36 MARGIN ST - BUILDING INSPECTION The Commonwealth of Massachusetts
r� Board of Building Regulations and Standards Town of
Massachusetts State Building Code, 780 CMR, 7ih edition Wilbraham
Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a 413-596-2800
One- or Two-Family Dwelling 1 Ext 118
(� This Section For Official Use Only
v^� Building Permit Number: Date Applied: i t
xM\l� Signature: I "q ` U y
Building Commission / nspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Addf ♦ ` 1.2 Assessors Map& Parcel Numbers
I.1a Is this an accepted street?yes----I no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensians.
Zoning District Proposed Use Lot Area(sq fit) Frontage(fit)
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? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Ownerr�o�R`ord: t / \
Name(Print) `� Address for Service: ,
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building' Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ S jiS Co 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ a !/ -
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $ -
^n Check No. Check Amount: Cash Amount:
6. Total Project Cost: $�r),Ay 'wo ❑Paid in Full ❑Outstanding Balance Due:
l.,cr
T3 7
5V
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
� � ��`�� ��„��^ License Number Expiration ate
Name of CSL- Holder
S ` �a`� List CSL Type(sec below)
Address —y�j /J Type Description
Cu. t
U Unrestricted(u [0 35,000 .Ft.
R Restricted t&2 Family Dwelling
Signature , M Masonry Only
RC Residential Roofing Covering
'i elephone WS Residential Window and Siding _
SF Residential SoLd Fuel Burning Appliance Installation
�U Residential Demolition
5.2 Re-istcred Home -tpruvement Contractor(HIC)
I H!C7 Cum,^.any Name nr HIC Registrant dame Registration Number
F.zpon Date
I Signature Tele;`h-one '
SECTION 6: W^.K:'.2S'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) -
Norke:s Corno-nsation Insurance affidavit must be completed and submimA with this application. Failure to provide
thi,affidavit will result in the denial of the issuance of the building permit. - -
Siened Affidavit Attached? Y- s .......... No...... . . ❑ --
r 1_.':TI0N 7a: OWNER AUTH[OkAZATiON TO BE CO1ViPLETEO'4—'IHN
I
OLY1Eu5 _ — �
AGENT OR CONTRACTOR APPLIES FOR BUILDING PERR'ii'.
I,_ �.��� as Owner of the subject property hereby
authorizF.._.W W,o�-eel �( —4-Cr�� _—_ to act on my behalf, in ail ma[[_rs
•.lap,-c to work authorized by this building permit a,:mlication. �
/Zo I t o F�
tiienatareofOwner =i/ _ _— _ — Date
SECTION?h: OWNER' OR AUTHORIZED AGENT DECLARATION
u r�����rv�.� ,as Owner or Authorized Agent hereby declare
that the statement:.and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. S
N. '^� _---
Print Name --__`— �D ' Jai
Signature of Owner nr Authorized Agent Date
(Signed under the pains and penalties of per LTyl
_ NOTES:
I. An Owner who obtains a building permit to do hisrh-r own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor HHQ Program),wil: not have access to the arbitration
program or guaranty fund under M.G.C. c. 142A. Other important information on the HIC Program and
Construction Super:isor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5, 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"
1 Shea Roofing Co.
Salem, MA 01970
(978) 745-7313
PROPOSAL July 2,2008
SUBMITTED TO: Steves Quality market
36 Margin Street
Salem, Ma.
We hereby submit specifications and estimates for:
To broom and remove loose gravel from top of roof surface area.
To mechanically install all new tapered insulation board to help to
increase roof pitch and drainage , using three inch plates and screws with
a minimum of twelve plates per U8 board.
To install new .060 EPDM rubber roofing membrane fully adhered
covering complete main roof running field sheets up all parapet walls and
into new rear gutter.
To install new wood nailer along rear roof edge.
To flash all vent pipe stacks and all other roof penetrations to
manufacturer's specifications.
To remove and board up both skylights.
To install new U4 pressure treated sleepers under both remaining
HVAC units.
To install new heavy metal drip edge trim along roof edge
To install new aluminum gutter.
To pick up and remove all roofing debris from job site.
All work is fully guaranteed for ten years from time of completion.
We propose hereby to furnish material and labor-complete in accordance with above specifications,for the sum of:
Twenty Two Thousand Five Hundred and Eighty Five----dollars ($22,585.00)
Payment to be made as follows:
Seven thousand ($7000.00)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 otter necessary insurance.
Our workers are fully covered by Workman's Compensation Insurance.
Acceptance of Proposal-You are aLtho ed to do the work as specified.
Authorized Signature: ' �-
Signature:
Date of Acceptance: 'U
CITY OF SALEM
4� PUBLIC PROPRERTY
it Ali
DEPARTMENT
s.
.I\III:K:I'1 U9li(:0I l
fK W„vlaNw,t�$7:< ,L r • Snui.t,M.tss.v(ati ir:i is 0197,^,
Tlr.t.,978-7$59595 • il.tx. 978.7410-1846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Please Print Lee ibly
\ ) Beane Infortnrtion
N a fnt: l Ou<incsvt)rganiratinN I redly idual):
1tltlross:
S Phone 0-
City;St:ut:;7ip'� I —
:\re you an employer:' C •ck the appropriate box:
'rype of project(required):
i 4. ❑ i am a general contractor and 1 fl. ❑ New construction
I S�1 ;tin a employer with r have hired the sub-contractors
cntpioyccs(full and/or part-time). 7. ❑ Remodeling
2.❑ 1 :tin a sole proprietor or partner- lilted on the attached sheet.
ship:unl have no empluyws These sub-contractors have K. ❑ Demolition
workers' comp. insurance. 9, Building addition
working for me in any capacity. 5. We are a corporation and its
lNo workers' comp. insurance 1 officers have exercised their CI Electrical repairs or additions
required.] I 1. plumbing repairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MGL ❑ 6 ,p.
c. 152, 91(4),and we have no 12.❑ Roof rcpaits
myself e r workers' cuntp. m to ccs No workers'
insurance required.) t � P Y"�� i � 13.0 Other
comp. insurance required.]
-:gym:,ppheanr taint dicks box OI inust ako III.... Ihl'4UIO1,IN:IOW showing,heir wurkets'cumpensalion pulley mfor rwtiun.
r I lomcuwnen who submit this affidavit indicating they am doing all work ana then hire outside colliroclun muss submit a new al'"avit indicting slmh.
-( t x that 9 k this box must aaaehsd an addilimaI hswt huwi Ig n name
e of the rs subcontracto and lhelr workers'comp.policy mfurmadon
I .
I run all employer that is providing workers'culrrpensntt«lr ur.carnnce jar my eutplo)ecs. Below is the pulray and job site
injonnali«m
I r.,uranu Company Name: -
\� Expiration,Date:
Policy S or Self-ins. Lie. P:
City;Statei"Lip:�
Job Site Address:
Attach it copy of the workers:ctitnpeusation policy declaration pale(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of}1GL c. 152 can lead to the imposition of criminal penalties of a
tins up to 51.500.00 and/or one-year imprisonment, as %icll as civil penalties in the form of a STOP WORK ORDER and a fine
of up u) S230.00 it day igalost the violator. lie advised that a copy of this ilatctnent Inay be lorw arded to the Office UI
Invran,aonas oil the DIA or instlraecc coscra�e ,crilica0un.
l du hereby crrlijp under th pair mid prnl rrprry that the information provided abate is true and correct.
I'ho il:e 6
9 7 t-3-� D J __71
O[Jicial use ordy, no not write in this area, to be cuurpleted by city or town O ficiaL
Permit/l.ievnsc#_ .. _.
Citv or Town: -
issuing:\ulhority (circle one):
1. hoard of health 2. Building Department 3. Cilyi fown Clerk 4. Electrical Inspector 5. Plumbing Inspector
G. Olher _ --- -
Phone H:
Contact Pcrsoa: --
Information and Instructions
,Massachusetts Gencral Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire,
express or implied, oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more
,if the t0regoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee ul an 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 maintenance,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."
'1GL 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 wbo has not produced acceptable evidence of compliance with the insurance coverage required."
.additionally, bIGL chapter 132, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfornwnce ut'public work until acceptable evidence of compliance with the insurance
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-contractor(s) name(s), address(es)and phone number(s)along with their certificates)of -
insw ance. 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
-be 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 Town Officials
Please be Sure that the affidavit is complete and printed legibly. The Department has provided a 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.
Please be sure to fill in ihe.permit/license number which will be used as a reference number. In addition, an applicant
that must submit multiple permitiliceace applications in any given year, need only submit one:tffidavi[ indicating current
policy information(if 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 die city or town may be provided to the
applicant as proof that valid affidavit is on file for future permits or licenses. A new affidavit must 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he (Mule of Investigations %%ould like to thank you in advance fur your cooperation aril should you have:my questions,
please do nut hesitate to give us a call -
fhe.D,:parnnett's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Offlce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
X.�i,ed 5-26-05 Fax # 617-727-7749
www.mass.gov/dia
1 : �
CITY OF SALEM
PUBLIC PROPRERTY
DEPART' ,TENT
12 II /-5 '1.. :' :
Construction Debris Disposal Allidavit
(required li)r all denwlilion :Ind renovation \\'ork)
In accordance \\ill, the sixth edition of the Slate Building Code, 750 C NIR section I 11 .5
Debris, .Ind the provisions of AGL c 40, S 54;
Building Permit if is issued with the condition that the debris resulting from
this work sh:Ill he disposed of in a properly licensed waste disposal lacility as defined by vIGL c
111, S 150A.
The debris will be transported by:
1 name (1l hurler)
he debris will be disposed of in
Inalnr ul Iauluy���J�� .
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