12 HAWTHORNE BLVD - BUILDING INSPECTION (3)r
The Commonwealth of Massachusetts
Department of Public Safety �+•
Massachusetts State Building Code(780 CMR)
7" Building Permit Application for any Building other than a One-or Two-Familyriwellg g,'
(This Section For Official Use Only)
((1I� Building Permit Number: Date Applied: Budding Official:
`y SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not aila ? t
No.and Street City/Town Zip Code Name of Building(if app% ble)
SECTION 2:PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below
Existing Building Repair a I Alteration ❑ I Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work: rtt,frf/ll ria#zje _17/1'9-ck !a?✓o/
.e /.i r,n 0 n 07✓n l.rn ..,C �/D E- o.� ✓3 U�/,l--i--.-ice�
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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 ❑ A4❑ A-5❑ 1 B: Business ❑ 11: Educational ❑
F: Facto F-I❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑
I: Institutional 1-1❑ I-2❑ I-3❑ Ih❑ 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:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ UA ❑ IIB ❑ HIA ❑ m ❑ I rv ❑ I 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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or incientify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation MA Historic Commission Review Process:
\ Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the budding contain an Sprinkler System?: Special Stipulations:
IM to t t✓ - 13 C
12 ( ZI Mitts
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
WPirlcw, F�_,zve/ fie/t�j 12 L/.Affi.r awl
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Pyfr, Se ti"Z# p? �44
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)
10.1 Registered Professional Responsible for Construction Control
,(Ye.a cz?_2W, 831-/
Nagy iRe strant) del"ePhone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2�G(e'neral Contractor r /�l l la
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ch
Company Name
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Name of Person Responsible for Construction - - License No. and Type if Applicable
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Street Address City/Town State aip
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Telephone No.(business) Telephone No.(cell) e-mail addr ss
SECTION 11:WOIzKER4'COMPENSATION INSUI:ANCE 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 ysuance of the building permit.
Is a signed Affidavit submitted with this application? Yes Q' No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)=$ o2?j/a .DO
1.Building $ 7 .i, 00 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
6.Total Cost $ Z QO (contact r- �ilcipality)and write check number here
SECTION 13:SIGNATURE OF BUILD. .G PERMIT APPLICANT
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.
GY) es si�P� A°vewdea- - /7 793, ye) aG l
Ple se print and sign name Title Telephone No. Date
Street Address City/Town State Zip
)
Municipal Inspector to fill out this section upon application approval:
Name Date
t
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'Y'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,Pro m e,Medical or other)
10 Surve ed Site Plan(Utilities,Wetland,etc.)
11 Specifications
12 Structural Peer Review
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report
15 Existing Building Surve /Investi ation
16 Energy Conservation Report
17 Architectural Access Review(521 CMR)
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation
20 Other(S ec' )
21 Other(S ec' )
22 1 Other(Specify)
*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) Registration Number
Telephone No. e-mail address
Street Address Ci /Town State Zi Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address
Registration Number
Discipline Expiration Date
Street Address City/Town State Zip
i
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Ate.
Professional Roofing Contractors , Inc .
James W. Shea, President
P.O. BOX 282 45 DEARBORN STREET
SALEM, MASSACHI-SETUS 01970
PHONE (978) 744-6888 FAX (978) 744-8814
prolrssionalroofinoit9verizon.net
PROPOSAL
May 2, 2016
Woman's Friend Society
12 Hawthorne Blvd.
Salem, MA 01970
RE: Gutter Replacement, Fascia and Molding Replacement
To install new gutter system and replace damaged wood on two sides of the front building with the following
steps:
1. Erect scaffolding to create safe access to the roof edge per O.S.H.A, requirements.
2. Remove the first 2 rows of shingles.
3. Remove approximately 20' of damaged fascia board from the building.
4. Remove approximately 20' of damaged crown molding from the building.
5. Install approximately 20' of new fascia and crown molding to match the existing damaged wood.
6. Paint the new fascia board and crown molding to match existing trim color.
7. Install 144' (72' on each side) of 6"- 16 oz. double bead half round copper gutters the length of the
roof line on each side. The gutter will be half circle and hung from the roof edge with custom made
brackets.
8. Install new, matching architectural shingles to replace those previously removed.
9. Install 3 new copper downspouts on one side. The 3 existing aluminum downspouts will remain on the
other side.
10. Patch multiple animal holes in boards on back building.
TOTAL COST............................................................S27,125.00
ACCEPTANCE OF PROPOSAL.............................................
TERMS OF PAYMENT.........................................................
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Office of Consumer Affairs& Business Regulation
�I hkME IMPROVEMENT 1ME CONTRACTOR gistration: 6276666 Type:
' zpiration: 4I6I2017 Private Corporatio,'
PROFESSIONAL ROOFING CONTRACTING INC
JAMES SHEA
45 DEARBORN ST ,�s.
I; SALEM,MA 01970 Undersecretary
Massachusetts Department of Public Safety ^/
Board of Buildinq Regulations and Standards
Ltcense CS-019729
4). J:AMES W SHEA
45 DEARBORN ST 1 "
SALEM MA 01970
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The Commonwealth ofMassaehusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
f Boston, MA 02114-2017
www.mass.gov/dia
\\' rkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibly
Name (Business/Organization/Individual): Pr U-ir r(i cnyl& ' 4z 1 f l s l 1 64 7"Aekdl !dY ` '(
Address: f f•�� • (I&
City/State/Zip:, f �en /G'. 6Clr 7O Phone #: f ��—
Are you an employer?Check the appropriate box: - Type of project(required):
1.®1 am a employer with employees(full and/or part-time).* 7. ❑New construction
2. I am a sole proprietor or partnership and have no employees working for me in
8. ❑Remodeling
any capacity.[No workers'comp.insurance required.]
301 am a homeowner doing all work myself.[No workers'comp.insurance9. El Demolitionaoce required.)'
4.❑ m n'I am a hocown and will be hiring concontractors to conduct all work on my property. I will 10 ❑ Building addition
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.E]Plumbing repairs or additions
5.E]I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.®ROOf repairs
These sub-contractors have employees and have workers'comp.insurance.[
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.)
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
)Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'camp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: 2 iJglIe lj -,L A)Jf c-f .
Policy#or Self-ins. Lie.#: /(9 ,ZZ U 13 - G)11,5 O/VO k—� / Expiration Date: "5 �/ZZ 7
Job Site Address: l d- 1diTIL.,h -ol—/[Q City/State/Zip: f{�E f If
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator. A copy of this statement may be forwarr.d to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify under the pains and pe/nnaalties of perjury that' z_ Kformatian provided above is true and correct.
Signature: /'// /_��`/ •�%( Date: l/��/a'ft14
Phone#Z k/7 -,_2
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#: