95 MASON ST - BUILDING INSPECTION (3) 03t)v CK - 38y
(\ a� 'rhe Commonwealth of Massachusetts
( OF
Board of Building Regulations and Standards CITY ti M
SALEh1
1 Massachusetts State Building Code, 780 CMR
Rrrised.11ur 201!
Ls.
Building Permit Application To Construct, Repair, Renovate Or D lish a
One-or Two-Funtil,Dwelling
This Section For Official Use Only
Building Permit Number: Date pplied:
' Building Official(Print Name) Signature ! Da
� I
SECTION I: SITE INFORM N
1.1 Pro erty Address: 5>< 1.2 Assessors Nlap Pa cel Numbers
9�5 /t/IGISa.
I.I a Is this an accepted street?yes T' no Map Number Parcel Nunrher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning--District Proposed Use Lot Area(sq It) Frontage(Il)
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. Owner'of Record:_ G 5 ,v)o S®� C !, G o(o^
Name(Print) City.State,ZIP '; l 5 / � l
No. and Street 'relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s),'SEK Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
i u I
_ ✓J f �t -I�o'
' 0 SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and \laterials)
I. Building S 0 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
'_. Electrical S Do0 ❑Total Project Cost'(Item 6)x multiplier x
1. Plumbing S 000 i. Other Fees: S
q. Mechanical IHVAC) S List: _
5. Mechanical (Fire S Total All Fees:S
Suppression)
Check No. _Check Amount: --cash :\mount:—_-"-
6. Total Project Cost: S S i 00O ❑ Paid in Full ❑Outstanding Balance Due:___
y�3d° CK
J� 5
1
Y
SE("1'ION 5: CONSTRUCTION SERVICES
5.1 C'oustruction Supervisor License(CSL) r C G ( %l
�/1�� �✓__�(�_ License Nuniher lispiruiun Date
M1'ame of CSL I folder
List CSL Type(see helow)
No aid S eet "Type Description
lhvestricted(13uildin�s ti to 35,000 co. fl.) ,r
C nc/I o+et.State.ZIP l —" R Restricted IXZ F;u»il ` Ili-
M Mason C
RC Roolin C......n
WS Window and Sidi-
Ol cl O SF Solid Fuel Flaming Appliances
l U I _ I Insulation
Tcic hone Email address D Demolition
5.2 Registered Home improvement Contractor(HIC)
I IIC C nn pang N:unc or IF IIC Registrant Name I IIC Registration Numher Expiration Date
_ T
No. mid Su• t /
r7 � 70 `'I G%(j Email address
City/Town, State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 .......... fb No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
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 in11this applicatio is true and accu ate to the best of my knowledge and understanding.
I not Owners or Authonied Agents Numc(Llecuomc.Signature) Date
NOTES:
I. 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 Honte Improvement Contractor(HIC) Program I,will nor have access to the arbitration
program or guaranty fund under M.G.L.c. I d2A.Other important information on the HIC Program can be fimnd at
�P I?+S�t�' ��ca Information on the Construction Supervisor License can be found at tagto.mas?.�ot' Ips
2 When substantial work is planned,provide the information below;
Total floor area(sq. ft.) I i 1 00 (including garage, finished basement'altics, decks or porch)
Gross living area 1 sq. ft.l __ Habitable room count _
Number of fireplaces__ Numbenif bedrooms
—
-
Numherofbathrooms _.__a--------
_—
� _ ___ Numbcrufhalf"baths
Tv e of heating s stern- ------
-Ga3__.___('HW Number of decks, porches_ wage
T)peo(eoolmgsysle01 aiv.eEnclosed __Open
;. "Total Project Square Footage"stay be substituted for"Total Projec(C'ost..
�i
Massachusetts - Department of Public Safct%
BOard of Buildio, R��_uLrtions and Standards
Construction Supervisor License
License: CS 86492
ANDRE L EBERSOLE
87 FLINT ST
SALEM, MA 01970
. Qtx;r
o--
��_ Expiration: 4/22/2013
( uuuissioner Tr#: 1240
OT a /
Office of Consumer Affairs& Bdsiness Bcga; .>r.
-ram HOME IMPROVEMENT CONTRACTOR
Registration ,'146495 Type:
Expiration: 4127/7013 Ltd Liability Corpc�
EB RSOLE CONSTRUCTION LLC
ANDRE EBERSOLE`---= ':;='if-
87 FLINT ST
SALEM, MA 01970 Undersecretary
.fi
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I\1,41
12C\Vn,lu.\,auc 51V!¢t' • Snu•.w, M.u\a,.nr
IlVorkers'Compensaidon Insurunce :lli(Oduvit: Hui lders/Cuntracturs/Electricians/Plumbers
I Illcant Inrorin'rlion
Pleat� Print Le 'AI
N017IC Ina.l,W%Iii)rtam,,ldnrvindnl,luun: Z dSoa re�' ", SJI
Athlrusx: 9 /P �i-, p, /�
Cily,.5tatc,%ill: ->� �r ZLI/.,L Ilhuna N: J �� ' / rJ�J `10 5 S
I .\re 1°u ml vinployetr!Chuck the apprnprldte boa:
I.1S 1 anl:r cmplu)ur wish� 4. Q I mn a general coluraetor and 1lprpr°fuel(reyulrrd);
anpluyecs(full Jnd/ur part-time).a huvu hired the.suh•cuntraciorsew construction
2.Q I,un i tole prnprictrrr nor partner- listed on the anachcd,hcut ternodelins
ship;u1J have no umpluyccet These sub-contractors have
working tile me in any capacity. workers' comp. Insurance. emolitionI No workurl'culnfl. insurance J. Q We are u ea uilding aJditiunnyuircJ.) perstion anJ itsutylecn hour ufureirc41 their lectrical repairs or additions3.Q 1 sill a homcuwnur doing all work right ofuaemption pur MCL umbing rupuirs or additionsmyself.(No,�nrkurs'comp. c. 152.41(4),and eve hove no elfrepuininsurance required.) r clnpiuyees. (No workers'
her
•1 rat.,;Iphcuw ilia vheeYs toe at mug AW fill"the,howl avlrse dw,rine elaeitwwhee'gN,IPwMWiJa,Po wee ulrojewiI ws
'I lum,ntwrwn whY„dMtil this affidavit indivJ,ine IhYy JII dYlnil al wurk and tho him uweiG euwn"M"'"'"wham a nave,410dartl iron ins,Iwo,
•C.MIM. 11or,that,k-vk this bolt mug Jaahal an additiwwl..hql,huwina flow most at the tue.emraetan and thew Ivurhera'rmep,patine Intlwrltarj,N,
/.fun un euep(oyrr that If pruvidlgq workers'ruurpeumtlon 1nran+ncs/Lr rats etnp/uydati Be/uw!f the pu//ay and/ub.rite
in�urnrutGrte,
Insurance C'unlpauy Vame:��_ ..
Policy is or Sclf--ins. Lie.I w L ;0d 6 _2 S 501
�----
�l C Espirauore Date: 1'i _2 — (Z
lob Situ -\Jdres:_. % l /� O 5 �� � / � N�
C'lly'slateezip:_ � p
.lttacA it copy of the workers'cumpunaallun policy Juclaratlon puke(showing the policy nu llbur and aspiration date).
Pmlun:to sure coverage as required un,lcr Section 251%ul'.%IGL u. 132 eau lead to the imposition or'criminal penalties of a
rind up ill.l'1.5110.11n Jnd/ur dee•year imprivunlncelt. Ja well ar civil pcnalth:s in the lunn of STOP WORK ORDER and a fine
o(tell feei!50.00 o Jay.Igaitul the viohlor. lie advi.tcd that i copy urlhis,Iwcmunt may be furwardeci to the UI'lice„f
Imougaulno ul';ha UTA loll,msacwce alt,cragu tcrilicauun.
/du ha r,,by t erti/y under that,pain, r a, t'•r of er/ury thus the in/bnnu//on/rruridrd[)�above/is true and Via,orrect.
r)�/!riot rrre olds. Oo nor writer in du.,urru, to be runry/rled by city el totrn a//trio(
i
('i tY ur 1'nwn:
-- Pcnnit/Llnm,r I ��
t„uing Aulhurily (circlo )fee):
Ib-Ari I. ilivJ of IlrJhb 1. Ihuldinq Ucp,unne
lwr ttl 1. Ci1I;'1'ut,n L•'le
Clerk J. ctrical Ingxio rr 5. Plmnbing llnyecror
G. t)f
('gnu Jcl love. un: I
1
[nformation and In
\L1bS•IC Itlsetts tJe \r
neral Lu3 Chillier 172 1'egUlreY all e11111IJyers O t another under mw contract of hire,
in the service n prOYI of JQ \rU(hCfl� compensation lilt their t'lllp lUyCCl.
