8 KOSCIUSKO ST - BUILDING INSPECTION C � 3�t(o �
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
( Building Permit Number: a pplied:
r Building Official(Print Name) Signature Date
rr SECTION 1: SITE INFORMATION
I' 1.1 Property Address: �c 1.2 Assessors Map&Parcel Numbers
IIIIII � � SZ�o S
1.In Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
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 Rgcord:
Name(Print) \� City,State,ZIP
� X� a S t_�, 2'I--O
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) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work2: '
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 Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (IIVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
Malt— -f-o SbAkzjn�'
/�MAI �� s[ ZSe
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �`\d�S%-D ,�`�d1
License Number Expr/rat-ion Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
(� U Unrestricted(Buildings up to 35,000 cu.ft.
.rty 1 1�1\ Restricted 1&2 FamilyDwelling
City/Town,S IP M Masonry
kc 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)
5a�4,Ck1, C o , HIC Registration Number Expr
HIC Company Name o IIj(�Registrant Name
�
No.and Street Email address
Ci /Town, S te,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
diiin�this ap�p ication is true and accurate to the best of my knowledge and understanding.
/iV.�✓N'i4i ..eft 1 ��
Print Owner's or Authorized Agent's Name(Electronic Signature) ])are
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.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"may be substituted for"Total Project Cost"
CITY OF Si-1 xm, NIASSACHUSETTS
• BITLDING DEPART%G NT
120 WASHINGTON STREET,3o FLOOR
TEL (978)745-9595
FAX(978)740-9846
KINtgFAi AY DRISCOLL
MAYOR T1tOI1tAS ST.PD RRl3
DIREC[OR OF PtBLIC PROPERTY/BCII.DING CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le¢fbly
Name(BusintssiOrganizatioNlndividttal):
Address: `I, c 1,�
City/State/Zip: Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
1.�&l am a employer with, /')) 4. ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time),* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.: 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑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.El Electrical repairs or additions
required,] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LC]Plumbing repairs or additions
myself.[No workers'comp. c. 152.§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
comp.insurance required.)
•Any applicant that chain box rl most also fill out the section below showing their working•compensation policy information
Homeowners who submit this affidavit indicating they am doing all went and then hire outside contractors mum submit a new affidavit indicating such.
:Contractors that chick this beat mum attached an additional sheet showing the name of the sub<omractors and their workers'comp.policy information.
l am an employer float Is providing workers'compensation insurance for my employees. Below Is the pollay and job site
information.
insurance Company Name:
Policy#or Self-ins.Lic.#: ��" Expiration Date: I p��
Job Site Address: `6 4 F1r �: P.'z \S- , � City/State/Zip:_ J"\ '`
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 S1,500.00 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
Investigations of the DIA for insurance coverage verification.
I do hereby certify under floe pains and penalties ofperjury that the informadon provided above is true and correc4
Signature: _ Date: I .I-
Phone#: 1�1\r\� - r) 7-",
Ojjleid use only. Do not write in this area,to be completed by city or town ojjkiat
City or Town: Permil/License#
Issuing Authority(circle one):
1.Board of Heallb 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person Phone#
i CITY OF S.U1 E.NI TNI.-kSSACHUSETTS
• Bt1LDLNG DEPARTSMNT
130 WASHINGTON STREET, 3m FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
IO�{gERLEY DRISCOLL
IMAYOR T HOMAS STYIERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COWMISSIONER
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 :
q (name of facility)
\O� ��""1-er
(address of facility)
signature of permit applicant
date
debrivlUm
Shea Roofing Co.
17 % Foster Street
Salem, MA 01970
(978) 745-7313
PROPOSAL May 20,2016
SUBMITMDTO: Charlie O'Neal
8 Kociusko St
Salem, Ma. 01970
We hereby submit specifications and estimates for:
To re-nail and/or remove any lifting or loose shingles in order to provide
smooth roofing surface over complete main roof.
To install ice and water shield covering all lower roof edges prior to re-
roofing.
To install up to 50 linear feet of roof boarding as necessary.
To install all new metal drip edge along all roof edges.
To install standard three tab (GAF) roof shingles covering complete roof
as mentioned above.
To counter flash, re-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$300.00.
To install new roof flange on roof vent pipe.
To counter flash re-flash and/or reseal existing roof air vents and
skylight as necessary.
To clean up and remove all roofing debris from job site.
We propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
Four Thousand Nine Hundred and Fifty-----_----_---------Dollars ($4,950.00)
Payment to be made as follows;One third to start balance 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 IV
o the work as speci ed.
Authorized Signature: >
Signature:
Date of Acceptance:
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Salem Historical Commission
120 WASHINGTON STREET, SALEM, MASSACHUSETTS 01970
(978)619-5685 FAX(978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem Historical Commission has determined that the proposed:
❑ Construction ❑ Moving
❑ Reconstruction ❑ Alteration
❑ Demolition ❑ Painting
❑ Signage El Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: Derby
Address of Property: R Koscivako Street
Name of Record Owner: Lynn and Charles O'Neal
Description of Work Proposed:
Reroof with 3-tab shingles in black or charcoal gray.
Dated: July 23, 2015 SAL�EEM HISTORICArL CO�M�MIISSION
The homeowner has the option not to commence the work(unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.