64 LINDEN - BUILDING INSPECTION 1 The Commonwealth of Massachusetts_
I y Department of Public Safety
\la.,adnueits Slate Budding Code I•-80 C\Ili)Sa•cvnih Ediuun !
City of Salem �
Building Permit Application for any Building other than a I- or 2-Family Dwelling
I('his Sacuon firt Ullicial U<r Only)
Budding Permit Number! Date Applied: Budding Inspector:
SECTION 1: LOCATION IPlease indicate Blocks and Lots for locations for which a street address is not available)
No.and Street G"f'� City (Town tQim Zip Code Lljy�.o Name of Budding bt.ipplcoble)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply of the two rows below
oArebuilding
rldin ❑— Repair-❑--Alteration-❑.'. dditHm-0 -Drnwli{iun-0-(f-'(rase-fil4uut-and-submit-A}�pvndix-l-)
Use ❑ Change of Occupancy ❑ Other 8-Specify:�f/0�
plansand/urcumtructiundocumentsbeingsupplied.is part of this permitapplicatiun? Yes ❑ No�endent Structural Engineering Peer Review r�f)uiOred? Yes ❑ No (3
Brief Dexnplion of Proposed Worky��-/�..f
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 Gruup(s): - Proposed Use Group(s): f
Existing Hazard Index 780CMR.34: Proposed Hazard Index 780 CMR 34:
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(.+q.kj and Total Height(ft.)
SECTION 5:USE GROUP(Check as a livable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ 1 E: Educational ❑
F: Facto F-1 ❑ F2❑ H: High Hazard H-1 O H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1.1 ❑ 1.2 ❑ 1.3❑ 1-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑
S: Storage S-I ❑ 5-2 ❑ U: Utility O Special Use❑and pleasv describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA is IIA ❑ 118 ❑ IIIA ❑ IIIB ❑ 1 IV ❑ VA V8 ❑
SECTION 7: SITE INFORMATION(refer to 780 CMR 111.0(or details on each itein)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: . Debris Removal:
I'uhlc❑ ChvcA it oul•iJa•II,,iJ Lona•❑ Indhratr rnumnpal❑ \ Irench will not be Liccmed Ui.In,.al?ua•❑
Private❑ „r "ArI1dv Zone: „r„ rcquircJ❑ur trench „r
_ n.dr•c.trm❑ permit i,enclu.ed ❑ _
I 14ailruad nghl-of-way: flazsrds to Air Navigation: \141L.i..ru i ........ I;.,,,., ;"..,,...:
\,,1 \pi'I"Allc❑ Lipari n•d is„ nIWIA .vt• i
. rl .n.c it u. Build c mI,.•,d❑ I 1d•.❑ ,-r.\,-O N'.,0 \„ ❑
SECTION 8:CON TENT OF CERTIFICA TE OF OCCUPANCY --�
.liliun.•II Jc _ .___ L-c l.n,ulv.i _ (,i`c••Il unynp b, n ____ liciul`anll „e.l lvr lli nor ._ _ _._ '
II, r.Ihrlud,lu,q.,nn.un.in�I•nnAlcr T\,tcm' �llvkml cupuloijw"
SECTION 9: PROPERTY OWNER AUTHORIZATION
N.nne.0 L( , ddrv,,d I'rup.rty l),y nrr
ter-, InA
V,une l Intl Vu.,Ind tiln'rt l III , ra\\'n !q+
Prul,c'rl\' l)\\nrr Conlao Inlorm.1llon'
�j_x .,�2- r�
rifle relephone No. Ibu,in ,%) rrlrphonr.Vo, (cell) r rn,ul.Iddrv.. j
If el+l+hiablr, the),n+perf\ u\,ner hereby aulhon[e,
V.,mr Street Addrr.�, Cilvi Town State Zip
1'.oct,91 the +ro Ier1% o\cner'.behalf, m all rnalters rvinore to work aulhon,vd by this buddln • 'rrmrt., + Ihcanun.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
111 I•wldln•Is los than III-M)cu.it ul endo,�d.+ace and/aI;not under Con,Inlchun Con ln,l then check heel O and.kI ,,,,Iwn to II
I0.1 Re istered Professional Responsible for Construction Control
� [rme-fRegistrmryTrlrp uh nr lVu. r-maI .\ ress rgutratiun Number -
Street Address - City/Town State Lip Discipline Expiratluri Date
I0.2 General Contractor -
\ any Name• �� -
ILI %r(as CtS&
!�J.,(mr u f gr>ury(t�/ ,�Y 6 �Cu�nsctiun Pf License No. and Type i(nARplicable pi
