2 HIGH ST - BUILDING INSPECTION D
;e .,r ar The Commonwealth of Massachusetts
Department of Public Safety
1/�� -,�•r �u .\I.rssachu.cus State Building Code(780 CMR)Seventh Edition
City of Salem
BuildingPermit Application for an Building other than a 1-or 2-Family Dwellin
t�1 (This Section For Official Use Only)
Building Permit Number: mte Applied: Building Inspector:
SECTION 1: LOCATION (Pleas •i�cate Block# and Lot# forlocations for which a street address is not available)
dLC
No. and Street City /Town Zip Code Name of Building(if applicable)
SECTION 2: PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building ❑ Repair Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/ur construction documents being supplied as part of this permit application? Yes ❑ No III/
Is an Independent Structural"Engineering Peer Review required? Yes ❑ No
Brief Description of Proposed Work:
a 1 OA2
- S i A
v
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): m•
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
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.) -ZS-
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E. Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional I-1 ❑ 1-2 ❑ 1-3❑ 14 ❑ 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 ❑ 18 0 IIA ❑ 1180 IIIA ❑ 1118 ❑ IV ❑ VA ❑ . VB Cl
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 it outside Hood Zone ❑ Indicate municipal ❑ :\ trench will not be Licensed Disposal Site❑
I'ricate ❑ or indentik Zone:_ or on site scstem ❑ required ❑or trench or,pecik:
permit is enclosed ❑ _
Railroad right-of-way: Hazards to Air Navigation: \1A I IiAb-m c ,•mmi>,i, n Rr i,m+ I'n r,,.:
\ut :\ppicoble ❑ I,til virtu re mthin airport of+pruadm area' I. hue renerc cumpleled'
, r l nn,cnt 6, Build cndo,cd ❑ 1'cv ❑ or No ❑ �L . \o ❑
SECTION 8:CONTENT OF CERTIFICA"TE OF OCCUPANCY
Iidilum .d Colo: C,c(Aruupla: rcpeol'Con,trucuun: lkcupant Load per Maur
D,n•, the building containan Sprinkler Sm avm': Special Stipulations:
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
Name(Print) Nu. and Street City/Town Zip
Properly Ow tier Contact Information:
Title Telephone:No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
Name Street Address City/To%vn State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building 2ermit a >rlication.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 35,000 cu, ft.of endoscd s pace and/or not under Construction Cunlrul then check here O and skip Section 10.1)
10.1 Registered Professional Res onsible for Construction Control
— —
Name(Registrant) - Telephone No. - e-mail address Registration Number
t eet Addres Citv/Town State Zip Discipline Expiration Date
1 2 nneral�� ntra or
lJ�'�
Company Name:
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
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 si ned Affidavit submitted with this application? Yes O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor
Item and Materials) Total Construction Cost(from Item 6)_$
1. Building $ Building Permit Fee=Total Construction Cost x._(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing $
Note: Minimum fee=$ (contact municipality)
4. Mechanical (HVACI $
5. Mechanical (Other) $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Bv entering my name below, I hereby attest tinder 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.
(lease print and >ign nome Title Telephone No. Dale
-treet Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval:
Nam D, to
CITY OF SM.E.`I, NLkSSACHUSETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET, )era FLOOR
TEL (978) 74S-9595
FAX(978) 740.99"
KIstgFRi EY DRISGOII
MAYORDR T ObW STYIERRS
DIRECTOR OF PLBLIC PROPERTY/lIUMDLNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/Plumbers
> > licant Information �I Please Print e
Name (ausirt OrWiratiorelndrvtdu:l): " !r'C'NS t �y� 5, 2
Address: ; 1 t ei L
City/Statc/Zip: ,5/kc_-r a4\ Phone
you an employer?Cheek the appropriate box: Type of project(required):
1 am a employer with 4. ❑ I am a general contractor and 1
employees(full and/or panm-Lie).• have hired the sub•contractoa 6. ❑Nato construction
2.Q I am a sole proprietor or partner- listed an the attached sheet : 7. Q Remodeling
ship and have no employees These sub-contractors have - V. Q Demolition
working for me in any capacity. workers'comp.insurartee_ 9. Q Building addition
(No workers'comp. insurance S. Q We are a corporation and its 10.❑Electrical repair or additions
required.) officers have exercised their
J.❑ 1 am a homeowner doing all work right of exemption per MOL 11.Q Plumbing repairs or additions
myself.(No workers'comp. c. 152,gl(4),and we have no 12.Q Roof repairs
insurance required.)t employees.[No workers' 17.Q Other
comp. insurance required.]
