190 MARLBOROUGH RD - BUILDING INSPECTION 2--- ZoZ(
r
". vo-Family
mmonwealth of Massachusetts nSPECTIONAL SERVICES
uilding Regulations and Standards CITY OF
tts State Buildin Code, 780 CMR r�g 1BI6 APR —b �rir�,�3h}Izai
n To Construct, Repair, Renovate Or Demolish d-or Tivo-Family Dwelling
his Section For Ofricial Use Onl
Building Permit Number ' Data ApOlti&
Building Official(Print Name) , Srgnaturo
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1 e r rou �t�
FIIs this an accepted street yyes no Map Number Parcel Number
Zoning Information: I.d Property Dimensions:
g District .^ > Proposed Use - LotArea(sgfl) Frontage(11)
Building Setbacks
Front Yonl Side Yards - Rear Yard' .
equired 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? Mmicipal On site disposal system ❑
Check if es❑
SECT[ON2: PROPBRTyOWNMill ! <
2.1 Ownert of Record: ii U4 . Uti tl Vl / l� lll t J
. P�f Ictn 13oehPS 186-190 V7url�uw�tti �� R �`1
�me(Print) City,SS am,ZIP I _
� R-ezzr1 Qr)- 7 �ria�,b�c�oSC�S(maf� <Bwi
No.and Street Telephone Email AddruSs
SECTION 3:DESCRIPTION OF PROPOSED 1YORW(check all that apply)`
E
ew Construction❑ Existing Building❑ Otvner-Occupied ❑ Repairs(s) ❑ Alteration(s) O Addition ❑emolition. Id. Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
Tzetvn pu-Se
SECTION 4:ESTIMATED CONSTRUCTION COSTS
ltcmQS1
Estimated Costs: Ofilc)al Use Only
abor and Materials)
I. Building t,8 I: Building Permit Fee:$ - Indicate.how fee is determined:
❑Standard City/Town Application Fee
2. Electrical ❑Total Project Cost?(Item 6)x multiplier x
J.Plumbing $ 2?QtherFees: $ /�,�'
4. Xlechanical (HVAC) $ List: ry
5.Mechanical (Fire Y Total All Fees:$
Su ression)
Check No._Check Amount: Cash Amount:
6.Tutal Project Cost: S bV0 d ❑Paid in Full ❑Outstanding Balance Due:
t l 2 CorJt 'TZ r �,v
SECTIONS: CONSTRUCTION SERVICES
y
5.1 Construction Supervisor License(CSL) 04551) 2 1
3 ,r� n � �
c, V, P-SS, 4p5 License Number Ec irati n Uate
Nome of CSL Holder
�,��1 List CSL Type(see below)
n
01 /C'Q,2oya "� Type. - Description .,
No. td Sueet
�( U Unrestricted(Buildings up to 35,000 cu. tl.
R Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonry
RC Roollne Coverin
WS WindowandSidin
SF Solid Fuel Burning Appliances
11� OSZy 16� b(1G)3 I I Insulation
Telephone Enuil:uldress D Demolition
5.2 Registered H omoImprovement
m rovementContractor(HIC) Z-ZI 1{
Qoyr60Je5 t601 (00 1tvtQ �C�'�S�YU t a [lie Registration Number Expiration Date
file Company Name or IIIC Registrant Name
No.and Street Email address
City/Town, State ZIP Tel e hone
SECTION 6:WORKERS$.COMPENSATION INSURANCE AFFIDAVIT(M.G?L 152.§ 2$C(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..........O No...........❑
SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED W HEN'
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
1cty) i �cl�e5 Y )C
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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 know edge and understanding.
1& 1gn -&de5 634A4� j L_ y Y ) b
Print Owner's or Authorized Agent's Name(Electronic Signature) I Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
___knot registered in the Home Improvement Contractor(HIC) Program);will n have access to the arbitration
program or guaranty fund under NI.G.L.c. I J2A.Other important information on the HIC-Progrann can be totinn it
,eww mass eov'oca Information on the Construction Supervisor License can be found at AAAm as� .
2. When substantial work is planned,provide the information below:
'rota) floor 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
TYpeofcoolingsystcm Enclosed Open
1. "Total Project Square Footage'may be substituted roc,rued Project Cost"
The Commonwealth ofMassaehusetts
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,AM 02114-2017
www massgov/dia
wivorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FRED WITH THE PERNnTnNG AUTHORITY.
A licant Information Please Print Le b
lv
Name(Business/orrg�amzallon/Individual): I C1M P
Address: �5 1�`� -Tzi1q (QlJ p t,
City/State/Zip:`Seek) l o � Phone M q 1 O p 0 S Z 196
Are you an employer?Check the approprlate box:
Type of project(required):
1.E]-1 am a employer with employees(full and/or part-time).• 7. O New construction
2.0 I sin a sole Proprietor w parurership and have an employees working torment
any capacity.[No workers'oomp.insurance required.] 8. Remodeling
3.O I am a homeowner doing all work myself.[No workers'comp,insurance required.]t 9. 'M Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. 1 will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole
proprietors with no employees. 11.0 Electrical rectors or additions
5.O I sin a general contractor and I have hoed the subcontractors listed on the attached sheet. 12.❑Plumlbing repairs or additions
These sub-contractors have employees and have workers'comp,immsrce.i 13.❑Roof repairs
6.Q We are a corporation and its officers have exercised their right of exemption per MGL c. 14.Q Other
152,§1(4),and we have no employees.[No workers'comp.insurance required]
'My applicant that checks box#1 must also fill our the section below showingtheir workers'
t Homeowners who submit this affidavit indicating they are doing all work than hire outsides co�ntraccttors must submit a new new affidavit indicating such.
