6 LATHROP - BUILDING INSPECTION GK 3235 $3&
The Commonwealth of Massachusetts
Board of Building Regulations and Standards RECEI ED CITY OE
Massachusetts State Building Code,780 CMR INSPECTION SEW05
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a P 2 3u
One-or Two-Family Dwelling b &UG
This Section For Official Use Only
Building Permit Number: Date Applied
�:{
X� C.1�—
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
L 1 a Is this an accepte street?yes no Map Number Parcel Number
1.3 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?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: �p
Name(Print) City,State,ZIP
--1�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': t- �
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials Official Use Only
1.Building $ -cs 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ SN ❑Paid in Full ❑Outstanding Balance Due:
CCAwSbIJ 500rtTo H•o• S3 �tl �ty
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Superviisoor License(CSL)
License Number Expvation ate
Name of CSL Holder
C.
List CSL Type(see below)
No.and Street e Description
U Unrestricted Buildin s u to 3S,000 cu.ft.
R Restricted 1&2 Family Dwellin
Ctty/fown,State,Z
M Maso
RC Roofm Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
Ste, Astration Number Expirati n ate
HIC Company Nat a or HIC Registrant Name
�� Na
No.and S et p M- (�r� y�y \!� Email address
Ci /Town,State,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
FOwner
NER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
bject property,hereby authorize
in all matters relative to work authorized by this building permit application.
Electronic Signature) Dale
SECTION 7b:OWNEW 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 in this application is true and. curate to the best of my knowledge and understanding.
Print Owner's or Authorized ame(Electronic Signature) Dat
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
%v%w.mass.>ovioca Information on the Construction Supervisor License can be found at www.niass.gov/dps
ss
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"
Shea Roofing Co.
17 % Foster Street
Salem, MA 01970
(978) 745-7313
PROPOSAL April 5,2014
SUBMITTED TO:
.Mr. and Mrs. Clausen
6 Lathrop Street
Salem, Ma. 01970
We hereby submit specifications and estimates for:
To remove all existing roof shingles from complete main roof including
front mansard roof.
To install ice and water shield covering all lower roof edges and under all
flashing points prior to re-roofing.
To install asphalt saturated felt paper covering all roof boarding prior to
re-roofing.
To install all new metal drip edge along all roof edges, both horizontal and
vertical.
To install architectural (GAF or Certainteed High Definition 30 year) roof
shingles covering complete roof as mentioned above.
To install up to 50 linear feet of roof boarding if necessary.
To install new roof flanges on roof vent pipes.
To board up old skylight opening prior to re-roofing.
To remove chimney to below roof line then board up prior to re-roofing.
To sister up roof rafter where chimney was removed to add support to
the area.
To counter flash, re-flash and/or reseal all sidewalls 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:
Five Thousand Five Hundred and Eighty Five----------Dollars ($5,585.00)
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,tornado 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 specked.
Authorized Signature:
Signature:
Date of Acceptance: 7
f CITY OF S.U.l"M. N'LkSSACHUSETTS
• BuUMLNG DEPjLRTm&NT
120 WASHINGTON STREET,r FLOOR
oT TEL (978) 745-9595
FAX(978) 740-9846
KI%iBERLEY DRISCOLL
MAYOR T komu ST.PmnE
DIRECTOR OF PIBuc PROPERTY/BI;t MING Co%massIONER
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 :
(name of facility) p
(a dress of facility)
signature of permit applicant
Li
dat
dcbrisal7dk
CITY OF SMEINI, NWSACHUSEM
• -BUIIDING DEPAErmENT
120 W iSHINGTON STREET, P FLOOR
TEL (978)745-9595
FAX(978)740-9846
KINEBERI.EY DRISCOLL
MAYOR THOMAS ST.PIEaRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMMIONER
Workers'Compensation Insurance Affidavit: Builders/Contractors/ElectriciawWPlumben
Analicant Information ( Please Print Leeibly
Name(Business.Organi:ationtindividuai): i% . \N,
Address: %QO
City/State/Zip:A�J.u,r� Phone It: N\% —13vl
Are you an employer?Cheek the appropriate box:
Type of project(required):
I.P 1 am a employer with :)=, — 4. 0 1 am a general contractor and 1 6. 0 New construction
employees(full and/or part-time).' have hired the subcontractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet; 7. ❑Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§I(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
COMP.insurance required.1
•Any applicm the choke bee d I most also fill out the ts:ctiao below showing their worker'cumptseeni n policy information.
t Iinmeowresa who submit IAts afffdeve indicating they are doing all work and then hire moside cmnrneror must submit a xv andavit indicting atrh
=Comraton chat check this box mum attached an additional•beet showing be name at"subenntracer and their workm'comp,policy infor nattom.
fain an employer that Ls providing workers'compensation lnsurancefor my employees. Below is the poUcy and Job site
informmion.
Insurance Company.Name:
Policy#or Self-ins.Lie.#: P":�'L"`'122—�I C` YY Expiration� Date: �\
Job Site Address: s- c Nh-c o Q � \ City/State/Zip: �—" x.,nh_LC1�
Attach a copy of the workers'compensation policy declaration page(showing the policy number and tixplradon 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 one-year impnsonmeht,as well as civil penalties in the form of a STOP WORK ORDER and a line
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 orthe DIA for insurance coverage verification.
/do lterelry certify?and
r the pains rend nahles ofperJary that the information provided above is true
and comr.
m i
e
Siena re: - Date: U I gJ )
Phone#
OJpcial use only. Do not write in this area,to be completed by city or town afflcied
City or Town: Permit(License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#'
r