12 HAWTHORNE BLVD - BUILDING INSPECTION (4) CK kwi-)l
The Commonwealth of Massachusetts
Department of Public Safety
Massachusetts State Building Code(780 CMR) �}
Building Permit Application for any Building other than a One-or Two-FamilEbwel4g
(Phis Section For Official Use Only)
Building Permit Number: Date Applied: Building Official: Z
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is no aila
,9 12 1lpwd h o2Ae,1541� Jlsl�l� m,4. 01R 10 WOme-" 's C1t,1�.1�3r,�o
i No.and Street City/Town Zip Code Name of Building(if applicable),t*
SECTION 2:PROPOSED WORK 7)
Edition of MA State Code used If New Construction check here❑or check all that apply in the two-Mws be7"6w
Existing Building NKTRepairdl Alteration ❑ I Addition❑ I 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 Cr
Is an Independent Structural Engineering Peer Review required? p Yes ❑ No I V
Brief Description of Proposed Work: K eA t oU-e. 4. t"(J h&eg rtm-/' AV& l dl S tl 1 4 7—(y el
An im s G( A/e,14 &ftjrle ullu adhpnP�J ehmtn �l dPsioe✓ ' a�blz�r
rob E cZu ff¢n�
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❑ 1 B: Business ❑ E: Educational ❑
F: Factory F-I ❑ F2❑ H ❑: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 H-5❑ J8
I: Institutional I-1 ❑ 1-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ IB ❑ IIA ❑ IIB ❑ HIA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer 1v780 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 indentify Zone: or on site system❑ required❑or trench or specify:
permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: ,%I A Historic commi_Iun Rrvlc�,•Ili o,es.,:
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 building contain an Sprinkler System?: Special Stipulations:
M A t t_ 4-1D C:.C .
i
SECTION 9: PROPERTY OWNER AUTHORIZATION
Naive and Address of Property Owner r� '/
oa
Name(Print) No.and Street City/Town Zip
Property/Owner Contact Information:
/3eXr> tfN�-tA�K /V, z //n
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 E3 and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
V-PftS J-9ea. _f3,F/
Name(Registrant) Tele hone No. e-mail address Registration Number
Nei" ()mod/1YJO{�1 (r1L- S���Q 7 _46— ._0 976
Street Address City/Town State Zip Discipline Expiration Date
10✓.J2 General Contractor
l�/O��rS�avla,Q Yw0�trta�P/ � �r/fc�4✓S � -�N L.
Company Name
inns sc�eli l q-7a9
Name of Person Responsible for Construction License No. and Type if Applicable
oZ f22 CAVA44 G J T Sia lPi�c, o /970
Street Address City/Town 9tate Zip
q 1 Y, J-,FP VOtL firdeJ.r 0U(241U AuldL
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE 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 issuance of the building permit
Is a signed Affidavit submitted with this application? Yes e No ❑
SECTION 11 CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)=$ /di
1.Building $ ® O U Building Permit Fee=Total Construction Cost x (Insert here
2 Electrical $ (J', t) appropriate municipal factor)_$
3.Plumbing $ 0o
4.Mechanical (ITVAC) $ fj_QJ Note:Minimum fee=$ (contact municipality)
5.Mechanical (Other) $ - J
Enclose check payable to
6.Total Cost $ /0 �'Q 0, �0 (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 all of the information contained in this
application is true and accurate to the best of my knowledge and understanding-
4 6 G / n 'G W Ax,< {�✓fSlf1,P�12I� q?y-741,y_
ease print and si name Title Tel No. Date
els /J-eu� bo rn �(d - s2 Lein �$ a�g zo
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval: r �3
Name Date
AMM
Professional Roofing Contractors , Inc .
James W. Shea, President
P.O. BOX 26?, 45 DEARBORN STREET
SALEK MASSACHUSE71'S 01970
PHONE (978j 744-6888 FAX (978) 744-8814
profe.ssionalrooi=inS@verizon.net
PROPOSAL
May 2, 2016
Woman's Friend Society
12 Hawthorne Blvd.
Salem, MA 01970
RE: Upper Flat Roof Replacement
To replace the upper flat roof with the following steps:
1. Remove existing rubber roof and insulation.
2. Remove 3 rows of shingles where the rubber roof connects to the shingle roof. The new rubber will
underlap the shingles, and new shingles will then be installed over the rubber.
3. Fasten 1.5" poly-iso insulation board to the roof deck.
4. Install 1.5" PT wood nailer around the perimeter of the roof.
5. Install a Carlisle Design-A fully adhered .060 EPDM roof system.
6. Flash all roof penetrations and chimney by Carlisle specifications.
7. Install Carlisle Russ Strip around chimney and angle change near the shingle roof.
8. Re-flash the lead counter flashing on the chimney.
9. Wrap all gutter brackets off the flat roof with uncured rubber flashing.
10. Install 16 oz. copper perimeter flashing.
TOTAL COST................................. ..................$109900.00
ACCEPTANCE OF PROPOSAL................ T:......... ................
TERMS OF PAYMENT.........................................................
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aCITY OF S.UENL 4 NMASSACHUSET M
BI:B.DLNG DEPART.%cm
120 W1SHINGTON STREET,3'n FLOORTEL.T� (978) 735-9595
FAX(978) 740-9946
KINIBFAi RY DRISCOLL
MAYOR THOMAS ST.PEERRE
DIRECTOR OF PUBLIC PROPERTY/BUIIDLVG CO%L\iISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/ElectriciansMIumbers
Annlicant Information _ - /�,J/1'1t`n Please Print Lealbly
Name(Business!Organization/Individatal): Pia t CSI 0✓ILLY /� y&i /-e J,e
Address: Ip o f 8 n k 2,i >✓ _ _
City/state/Zip: f IYIn'Zi�. 444 b [g 7 0 Phone#:
Are you an employer?Check the appropriate box: Type or project(required):
1.(9 1 am a employer with._7 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employes(full and/or part-dam).• have hired the sub-contractors
2_❑ 1 am a sole proprietor or partner. listed on the attached sheet.: 7. ❑Remodeling
ship and have no employees These sub-contractors have R. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition
[No workers comp.insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised then
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.g Roof repairs
insurance required.]t employees.[No workers' I3.❑Other
comp. insurance requited.]
'Any applicant that chocks box al must also fill out the testien below showing their workers'mnq mnation policy information.
i I Imxowmas who submit this of lavit indicating they are doing all work and then hire outside rortuartors neat submit a new air it indicating such,
:Contracts that check ibis bwc must attached an addirim W deei showing the rmme of the sub-eomractms ow their worsens-coup.policy infomatioo.
1 am an employer that is providing workers'coatpensadan insurance for my employetm Below is the poft y and Job site
information.
insurance Company dame: 7f1{mil Gtl
Policy#or SclFins.Lie.#://4 y7- y -0 YrQ V jig"b -15 Expiration Date:
!ob Site Addrsas: /�- Nl9'L%MdA Vey- z l S City/State/Zip: S_ .-.A aL`t 7D
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 1,500-00 and/or ortayear imprisorunent,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations orthe DIA for insurance coverage verification.
1 do hereby cenify yunder thfe/pales and penaltles ofperlstry that the information providedrabove Is true and cornet
Signature: .!1�Y6�Jy� " Date:
Phone#: 41,/?—,,?Q 3
Official use 0411y. Do not write in this area,to he completed by city or Iowa official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone#:
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-019729
Construction Supervisory+ _ 1
DAMES W SHEA
46 DEARBORN ST �.-
r. SALEM MA 01970 .
fnn Co CA, Expiration:1011 512 0 17
Commissioner
,*a GiOMMONWE3ALTH OF MASS. IC}iUSETTS
• • • • • • •
•• BOARQ F r
:,,SHEET METAL WORKER$ '1
=ISSUES THE:.,0LLC)WING LIM SEA H
t MASTER UNRESTRICTED
JAMES W SHEA t
45 D ARBOR[ ST
SALEM,MA 0 G970 2429'�
SJ
n . 'tpi3823, + 16t28/�i017 ' ` 60$2.? r.a
\ - n%/c 'nvouu�innrnl(l c/e L�iX9 ur�uacll�'..
_ .'1i� Office of Consumer Affairs& Business Regulation ,
ME IMPROVEMENT CONTRACTOR
gistration: 1.62766 Type:
'Axpiration: -4/6/2017_ Private Corpora0o.j
PROFESSIONAL ROOFING CG gTRACTING INC
f" JAMES SHEA ,
45 DEARBORN ST - - -
SALEM,MA 01970 -
Undersecretary
j SM�IC okw1 ALtsei`O Kii SR "HU8ETTS
• • • • • ' is
a 77 ,5O RD O , s
PLUMBERS, ANV GdSF ITTERS
ISSUES THE tFOL LOW ING LICENSE
LIGENSED•'AS AN'1T0 ULPGI'"