21 MARION RD- B-11-62 ROOF /
rr The Commonwealth of Massachusetts
1'. I•-1 "1!' Department of Public Safety
SI-,ss•ichuwtts State Budding Code 4, CS1R)4eenth Edition
City of Salem
Buildins Permit Application for any Building other than a I-or 2-Family Dwelling
�\ (This Section For Official Use Only)
Budding Permit Number: Date Applied: Building Inspector:
SECTION 1:LOCATION tPlease indica a Block 0 and Lot 0 for locations for which a street address is not available)
C91 ai-T n S - "s2leLa MeL !72) Picy6ma nj2KOrd
No.and Street City /Town Zip Code Name of Build g(it applicable)
SECTION 2:PROPOSED WORK
If New Construction check here O or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use O Changeuf Occupancy ❑ Other ❑ Specify:
Are building pla ns and/ur construction documents being supplied as part of this permit application? Yes ❑ No Et--
Is an Independent Structural Engineerii Peer Retvsiew r a)ui red'y� / ` Yes O No 0—
B((/�'of Description of Proposed Work: P"'11�CXrJ ��' Afoxi 6-T 'e06/ -���tlz �-q /�
✓a,f O4&.,&*W � S -ea .4.n9 E -*e c,< /ru/
TA T J
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 Group(s): Proposed Use Group(s): Y
Existing Haurd Index 780 CMR 34: Proposed Haurd 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(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc O A-3 ❑ A4 O A-5 O 1 B: Business O E. Educational ❑
-1OF2❑ -t❑ -2O -3 O -5❑F: Facto F 4
1: Institutional I-1 ❑ I-2❑ 1-?❑ I-1❑ M: Mercantile❑ R: Residential It 11 R-2❑ R-3❑ R-4❑
S: Storage S-1 O S-2 ❑ U: Utility❑ Special Use O and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA ❑ Ill ❑ IIA ❑ [ISO MA O IIIB.O 1 IV O 1 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❑ C hark d outside Fb�ai Lone❑ Indicate municipal❑ A trench will not be Licenseai Di,po.sil Site❑
required❑or trench or.pectfc:
Ili tratc❑ or unicnulc Zone;_ or on.dr sc.trm ❑ permit is cnclo.ed❑ _
Railroad right-of-way: Hazards to Air.Navigation: \IA ni-4•ri, t ..nuns-t,m 14.,�,„ Pn•,,
\ot .\lphcable O 1.?t nicnov„nhu,airport appo,ach area' I.their re, e,c onnl•IctoaC
I to 1411111 endo.a•d ❑ l r,❑ or.\o❑ 1'a•,❑ \o ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
L•buon I t'oJe L,,l.rouF,i.c r,reot Construction: Occupant Load i•cr I loor
I>'•e� the bwlJu,a;contain an�pnnAlrr>,.Icm': �fk•nal?upulauom
• SECTION 9: PROPERTY OWNER AUTHORIZATION
t�.m of Property
; nVanp p - al MariDn l�� 9�0 Name(Pnnf) No.and Street City/Town Lip
Propert%t vnec(;antactI 7umalion:
nlr J Telephone No.(business) Telephone No. (cell) a-mad addre s
If.1ipplicable, the property owner hereby authorizes
J:
Name Street Address City/Town State Zip
to act on the pro+rote.rev ner's behalf, in all matters relative to work aulhonzed by this building permit a + liauion.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
(If building is lass than,ii3OW cu.ft,of.vu'ksad s wn and/ur nart wrier Construction Control then cheek here O and kip S,,ctiun 10.1)
10.11telgistered Professional Responsible for Construction Control
Q-
110bom fflaoQ,,oj,!7 3' b - by�d IygaftCavv1 `h /� 335(0
NIrQt (Re bislra t TrlrFne,rjq. l e-mail address ) Registration Number
-zD
Street Address City/Town State Zip Discipline Expiration Date
10.2 General C tractor
U(4r
u ti Name:
r SIN �G✓14 )� S 0�5 9�S - l call
Namee LtI Person Resl�m,7lble for n't tiun /' Li rise No. and Type if Ap licable
Ull / r fASTrC1/� �y�Y�rI
Street Address p���/ p� City/Town /1 Sta e
b'� •, - S, �D 7��-1LZ1- ��SL� 1A11A.)/
Telephone No.(business) Telephone No.(cell) e-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 2SC(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:CONSTRUCITON COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) I Total Construction Cost(from Item 6)=S
1. Building Is 00, 59,3 019 1 Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical I $ I appropriate municipal factor)=$
3.Plumbing S
4. Mechanical (HVAC) S Note:Minimum fee=S (contact municipality)
5. Mechanical (Other) S
Enchlse check payable to
6.Total Cost S,:)0.�T 3, QD (contact munici alit )and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,I herebv attest under the pains and penalties of perjury that all of the inRII)a
application is true and accurate to the best of my knowledge and understanding.
