5 LATHROP ST - BUILDING INSPECTION r ` 0 L4 - S 4,Z5 RECEiVESERVICES
The Commonwealth of Massac ,setts - 30
' #�4y Department of Public Safety '(('a �(aR 'ILA A -
N(�/°Q' Massachusetts State Building Code 78000
Building Permit Application for any Building other than a One-or Two-Family Dwelling
wL (This Section For Official Use Only).
Building Permit Number: Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block R and Lot N for locations for which a street hddKsj is not available)
No.a reet City/Town Zip Code Name of Budding(if applicable)
SECTION 2•PROPOSED WORK
Edit State Code used_ If New Construction check here❑or check a6 that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ r\ddition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Charige of Use' ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No O—----
Is an Independent Structural Engineer' g Pcer Review required? Yes ❑ No ❑
Brief Description of Prop sed Worr C� �' L u W'
S <w�c -�r u Z v.a ��S C 1 h CY. cx
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 CNIR 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❑ AS❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ H: Hi h hazard H-t❑ H-2❑ H-3 ❑ H-4 Cl HS❑
1: Institutional I-1 ❑ I-2❑ I-3❑ 1-4❑ M: Mercantile❑ R: Residential R-1❑ R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ Ur Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill ❑ ❑A ❑ IIB ❑ IIIA ❑ BIB ❑ IV ❑ I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Debris Removal:it h Pe
rmit:erm :
Water Supply: Flood Zone Information: Sewage Disposal: Trench
Site❑us Licensed Disposal Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P s
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \I_\,I ist n C„mmk v i n c,w,, I u,ces,:
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 Cude: Use Group(s): Type of Construction: Occupant Load per Floor:
Ducs the building contain an Sprinkler System?: - Special Stipulations:
3o Eckto �
I1�1rtTn..., SECTION 9: I'ROPERTYOWNERAUTFIORIZATION
Name iiltf\ lU iess ojArg pertty Owner $
Name UP'Fnq A No.and Street a City/Town Zip
�`� �S flet
r
Property Owner Contact In PAN orm, ion:
Title Telephone No. (business) Telephone No. (cell) a-mall 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 budding is less than 35,000 cu.ft.of enclosed space and/or not tinder Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control -
Nannc(Regi.tr t) Tel hone No c-mail dress Registration Number
Street Address City/Town State Zip Discipline Expiration Dot
10.2 General Contractor _
Company Name
CS \035�0
Name of Person Responsible for Construction p� License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No.(business) Telephone No. cell e-mail address
SECTION 11:IVORKERS'C:ONIP1dNSA I ION INSURANCE.AFFIDAVIT M.G.L.c.152.§ 25C 6
A Workers'Compensation Insurance Affidavit from the NIA 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❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Nlaterials) Total Construction Cost(from Item 6)=$
1. Building $
Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)=$
3. Plumbing $
1. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost $ (contact municipality)and write check number here
SECTION 3: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. -
Please 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
r
CITY OF S 1LENI, NL1SSACHLSETTS
.� BuuDi\G DEPARTMEINT
i'_O 1Y/ASH11VGTON STREET, 3'FLOOR
TES.. (978) 745-9595
Rita(978) 740-9846
1C.%fBFRi F.Y DRISCOLL
MAYOR DIRECTOR
ST.PtF R R F
DIRECTOR OF PUBLIC PROPERTY/BCII-DLVG CO\D.nSSIONER
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
\ ` 4u,
Name (Business:Organization,'Individual): �\N v �\ \ G^
Address: l]� �-r f�1�
City/State/Zip: 0 \ 5 ^Phone
�'A� �rqe�you an employer?.Check the appropriate box:. Type of project(required):
'1� am a employer with., 4• ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)P have hired the sub-contractor
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in an i[ work ' comp. nsurance.i Y ca ac P' Y• ers 9. ❑ Building addition
IN'o workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[,so workers'comp. c. 152, 91(4),and we have no 12.❑ Roof repairs
insurance required.}t employees. [N`o workers' 13,❑ Other
comp. insurance required.)
-Any applic:mt slut checks box Bl muat also fill uul the section below showing their woiken'compensation policy islib malion.
'I Iomcownen who submit this affidavit indicating ihcy arc doing oil work and then hire outside contractors most submit a new alydavit indicating such.
<: n�nwwn lhul check this boa must attached on additiurwl shout showing the narne of the sub•contneton and their work<n'comp.policy information.
I unt an employer that is providing workers'compensation in.surancefor my employees. Below Is the policy and job site
information.
Insurance Company Name: �A _•�D
Policy #or Self-iris. Lic. N:_ZA cz- \ k,\n Expiration Date: Sy\ f�
Job Site Address: �j ,..—I� City/State/Zip: s&!Z, — }o 1111�
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 line
of up to S250.00 a day againsi,the violator. Be advised that a copy of this statement may be forwarded to the 011ice of
Investigations ui'the DIA for insurance coverage verification.
I eta hereby certify under the pah s ud penalties of erjury that the informmrion provided above is true and correct
Date: ` ay
Phone
E
only..Do notwrite in this urea,to be completed by city ar town ojficiat
n: PermitN.iccnse#
hority(circle one):
liealth 2. Building Department 3.Cityfrown Clerk 4. Elect ical Inspector 5. Plumbing Inspector
on: _ _._;,_ Phone 0:
[
; h�• CITY OF si1L&Nf, ti(:1SSACHUSE17S
l t _ BULDLNG DEPART.N NT
130 WASHLYGTON STREET, 3' FLOOR
"IFL (978) 745-9595
F.ti.x,(978) 7404845
K11tBER1.EY DRISCOLL
,ILAYOR T HOAAS ST.PIERRE
Di.ZECtOR OFPUBLlC PROPERTY/BCILDCVG CONNISSIONER
Construction Debris (Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of iVfGL c 40, S 54;
Building Permit k is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as dofincd by LIVfGL c
l 11, S 150A.
The debnriis will be transported by:
(name orhauler)--
The��de11bris will be disposed of in
--jj _
(name of tactlity
(add ess of facility)
Ah
signature of Perm it applicant
_ I _
le
Shea Roofing Co.
17 % Foster Street
Salem, MA 01970
(978) 745-7313
PROPOSAL March 24,2014
SUBMITTED TO: Mr. and Mrs. Clausen
5 Lathrop Street
Salem, Ma. 01970
We hereby submit specifications and estimates for:
To remove center chimney down to second floor.
To board up chimney roof opening and re-shingle same area tying into
existing roofing.
To remove old then install new sheetrock ceiling on second floor.
To dispose of all work related debris into dumpster located on property
We propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of:
Two Thousand Five Hundred and Fifty ---------Dollars ($2,550.00)
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.
C
Authorized Signature:
Signature:
Date of Acceptance: