
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 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 (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
1, Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due!
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
\,), \N 11"-1 Shy.` License umT� Expiration Date
Name of CSL Holder
Lis[CSL Type(see below)
No.and Street h Type Description
_ Unrestricted(Buildings up to 35,000 cu.ft.
�AJ�'r� ��� R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) `�0 a D I
�� \\ \- `— 5�", HIC Registration umber Exprmnon Date
HIC Company Name or HIC Re tstrant Name
No pand Street Email address
�oyyx i
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
I,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: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 accurate 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.eov/dos
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 half/baths
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"
aCITY OF S ULEINI, N'IL1SSACHUSETTS
BUILDING DEPAR'I1lENT
120 WASHINGTON STREET,3'h FLOOR
'ILL (978)745-9595
FAX(978) 740-9846
IM BERLEY DRISCOLL
MAYOR TrIOMAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUI DL*IG CO\INQSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbera
Applicant Information Please Print Leeibly
Name(BusimssiOrpnizationAndividual):
Address:
City/State/Zip: O \c\\'� Phone#:
Are you an employer?Cheek the appropriate box: Type of project(required):
I;'I am a employer with— 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet: 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their lo.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12,1!lRoof repairs
insurance required.)t employees.[No workers' 13.❑Other
comp, insurance required.]
•Any applicant that checks bmt 81 must also fill out the section below showing their workers'compensation policy iniumtation.
t I lam:owmers who submit this affidavit indicating they ate doing all work and then hire outside cmuntemrs.1 submil a new affidavit indicating such.
:Commders that cheek this box must attached an additional sheet showing the name of the subcomrsctors and their worlso s'comp,policy iormmanon.
I am an employer that Is providing workers'compensation Insurance for my employees. Below Is the policy and Job she
information.
Insurance Company
Policy#or Self-ins.Lie.#: Va�— O7 � r .� Expiration Date:
Job Site Address: City/StatetZip:Sow ',— ,Sty
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration 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 S I,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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Iavestiguliuns of the DIA for insurance coverage verification.
l do hereby certo under the pains a d nahles of peryu that the information provided above Is true and carrel
zn 1 Ire Q
OJrciai use only. Do not write in this area,to be completed by city or town oJrciaL
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board of Ilealth 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person:— Phone#:
Shea Roofing Co.
17 % Foster Street
Salem, MA 01970
(978) 745-7313
PROPOSAL August 9,2011
SUBMITTED TO: Gabrielle Raymond
25 Green Street
Salem, Ma.
We hereby submit specifications and estimates for:
To remove all existing slate roof shingles from remaining slate side of
main roof.
To install ice and water shield up along all roof edges and along all
flashing points prior to re-roofing.
To install asphalt saturated felt paper covering all roof boarding prior to
re-roofing.
To install all new metal drip edge along all roof edges, both horizontal
and vertical.
To install architectural (GAF Timberline Lifetime High Definition) roof
shingles covering same side of main roof.
To install up to 100 linear feet of roof boarding as necessary.
To counter flash ,re-flash and/or reseal all sidewalls as necessary.
To counter flash and/or reseal the chimney flashing as necessary. If lead
flashing is too damaged on the chimney we will grind it out and re-lead at
an additional cost of$360.00.
To clean up and remove all roofing debris from job site.
This new roof is guaranteed for five years against any problems created
by faulty workmanship.
We propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
Four Thousand Eight Hundred and Eighty Five------Dollars $4,885.00
Payment to be made as follows;
Upon completion
All material is guaranteed to be specified. All work to be completed in a workmanlike manner according to
standard practices. Any alteration or deviation from above specifications involving extra costs will be executed
only upon written orders,and will become an extra charge over the estimate. All agreements contingent upon
strikes,accidents or delays beyond our control. Owner to carry fire,tomado and other necessary insurance.
Our workers are fully covered by Workman's Compensation insurance.
Acceptance of Proposal—You are authorized to do the work as specified-
Authorized
Signature:
Signature:
Date of Acceptance:
CITY OF S�UY.2N1, TNL-u$.�mussm
BUU.DLNG DEPARTMENT
j 130 W.i sHL%4GTON STREET, 3"D FLOOR
o� TVL. (978) 745-9595
FAX(978) 740-9846
KIN
[BERLEY DRISCOLL
MAYOR THo&AS ST.Pwmm
DIRECTOR OF PUBLIC PROPERTY/BUUMLNG CONMUSSIONER
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) o
tL'..p s" ,s mod\ , S
(add ess of facility)
signature of permit applicant
date
debrisit oc