1 MANSELL PKWY - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board oI Building Regulations and Standards CITY
/ OF SALEM
Massachusetts State Building Code, 780 CMR, 7m edition
1 Revised Jururrrry
Building Permit Application To Construct, R "air, Renovate Or Demolish a /• '/118
)ne-or Tsvo-Fermi! Dwelling
This Sectio or Official Use Only
Building Permit Number: Date Applied:
r
Signature:
HuildingC us er/1 •tor of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
� JylaHse!(
I.l a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ P P� y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerto`R:red: yvt6zvSed P"ua+/
Name(Print) Address for Service: t
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑FEj wner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ 1 Number of Units_ I Other Specify:
Brief Description of Proposed Work'': 61—%� rimne–rW7-0
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S ❑Total Project Cost)(item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No. Che (O'
Cash Amount: ash Amount:
6.Total Project Cost: S SS� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) C5 -qq_� 0-7 -7-(3-do
6l�iGiVtG License Number Expiration Date
Y�NIti
N:uneyoof*CSL-Ilolder U
I�-O �nx 7�3� List CSL Type Isee below)
r Descri tion
Addres
U Unrestricted u to Cu.Ft.QtiJLTc 1. U(9jG R Restricted 1&2 Family Dwelling
Signaw M Masonry Only
RC Residential Rooting Covering
Telephon WS Residential Window and Siding 'r'
Li't-0 3(p- 0-7--S SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
/-ITT ire. Pyr-AOcrta
HIC Company Name or ffIC RegisirafitName Registration Number
Address G
?76'UR7-<R76 Expiration Date
Signature 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
), / - as Owner of the subject property hereby
authorize CYofMA l�lb,un/ M(Divto in met iAee to act on my behalf, in all matters
relative to work authorized by this building permit applicPation.
Simnaturc of Owner = Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I
f, �p�A,vl � li1u0 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
C��t��o
Print Name
Signature of Owner or Authorized Agent Date
(Sibined under the pains and penalties of 'u
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 ffpl have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 10.116 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,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 S:U.EN1, NLXSSACHUSETTS
.� 3UUMING D E P.*,RT.%LEIN T
• 130 WASHIINGTON STREET, 3w FLOOR
TFI_ (978) 745-9595
FAx(978) 7.10-98.16
fC1JBFRt _yDRISCOII. THOhIASST.PtFIME
MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDIING CO>WISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r licant Information Please Print Le ibl
VJttle IOusiixss.OrganiratiorylnJividuaq: `� S
Address:
City/Statc/Zip: � ���1!Vu/i3i3 Phone k:
Are you an employer?Check the appropriate�b�: Type of project(required):
1.❑ 1 am a employer with 4. (✓1 1 am a general contractor and 1 6. ❑New construction
part-time)."and
enc to ees /or art-time).• have hired the sub-contractors
P Y ( listed on the attached sheet.t 7. ❑ Remodeling
2.❑ 1 ship
a sole have
no proprietor or partner-
ship and have no employees Thou 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 l0 ❑ Electrical repairs or additions
officers have exercised their
required.)ahri right of exemption r MGL I I.❑ Plu mg repairs or additions
},❑ i ys a,(N homeowner doing all work c bl 52,91(4),and we have no 12. oof repairs
myself,(No workers comp.
insurance required.]t employees. [No workers' 13.0 Other
comp. insurance required.]
-Any applicant Jut ducks box MI must ols„fill tut the seclioo blow,showing ibeir wmken'compensation policy inhumation.
t 11,"cownen who submit this aRldsvit indicating ihey ate doing all work and thea hire outride contremors must submit anew a?•davit indicating ruck
:c,mrncloo thol check chis boa mut anached an adt itiumd sheet showing the name of the subcontractorsand their workers'wrap.puliry information.
I um on employer that/s providing workers'compen radon insurance for my employees. Below Is the policy and fob site
information.
Insurance Company Name: ' I U.YG�� C1"`SV+a'^•`c 2 (�
Policy il or Self-ins. Lic.N:,q� (.J GO/�)0 >7 lq O_7 Expiration Date:
Job Site Address: / 19---kelt Pe/*n!E!4 City/State/Zip: -S4te&a,
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
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 51,500.00 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 Jay against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DI r insur cc coverage verification.
I do Itereby certify and the i s and penalties of perfary lirat the information provided above is true and correct.
s. . 1 nnrc 9, r} 0
P t J.
Official use only. no not write in shin area,to be completed by city or town officiaL
i
City or Tusvn• ___- . . PcrmlVf.lccnse q _.__. .._ .--
Issuing Authorily(circle ane):
1. Board of Ilealih 2. Building Department 3.Cilyiruwn Clerk J. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact i'erson: _ .. - -_._ ... Phone to:
(
Information and Instructions
Massachusetts Gcneral Laws chapter I52 requires all employers to provide workers' cumpemation tiu their employees.
Pursuant to this mmura, an em lures is dclimed as"...every erson in the service of another under an contract of hire,
P P Y
cypress or implied, oral or written."