'Contractors that check this box must attached an additional sheet showing the name of the sub-compactors and state whether or not those entities have
employees. If the sub=contractors have employees,they most provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurancefor my employees. Below is the policy and job site
information. X
Insurance Company Name: 1 roe V eleV�4
Policy#or Self-ins.(L�'ic.#: /i 77 �fi�e// Expiration Date: �]� �]
Job Site Address: 19 U Mu Y r U C h V C f� 5 ede m Y � 'i4 o l q-)O
d _GSty/State/Zip:
Attach a copy of the workers'compensation olicy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a tine 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby ce • under the paiinnss andp aloes ofperfury that the information provide above is true and correct
Signature, � ill Date ��I
Phone M S Z
Off iciat use only. Do not write in this area,to be completed by city or town offrcud
City or Town: Permlt/License#
Issuing Authority(circle one): _
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#'
Information and Instructions
Massachusetts General 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
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 then 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,MGL 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 fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LL.C)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 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 the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit 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 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 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.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
FPx q,1 �3 92� -ZZ�B
CITY OF S�U.E2tii, MASSACHUSETTS
B1:RDING DEPARTMENT
• 120 WASHINGTON STREET,31O FLOOR
TEL. (978) 7.45-9595
FAX(978) 740-9846
Kp�BERI.EY DRISCOLL IIIOMAS ST PIERRE
;KAYOR DIRECTOR OF PUBLIC PROPERTY/BUHMING CONMUSSIONER
Demolition Permit Sign-Off
celI
5�,4g 6`7
(Supplement to permit application)
8
9"I�
1, ' o/j r» &c�PS hereby supply the following releases as part of the
application for a permit to demolish the structure located at /10 d 6 J7
and shown on the Assessor's Maps
a of as being on Map # Block # Lot #
ao
t The 8" Edition of the Massachusetts State Building Code, 780 CMR, states in part: ''A
ompermit to demolish or remove a building or structure shall not be issued until a release is
obtained from the utilities, stating that their respective service connections and appurtenant
0 pequipment, such as meters and regulators, have been removed or sealed and plugged in a safe
o vmanner.
mm
06111 Utility to be Notified Notice Received by Date Received
0
•'` Gas
m Tele hone. J7�3
Electric
5e�(
W 1 et� i Public Utilities (Muni
jHealth Department
Z �i ✓ Fire Department a�
Other -
j Other -
Demolition debris hauler: QW
Location of licensed
demolition debris landfill:
Signature cif Applicant Date:
_.._
Signature of Owner- Date:
This sheet must be returned to the Inspections Department along with a completed
application for a permit, a site plan, and any other applicable information and fees.
lh:moptrm.dck:
natianalgrid
March 25,2016
To: Stephen Gagnon
Re: 190 Marlborough Road,Salem, MA
This letter is to notify you that after our investigation it has been determined that there is
no live gas @ 190 Marlborough Road, Salem, MA
If you have any questions please feel free to contact me at 781-907-2931
Sincerely
WICh..
Linda Gadourey
GAS CUSTOMER FULFILLMENT
National Grid
40 Sylvan Rd
Waltham, Ma 02451
781-907-2931
nationalgrid
40 Sylvan Rd
Waltham MA 02451
March 18, 2016
Henry T Gagnon
PO Box 431
Topsfield MA 01983-1613
RE: Service Removal for Building Demolition.
Dear Mr. Gagnon,
This letter is to confirm that, per your request, National Grid has removed the electrical
service and meter 068677012 from 190 Marlborough Road, Salem MA on 3/16/16. If
you have any questions or need further assistance, please feel free to contact me at
(508)357-4522.
Sincerely,
Deborah Correa
Customer Fulfillment
Ph#508-357-4522
Fax# 1-888-266-8094
deborah.correa@nationalgrid.com
Cr7'Y OF SALEA MASSAC HL SEM
BmDmDEPAjmrkz
120MAgmym1DT MEET,YOFLoox
7kL(978)745-9395.
PAX(978)740.9846
%IIvJBERLEYDRISQ7LL
MAYOR 7CM8 ST.PMM
DIRECTOR OF PURUCrnCFEMY/BlmDMCCM MM
Construction Debris Disposa/Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 790 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
�y r� <d avid SAd w t ,
(name of hauler)
The debris will be disposed of in: SO Ya.A Du ykr5
Solid l,vr,5
(name of facility) J
�X 07
(address offacility)
Sign ture of applicant
� b
Date