19eo.e pant .cod sign nome ride To
tits cf .lddre" C itv;Totyn Ftatr
Municipal Inspector to fill out this section upon application approval:
13 rd ii B I j i d n lz(
License: CS 759B5
Resific'edtu 00
WILLIAM A MANGIASI
13 GIBSON CIRCLE
MEDFORD, MA 02155
Ey,.Pcaiijn: 7117J2011
T 18110
9 ,
14
1' 0 Ll 4�1d-
�B oa "If di J Reg�]I h-S, an' tal I-d a S
One Ashburton Place - Room 1301
Boston. Massachusetts 02108
Home Improvement Contractor Registratioll
Registration: 123356
Type: Private Corporation
Expiration: 2/4/2011 Tris 279458
WJN CONSTRUCTION CORP.
WILLIAM MANGIASI
407 REAR MYSTIC AVE. UNIT 36A ---------
MEDFORD, MA 02155
Update Addr6ss and return card. Mark reason for change.
Address ❑ Employment .—i, Lost Card
Renewal F
ACOR E(MMB)DNYYYI
' PRODUCER D- CERTIFICATE OF LIABILITY INSURANCE �„ oc
5 25 1D -THIS CERTIFICATE IS ISSUED AS A MA TION'SBlgreve hHall Insur.Assoc.Inc ONLY AND CONFERS NO RIGHTS UPON E305 North HOLDER.THIS CERTIFICATE DOES NOT OR
Mafia St. ALTER THE COVERAGE AFFORDED BY LOW.
Andover MA 01810Phone: 978-975-1300 Fax:978-975-7596INSURERS AFFORDING COVERAGEAIC#
INSURER A: Acneu emceccien ma. ro. 41360
W.7N Construction Corp INSURER B:
Thor Construction INSURERC:
407 Rear Mystic Ave #36A
Medford MA 021SS INSURER D:
INSURER E:
COVERAGES _
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTA DING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATEMAY BE ISSUED O
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,HIS CERIONS AND CONDITIONS ISSUED
OF OF CH
POLICIES,AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR HEIR TYPE OF INSURANCE POLICY NUMBER DATE MID PATE YMIDD - LIYIT9
GENERAL LIABILITY
EACH OCCURRENCE s1000000
A X COMMERCIAL GENERAL LIABILITY 8500036963 05/21/10 05/21/11 PREMISES Eeo airence $300000
CLAIMS MADE O OCCUR I MED EXP(My o e pesos) $ 5 00 0
' PERSONALSAO INJURY $1000000
'GA
GEML AGGREGATE LIMIT APPLIES PER: GENERAL AGG TE $2000000
POLICY PRO- Loc PRODUCTS-CO /oa AGO $2000000
JECTAUTOMOBILE LIABILITY -
ANY AUTO COMBINED SING ELIMIT '$(Ea a ,I,,nl) ,
ALL OW NED AUTOS
E
SCHEDULED AUTOS BODILY INJURY(Per person)
HIREDAUTOS
NON BODILY INJURY _ E
AWNED AUTOS (Per a�deM)
PROPERTY DAM GE E
(Per awdw*
GARAGE LIABILITY -
ANYAUTO AUTO ONLY-.EA kCCIDENT'. $
OTHER THAN EA ACC S
AUTO ONLY: qGG $
EXCESSNMBRELLA LIABILITY
EACH OCCURRE ICE - 3
OCCUR CLAIMS MADE AGGREGATE $
' DEDUCTIBLE
3
RETENTION 3
WORKERS COMPENSATION AND $
_
A EMPlOYERS'LIA8ILRY. - - - TORY LIMITS ER '
ANY PROPRIETOWPARTNEWEXECUTIVE 910389 01/01/10 01/01/11 EA.EACHACCIDNT 6500000
OFRCEWMEMBER EXCLUDED?