Street Address. City/Town State - Zi
G�Z-sic- p
Tele hone 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 O No O
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated 10 :
and MConstruction Cost(::6 _$ L (�
I. Building .$
Permit Fee=TuWIn Cost x_(Insert here
2. Electrical $ appropriate mun3. Plumbing $Mechanical (HVACSe:Minimum fee-$ ntact municipality)
5. Mechanicalther) pheck payable to6. Total Cost $J -(/Inici alit )and wriber here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
Ry entering my name below, I hereby.+Iles,under the pains and penalties of perjury that all of the Information c,,nt•ilned n+Ihre
applicolum Is Irur and accurate In the be,t of mY knuwlvdge.lnd under,Lm ling.
. m-rn ('0 _� --
e nn.InJ-i n n.I'ns' e ' � Ualr
l g c �(f� rifle G'Icphonr \
`I AIAA) SOI�Oirll / , /Allr�/L at
Sunicipil Inspector to till out this section upon application approval:
\amp L:c
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
WJ 600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A Meant Information Please Print Legibly
Name(Businessss/organiea on/Individual): L._W\
3sAddress A6UCI�Q✓tlU� ��pA� — -- —
City/State/Zip e M A Q 1 M Phone#:
Are youan employer?Check the appropriate box: Type of project(required):
1I>�. 1 am a employer with�_. 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 2- ❑Remodeling
ship and have no employees - These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers comp.insurance. q. ❑Building addition
[No 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 I LEJ Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we have no 12.❑ Roof repair
insurance required.]r employees.[No workers' 13.❑Other
comp.insurance required.]
Any applicant that checks box gl must also fill out the section below slowing their workers compensation ini iry inhumation.
t Homeowners who submit this affidavit indicating they am doing all work and then hire omside canaacu ss must submit a new affidavit indicating such.
lCmoseors that chack this box must mu ched an additional sheet slowing the name.1 be sab.ausictms at their workers'camp.policy information.
lam an employer that is providing workers'compensation insurance for my employees. Beiew is the policy andjob site
information.
Insurance Contpwty Na Ar --. -- Ytt{ 1 Ca.![. i)—f c.mA CRC- __—
Policy#or Self-ins.Lic.#: .S ROB; —Vnj_06(pT Expiration Date:_.,-_L—&- /A� /q
Job Site Address: 6ir i& ____ City/State/Zip:_' GI
In/T,___
----
Attach a copy of the workers'compensation policy declaration page(showing the policy number amd expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to$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$250.00 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 nder the pains and pe, shies ofiserjury that the information provided above is true and correct.
Sianatur� �- � ,1.. Dane:,-2
Phone#:
OffWa/use only. Do not write in this area,to be completed by city or town oj)kial
City or Town:-_ Permit/License It
Issuing Authority(circle outs):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: _ Phone#:-_
• -�'^1 tip ID: JW
mac:r�rt�y
CERTIFICATE OF LIABILITY INSURANCE M
_,.D9/26111
THIS CERTIFICATE. IS ISSUED AS A MATIFR OF IN1-ORMATION ONI Y AND (ANT ERS NO RIGHTS UPON IHE CERTIFICATE HOLDER, THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSUrUTE A CONTRACT BETWEEN THE ISSUING INSURER(S). AUTHORIZED
REPRESENTATIVE OR PRODUCER,AND THE CERTIFIGAIF HOLDf:R.