I'ur.uJlu w this astute,an emplgree is defined as .. every pet
ion
or Implied. oral or written." or an two or more
An employer Is defined as an individual. purtnenhip.•MOC1411Jn,corporation or other legal entity. Y
rim r,16.a assoclatioa or other legal entity,cmploying employees. Hewcvcr the
.a the I:mgomg engaged m a lams idupnsQ.and including the legal representatives of a deceased employer•or the
I e:mvcr or uuaaa of.uh individual.p
Occupant ut the
owner of a dwelling house having not more than three aparcmenta and who reside,herein.or the occup
owner o huusa of g house
who employs pen"",to do mainurnunce.:Instruction or repuir work tried
such dwelling house
.x ,it the grounds or building appurtenant hereto shall not because of such employment be deemed to be an employer."
shaper 152. :SC(6) also states that ,every state or local licensing agency%had withhold the Issuance or
.-,IGL rl of r license or permit to overate•business or to construct buildings In the commonwealth for any
rent%vapplicant who has not produced acceptable
cc15C pt sblee-,Neither he oct Of m nonw id rlth nor any of its political ance with the insurance gsubdivisions shall
AdJitionully, NiGL chapter I5_, 3-
enter into any:unmet I-or the Performance
fPublic
the con tilt g litala ityviJan:e ul'complia%t:e with the insuraneQ
mquiremcne of this chupter havQ been presented
,applicants Pp t our situation and.if
es Jot bona number(,)along wick their canificate(r)of
Pleawt sill.wt the workers' compensation at1)davit completely,by checking the boxes that u Y o Y
necessary, supply sub-contrJctor(s)name(.,),JddrcLi ) P with no employe
insurance. Limited Liability Companies(LLCworken'tcompansaed u partnerships
insurance-(It ao)LLC or LLP does have
Qr the e
of Industrial
netnbers or partners.are not required to carry submitted to the
employees.a policy is required. Be advised that hi,�l�be sure to tivit mayl{p and duo Ao itl'1ldmiv�It ntThis affidavit should
accidents for confirmation of insurance coverage.
he rcwrned to the city or town that the any questions
ue,ofns regarding the law or the permit of Orr if uI are required to obtain a workers'
t o
industrial Accidents. Should you have any 4
compensation policy,please call the Deputvttant nt the number listed below. Self-instued companies should enter then
Sclr•insuranee license number on the a ro riatQ line.
City or'rown omclals ringed
Pleas affidavitthat the you co II it isicomplete
n the avant the Office lot�lnvestigJt onibly. The a has to contact you regarding het has provided is space at tapplilictant
1'l:use be sure to till in he permit/license ntunticr which will be used as a reference number. In addition,vit is applicant
l It
that
cy submit
information Iitmultiple
e Pe Site Irinedarv'lobrSi a Address!'he applicantdsh"uld only twriteit-Ill locations inicutin`lunyn
town) copy of the unlduvit that has been officially stamped or marked by ilia city or town may be proviJcd to he
lute
ts or
nses. A now
y epn *'here a home t a velar cinzcn isdavit tabenining a Is on file for icensQ or pelnnit not related to any bustinessavit lor comoust mercial 1 venture
t d to complete this affidavit.
i.e, ;I dug license or permit to burn leaves cte.)said person is NOT require
I he I>tiite of Investigations w
uuld like to thank you in advance for your cooperaeion and shuuld you hace:Iny questions,
please du nut hcsitatc to give m a call.
fhc Ucp:uunent's address. telephone aTh C"umber
mmmonwealth of Malssachusettll
Department of Industrial Accidents
Offlce of lovesdQadoes
600 Washington Street
Boston, MA 02111
T'e1, q 617-727.4900 ext 406 or 1.877-MASSAFE
Fax M 617-727-7749
www.mass.gov/dis
Y�
CITY OF Sm-&Nf, A-SS.kCHUSETTS
BI;ILDLYG DEPARTNONT
' 110 WmlimGTON STREET, 3i0 FLOOtt
TM (978) 743-959S
FAX(978) 740.9846
KIJCBERLEY DRISCOLL
,MAYOR THomu ST.Pm uts
DIRECTOR OP PLBLIC PROPERTY/BCtwmts CONNISSIONER
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 MOL 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
l 11, S I50A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
-- (name of facility)
(address of facilltyj-
a re o/f permit applicant
gate
kbn+.ul(La