N yea,d.0p ender E.L.DISEASE- EMPLOYE S500000
SPECIAL PROVISIONS p Ib
EL:DISEASE-_- CY LIMIT $5 00000
OTHER. .
DESCRIPTION OF OPERATIONS/LOCATIONS/VEHICLESlEXCWSIONS AOpED BY ENDORSEMENT I SPECIAL PROVISIONS
I
CERTIFICATE HOLDER CANCELLATION -
XXXXXXX SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE kNQELLED BEFORE THE EXPIRATION
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL _DAYS WRITTEN
- NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE ,BUT FAILURE TO DO SO SHALL
IMPOSE NO OBLIGATION OR LUIBILT'OF ANY NIN U THE INSURER,ITS AGENTS OR
- REPRESENTATIVES. ''
AUTHORMED REPRESENTATIVE .
Lawrence J. Hall
ACORD 25(2001/O5) ®kCORD CORPORATION 1288
I
r
40'(
I a Unit
Yv-ar3611 f*1ystic �IvlcnuQ eont C d 41 �� / r
Z.lrlll J6`�l
M vdford, Mlqq. 02155
«w�•. x�e�„�ov .ems y �,. 781-396-5420 (Fax)781-396-5450
We Are: IgLicensed ®Insured Wa tory Trained INFactory Certified Installers
Proposal Submitted To: Phone#'s
Date: 05/11/2010 H: W:
Street: 2t Marion Street Job Name Pickman Park Condo
City,State,Zip Code Salem, Mo. 01970 Job Location --
Proposal to furnish and install the following
❑ New Roof/Strip Off Entire Building
Complete Roof Preparations—Services provided to help you avoid hassles and to protect your home
❑ Home exterior to be protected by tarps and plywood
❑ Shrubs, landscaping,trees to be protected from damage
❑ Entire existing roofing material to be removed to existing decking.
❑ Site to be cleaned everyday, debris removed at project completion
❑ Deteriorated existing decking replaced at a cost of:$4.50 Per Lineal.Ft.
❑ 8"Metal drip edge installed at eaves ❑ 8" Metal drip edge installed at rake edges
❑ New lead step flashing will be installed around chimney base
❑ New plumbing vent flashing will be installed and flashed
❑ Shingle valleys will be installed
❑ Contractor will pick up building permit
❑ 6' lee and Water shield installed at all eaves to protect from ice dams(and meet codes in the north)
-Provides the best protection for your home
❑ 3' Ice and Water shield installed in all valleys, around penetrations, and chimneys to protect critical areas
-Protects the most vulnerable areas on the roof
❑ GAF Shingle-Mate®reinforced underlayment installed over entire decking(the best underlayment available)
-Serves as a second line of defense
❑ GAF Ridge Vent System will be installed
-Ensures that your roof system will last,your utility bills will be lower,and your warranty will be valid
❑ Clean up and cart away all debris.
Quality Shingles
❑ GAF Timberline Series ❑ 30 year$13,650.00
Color_ _ Other Shingle
GAF Hip and Ridge that matches shingle warranty will be installed
Warranty:
❑ Roof to carry manufacturers (30) year limited standard warranty and
Thor's (2) year labor warranty.
Total Contract Price: $20,593.00
With payment to be made as follows: 5% Deposit/ 1/3 Start of Work/ 1/3 Midway Thru / 1/3 Completion
Date of Acceptance: �/d l 1 ) Contractor: Thor Construction Company
Prope `v Owner S' na are:
�� / k) .
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:. MU;KI IO•Dn1iCU1.1.
Div,t'n 12G W Asbtl wro:`S rn euT • SALl;M,MAsi.va tt'ib'1'I i G197C.
Tta.:978-743-9595 tr has: 978-740.9.146
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
\nnlicant Information �( Please Print Leeihly
Nametl3ustoes/OrBaniz /ation/Individual): Wli— e _/on STMa/ilm 61or".
Address: yo 7 �?p
CityiStstei/..ip: ��1f27 -Iola Phone i.'-: R/—396— tf1�4d
.tire you an employer?Check the appropriate box: "Type of project(required):
I.❑ I 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 7. ❑ Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. t
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition
To workers' con insurance 5. VWe are a corporation and its
I P• 10.❑ Electrical repairs or additions
required-] � officers have esercixed their _
3.❑ 1 ant a homeowner doing all work right of exemption per MGL 1 LE] Plumbing repairs or additions
myself. [No workers' comp, c. 152, ¢1(4.),and we have no 12.[�Ruof repairs
insurance required.] t employees. [No workers' 13.❑ Other
comp. insurance required.]
-Ally.applicant nut chucks box 01 must also lilt out the kclion below showing their workers'compensation policy inlivmutiun.
' Ilomaiwmns who submit this mYdavit indicating they are doing all work and then hire outside commeron must submit a new affidavit indiuding such.
-Conlralaur%that chuck this box must attached an additional Acel showing the name of the sub-contractors and their workers'comp.policy information.
1 nor urn eanplpyer t/tat is providing workers'contpetrsntion insuraaee for tiny employees. Behov is the policy and job site
innforinutiom
Insurance Company Name:_�1
Policy d ur Self-its. Lic. t%: r/ ___._ .. .. _... __ Expiration Date: j/ �'J
Job Site Address: t?/ mil-0A �� Cityistuteizip: S%�2ih /�y///7 0/
Attach it copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
hailure to secure coverage as required under Section 25A uf:vlGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500A0 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. 13e advised that a copy of this slulcment may be turwarded to the Office of
Invcsli.,aliulls of the DIA for insurance coverage ccritication.
I du her cerlijy under the pains and penalties of perjury that the information provided above is/rite and correct.
Sig ,tot t "9120
Datt: aoi0I I, t i 7rF/-
Ofjicial use oily. Do nor write in this area,to he cumpleled by city or town ojjic•iaL.
City or Town: Permit/Licensed___-- -
Issuing Aullturily(circle one):
1. Board of llealth 2. Building Department 3. Cilylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Tenon: _......- _ _ . _ -_--_ Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an empluree 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
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of 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."
MGL 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 who has not produced.acceptable,evidence of compliance with the insurance coverage required."
.additionally, &lGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill 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 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 date 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;tad 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 till in the permit/license number which will be used as a reference' number. 4n addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(ifnecessary)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 ciiy 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 must be tilled 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 burn leaves etc.)said person is NOT required to complete this affidavit.
I'hc ODice tit Investigations would like to thank you in advance for your cooperation and should you liave any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents `
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 5-26-05 www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
d INS IIQ IT # SA I I M. \h"At ;I! <i I
Construction Debris Disposal Affidavit
(requited fior all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CN1R 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 he disposed of a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hinder)
The debris will be disposed of in
(none w lacility)
(�411 er-e�
(address W facility)
UViVAz i
siputuleof ImIllit ;1131)11 t
AW/0
JUL-19-2010 10:43 FROM:SHEFFIELD HEIGHTS 7812312363 TO: 19787409846 P.1/1
American Properties Team, Inc.
TO. Salem Building Inspector
FROM: Jennifer Pappas, Property Manager
RE: Roof Rcplaccmcnt - 21 Marion Road
DATE: July 19, 2010
Please be advised that the Board of Trustees for Pickman Park have approved a roof
replacement project at 21 Marion Road. This work will be completed by Thor Roofing
& Construction,
Should you have any questions or require additional information, please feel free to call
me directly at (781)932-9229 x675.
600 WEST CUMMINGS PARK-6UI7E 6080, WOBURN •MA -01801,781-B82-022B -FAX 791,0354280