An employer m defined as"an individual, partnership,association,corporation or tither legal cnnty, or any two or more
,,n the toregu;ng engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee ul .am Individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenunce,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
\IGL chapter 152. §25C(6) also states that "every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant wlio has not produced acceptable evidence of compliance with the Insurance coverage required." -
Additionally, hIGL chapter 152, a25C(7)states"Neither the commonwealth not any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance withtheinsurance
- requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary,supply sub-contractors) namc(s),addresses)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
.-accidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line. -
City or'rown Ofttciais
Please he sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom
Of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pl.ase be sure to fill in the pennit/license number which will be used is a reference number. In addition,an applicant
that must submit multiple penniti'lieense applications in any given year,need only submit one affidavit indicating current
Policy information of necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future Permits or licenses. A new affidavit niust be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I It,; 01 lice of Investigations would like to thank you in advance for your cooperation and should you have;rny questions,
Please du nut hesitate to give us a call.
The Deparnncnt's address, telephone and fax number:
The Commonwealth of Massachusetts a
Department of Industrial Accidents
OIBce of Investisadons
600 Washington Street
Boston, MA 021 l 1
Tel. N 617-727-4900 ext 406 or 1-877-MASSAFE
Fax Al 617-727-7749
www.mass.gov/dia
r� -
� � CERTIFICATE OF LIABILITY INSURANCE
RODDOER (617)471-122D FAX: (617)479-5147 THIS CER-nFicATE IS ISSUED AS A MATTER-OF•INFOWWITION
ONLY AND CONFERS NO RIGHTS UPON: THE 'CERTIFICATE
mitty Insurance Agency, Inc. HOLDER. THIS CERTIFICATE DOES NOT"AREND.'•Ex-MD OR
f 0 D Victory Rd. ALTER THE COVERAGE AFFORDED BY.'THE..P.OUCIES BELOW-
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roti ch Quincy MA 02171 INSURERS AFFORDING COVERAGE MAIC 6
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?.O. Box 365wsuRER C:GreatAmerican_Insurance
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Copsfie d MA 01983 INSURER E:
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ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CEXTI(•TL^ATE MAY BE TSSLIEU OR
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POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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Job#:
Roofing—Siding-Painting Office:978-887-5870
239 Boston Street—Topsfjeld,MA 01983 Fax: 978-887-5875
Jane Cruz
1 Mansell Parkway
Salem,MA 01970
(978)808-1091
Email: nancy@nancyyorgy.com
Dear June, November 1,2010
The following estimate is for the roof installation for the property located at the above address.The following paragraphs describe the work that
will be performed. GAF-Elk Corporation Weather Stopper System Plus Limited Warranty offers you a full coverage warranty on defective
shingles—to be obtained directly from the manufacturer(see enclosed brochure).
Installation Procedure
• Strip existing roof on the entire house down to the roof deck
• Install an 8 inch drip edge on all leading edges(rakes&fascia)
• Install ice&water on all leading edges&valleys
• Transitional walls are optional and incur an additional cost for the siding repair
• Install new vent pipe flanges
• Replace any rotten or damaged decking(we allow 32SF @ no charge,$80.00/sheet thereafter)
• Replace any rotten or damaged ledger board(we allow 30ft.at no charge,$3.00/ft.thereafter)
• Install 15 pound felt paper on all areas that is not covered by ice&water shield
• Install new GAF 30-yr Architectural shingles
• Install new ridge vent system
Additional Soecdhcudons
• Homeowner to choose color of shingles COLOR:
• Our dumpsters are sent to a recycling facility;therefore no additional trash may be placed in them. The transfer station will charge us
a fee for additional trash which will be passed on to the homeowner.
• Chimney re-pointing and re-leading is not part of the roofing contract and will be quoted separately.
• Transition walls are an option,and if the existing flashing is in good shape,usually do not require replacement
• During a roof job,the nails could break the sheathing during the nailing of the shingles
• We are not responsible for any of the cracks that may arise in any walls or ceilings
• Please cover all your floors in your attic to protect from dust and debris
• We will remove all of the job related debris
• Permit costs vary from town to town and are not included in this bid
Initial the options you are choosine below:
Cost for Labor&Material for Roof(Main House): $4,500.00
Cost for Labor&Material for Roof(Rear Porch Roof): $ 795.00
Cost for GAF-Elle Weather Stopper System Plus Ltd.Warranty: $ 250.00
Payment Terms:
1/3 deposit due upon signing contract: $
1/3 payment due upon start of job: $
1/3 payment due upon completion of job: $
Total Amount Agreed To Be Paid: $
Remit to. Alpine Property Services Inc.-P.O.Bas 365,Topsfreld,AM 01983
The following schedule will be adhered to unless circumstances beyond Turnpike's control arise:
Work Scheduled to Begin:_TBD Expected Date of Completion:_TBD
Warranty: Alpine property Se ices Inc.guarantees all work performed for a period of one year. If any problems occur we will cover the cost of
all labor and material to corre a problem and meet the customer's satisfaction.
ZVI
Dave Loehr,Operations Manager June Cruz
Alpine Property Services Inc. Homeowner
CITY OF SALEM, UxSSACHUSE17S
• BUIMIING DEPARTMEINT
130 WA.4HLNGTON STREET, 3� Rom
\ TEL (978) 745-9595
PAX(978) 740-9846
KIJiBERi.EY DRISCOLL
MAYOR THo>`tAc ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUMDING CONWIS5IONER
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:
a�—
(name of hauler)
The debris will be disposed of in :
y! ✓tu
(name of facility)
(address of facility)
sign;r of permit applicant
Sate
drbriv:Ldx