IMPORTANT; H the cortrticate holder ir,an ADDITIONAL INSURED the 11,111,yl t I 11I,st be endorsed It SUBROGATION IS WAIVED subjurt to
The terms and conditions of the policy rertam police.,.nay regn I an eodorsnn.I ut A trIamrrt m on this Certificate does not confer rights to the
cort0icato holder in Her of such andomomoot(s',-,,.,.
f noourT� .. ;n inl
.MassPa Insurance Survh nY,l.l( 978-998 6896 !
127 Gerdon StreetUnit IS 978-998 6897 - "'-
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:Beverly.MA 01915
Sharlene Silas Wulleman
�:rvr,ulluf.l,. RYANSON
[:I I:�I(IMFN In II'
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Ryan&Son Roofing,h)r w:onu„f Are Amerman Insurance. Co
93 New Salem St .,IIuuI If
Wakefield,MA 01880
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.COVERAGES CERTIFICA/ENUMHEk' _ _ REVISION NUMBER _
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CERTIFICATE HOLDER - -'
CANCELLATION ......
SHOUT )ANY UP THE ABOVE DESCRIBED POI ICIES BE CANCELI-ED BEFORE
Evidence of Insurance
tI1E FXPIRAIION DATE THEREOT NOTICE WILL RE DELIVERED IN
AG:OHDANCE wflTf THE PgLICY PHOVISIgNS.
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License: CS 104865
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CLINTON GALVIN .,..
102 DELMONTAV5 APT 2
LOWELL,MA 0 8
Expiration: 711I2M4
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:��ft@ L/OIIG))1011AL1Pll[�!(Orcce of consumer Affairs&Business tAY.eJg([oc"1IUe"SEa�' .
1 X`� -HOME IMPROVEMENT CONTRACTOR
Registration: 169538 TYPO=
' Privale Corporaliot
Expiration: 7l1/2013
RYA AND SON ROOFING INC. .
.CLINTON GALVIN
-93 NEW SALEM ST:' '
�WAKEFIELD.MA 01880. ., _ Uodersecrctary
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Proposal
Ryan And Son Roofing, Inc.
93 New Salem Street, Wakefield MA 01880
www.RvanAndSonRoofing.com
Submitted To:
Henry kantorosinski
62-64 Linden st
Salem, ma
Phone#: 781-233-1851
Email: n/a
We are pleased to hereby submit this proposal to furnish materials and labor, completely in accordance with the below
Specifications:(Additional charges may applyfor any change's not included below in proposal either by request of owner,or if Ryan and Son
Roofing finds unforeseen circumstances that will affect the performance, quality or integrity of this job).In the event legal action is taken to enforce any
provision of this agreement, the prevailingparty shall be entitled to all its reasonable costs, includingreasonable in-house or outside attorney's fees.
Not responsible for debris in attic.
THIS PROPOSAL IS TO
• Strip existing shingles down to bare wood
• Check for rotted wood and replace as needed
• Nail down any loose wood
• Install ice & water shield to fast 6', which is 2-rows and in all valleys
• Install 301b felt paper to remainder of roof
• Install all new 8" white drip edge on perimeter and step flashing,where needed
• Install GAF Lifetime/30-year architectural shingles in color of your choice
• Install ridge vent and hip& ridge cap, to match
• Properly flash any protrusions and all new pipe flanges, if any on roof
Clean Up:
• Will cover area with tarps to minimize debris
• Remove debris related to work
• NOTE: Please cover any belongings in the attic, as they will get dusty, if applicable
Payment Terms made as follows: (This includes labor, dump & materials)
Total cost: (If no changes) $5400
Respectfully Submitted by: Accepted by:
All work is 1000/aguaranteed for 10-years on craftsman ' other warrantees we through the manufacturer.All warrantees will be null&void if
job is riot paid in full.Thank you for letting us some you!!!Ryan And Son Roofing,Inc.is fully licensed(#159797)&inured.ASA/
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