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42-48 LEACH ST - BUILDING INSPECTION o� 30� Cf; 331C 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-Family Dwelling ` n (This Section For Official Use Only) Building Permit Number:. Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available) Lya-tw6 l.",C_�N` �vr, O TA-1 O No.and Street City/Town Zip Code Name of Building(if applicable) SECTION 2:PROPOSED WORK Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows below Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 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 ❑ Is an Independent Structural Engineering Peer Review required? - Yes ❑ No ❑ Brief Description of Proposed Work: "Co Sk s 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 ❑ A4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5❑ I: Institutional I-1❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-111 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 ❑ IB ❑ IIA ❑ IIB ❑ IRA ❑ IIIB ❑ 1 IV ❑ VA ❑ VB ❑ 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 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 Tight-of-way: Hazards to Air Navigation: MA Historic Commission Review Process: 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: setj->- 5 1� -,-,b (Z.C,t-T SECTION 9: PROPERTY OWNER AUTHORIZATION Name and Address of Property Owner Name(Print) No.and Street City/Town Zip Property Owner Contact Information: 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) f building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Res onsible for Construction Control Name(Registrant) pTe'lep �'hon No. e-mail dress R ation Number `bQ lk,—Nr o Pp� pax�6 w�� Tyr-,- ©MQl S Street Address Cjtyjm�n State Zip Discipline Expiration Date 10.2\General Contractor (� S Company Name /7� L� / Name of Person Responsible for Construction License No. and Type if Applicable "So �, sti.�o,—, Ina. 0\ 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 signed Affidavit submitted with this application? Yes❑ No ❑ SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Item 6)_$ 1.Building $ U O-0 --.. Building Permit Fee=Total Construction Cost x (Insert here 2.Electrical $ appropriate municipal factor)_$ 3.Plumbing $ 4.Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality) 5.Mechanical Other $ Enclose check payable to 6.Total Cost $ So (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 kn edge and understanding. U:\\ s� Please print and sign name Title Telephon No. Date 0 ���� 1`� R,f\4 Street Address City/Town State Zip Municipal Inspector to fill out this section upon application approval: ✓ 7,.- Name Date CITY OF S�U.EN4 NIASSACHLSE= • BUILDING DEPARTMENT ` 120 WASHINGTON STREET,Ste FLOOR TEL (978)745.9595 FAX(978)740-9846 KIMBERL.EY DRISCOLL MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDLWG COMMSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly dame(eusinessiOWniratioNmdividual): V \\; t v.. S�_1p _ Address: `�P AN-A- city/state/Zip: r1� yr C� Phone if: Are you an employer?Check the appropriate box: Type of project(required): 1.61 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or pan-drue).0 have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling ship and have no employees These sub-contractors have S. ❑Demolition working for me in any capacity. workers'comp.insurance. 9, ❑Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I 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.fg Roof repairs insurance required.)t employees.[No workers' 13.0Other comp.insurance required.] ;Any appliam that ehacks box of must also rill out the section below showing ibctr workers'tampnution policy information. t Ifomeownns who subatit this affidavit indicating they are doing all work and then hire outside eonnacbers must submit a new affidavit indiening suds :Contmcwrs that cheek this bon must anached an ndditioml dhm showing the mono of the nub conumsc s amt ihelr wortam'comp,policy infommtioo. I am an employer that Js providing nwrkers'compensation insurance for my employee Below is the pulley and job site information, e Insurance Company dame: Policy#orSelf--ins Lic. Expiration DateAy�) Job Site Address: City/Smtetzip: 5_ c_� h 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 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 maybe forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby certify un er the pal s nd penatles ofperjury that the h!rormadon provided above is true and correct ntu • Phone#: Official use only. Do not write in this areo,to be completed by city or town ofJ"ural City or Town: Permit/License# Issuing Authority(circle one): I. Board of Health 2.Building Department 3.CilylTown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#' CITY OF S UY.M, INLkSSACHUSETTS ' BUILDING DEPART*WNT 120 WASHINGTON STREET, r FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KIMBERLEY DRISCOLL MAYOR THo&AS ST.Pmm DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNUSSIONER 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 11 t, S 150A. The debris wi 11 be transported by: (name of hauler) The debris will be disposed of in : (name of facility) (address of facility) signature of permit applicant date debrfsair.doc Shea Roofing Co. , 17 % Foster Street Salem, MA 01970 (978) 745-7313 PROPOSAL March 28,2015 SUBMlrrED TO: Peter Kelly - 42-44 &46-48 Leach Street Salem, Ma. 01970 We hereby submit specifications and estimates for. To remove all existing roof shingles from both complete roofs excluding lower front porch on 42-44. To install ice and water shield completely covering all lower roof edges and under all flashing points prior to re-roofing. To install synthetic underlayment 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) roof shingles covering complete roof. To install new roof flange on roof vent pipes. To install new roof air vents. To counter flash and/or reseal 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$250.00 per chimney. 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. Twenty Eight Thousand Five Hundred----Dollars ($28,500.00) Payment to be made as follows; One third to start($9,500.00) 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 W rkman's Compensation Insurance. Acceptance of Proposal—you a a h ' e o do tbcwo s s 'fled. Authorized Signature: Signature: Date of Acceptance: 3 Z