-J
•Any applicant that dtoch bass At mine aim fill um the section bolow sbowina their workers'caroprnwGtA policy irrfurmatlon_
'I l.vnesttrnes who subnN this affidavit indicating they an doing all work and then hire outside eomecpms mtrat submit a rraw arHdsvil indicating suck
{.muyyon AM check ibis box mow armhd an a Wiliwd cheer ihowing On trwne of the dk<011ingitere and their wor►ma'comp.policy infOl inab".
/raw an employer that fs pravidln workers'congpenmdon insurance jar my emplaytes. Below Is the paltry and Jab sip .
information.
Company c���
In.uranca Company Name:
-
Policy N or Self-ins, Lie.N: , ^� /� Expiration Date:
Job Site Address: 4k 6i k I-F 1' ��111�ilN{:> City/StatryZip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and esplratlon data).
Failure to secure coverage as required under Seclion 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 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 S250.00 a day against the violator.- Ile advised that a copy of this statement may be forwarded to the Office of
Invcaugati tVI data DIA fo i i) ance coverage verification
/(/a here cerl under t na and penis//eat ojper/ury that the hIjormallon provided u is i e and correct.Data: ( l C)
Phone A:
Dfricial use only. Da not write in this area, to be cutrrp/eted by dry or town o/naiuL
City or-futon:
i
Asuing.lulhurily (circle une): --
t. Iluard of Ileallh 2. Building Deparimcal J. City/rown Clerk 4. Electrical hnpector 5. Plumbing Inspector
6. Other
C,mlact Person: _ ._. __. Phone l6
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
NI''t"It I_'0�l'.�,ntNr�ON 5TnECT Ssi rat, bL�unt.i a sr.rnOPv,;
'f r t.:478-74 i-9 i95 1 I's x:978.74 0-98 46
Construction Debris Disposal Affidavit
(re(luired for all demolition and renovation work)
In accordance will' 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
11 t. S 150A.
The debr s will be transported by:
Umme of hauler)
The debris will be disposed of in
_ _-.....-----......
(name of faci ity)
taddress of facility) l
signature of{xrmit applicant
date
Jrhl null due
q
t
i GANSENBERG CONSTRUCTION i
21r Lincoln Rd.
Salem Ma 01970
978-335-4742
#cs092108
PROPOSAL SUBMITTED TO: hic #161159 WORK PERFORMED AT
` High St
NAME: Doug Bollen DATE OF PLANS:
Tba 9/l/09 -
ADDRESS: Salem park&rec
PHONE: 978-744-0180
We hereby prowpose to furnish the materials and labor necessary for the completion of:
Remove existing roof and all sheathing. Apply % " 5 ply roof plywood. Screw down
''/z"fiber board-.(screws and plates)on entire roof. Glue down 3 sheets of rubber with 30 .-
cleats. Seam tape all rubber joints. Hang new Fascia boards (1x8) and Shadow
boards(lx2) All to be pre-primed pine and attached with galvanized nails. Clean
grounds. Dumpster supplied by contractor
• All materials are guaranteed to be as specified, and the above work to be preformed in
accordance with the drawings or specifications for above work, and completed in a
substantial workmanlike manner for the sum of $4,600.00
********** Deposit $2,500 .00 for material *********** -
$2,100.00 upon completion
Respectfully submitted:
Note- this proposal may be withdrawn if not
Accepted within 14 days
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted.
You are authorized to do the work as specified. Payment to,be made as outlined above
Date Signature
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