59 MEMORIAL DR - BUILDING INSPECTION The Commonwealth of MassachusettslTL ; ; tr ;E
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 C SALEM
IM OCT 12 Q 41sed Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only "
.� Building Permit Number: Q. _Date Ap ied:
(� Building Official(Pnnt Name) - Signature F >Date
�r
SECTION 1: SITE INFORMATION' ,-
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
M Mew o�c 7.. Uo'1 ES
r
1.1 a Is this an accepted street?yes_ no Map umber Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
10 1 30
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?Check if yes11' Municipal C9 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Y26
ecord: p �1
m2�s6G tYC.LUn � W 144"
Name(Print) City,State,ZIP
�l� yIle r,.(( �� (to- 3• rq&c),�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction K Existing Building 0 1 Owner-Occupied 8 Repairs(s) ❑ 1 Altemtion(s) 1 Addition A
Demolition V Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : b VJ 6JcT, .n d2—or—A
C e-, IF I rat.-)
'SECTION`SECTION 4:ESTIMATED CONSTRUCTION COSTS z`
Item Estimated Costs: Official Use Only
Labor and Materials) �'
1.Building $ Q'11 1. Building Permit Fee:$ ndicate how fee is determined:
$
' ❑Standard City/Town Application Fee
2.Electrical
❑Total Project Cost?(Item 6)x multiplier x `
3.Plumbing $ 2. Other Fees: $ - -
4.Mechanical (BVAC) $ List:
5.Mechanical (Fire $
Suppression)
d Total All Fees. $
Check No. Check Amount: " Cash Amount:
6.Total Project Cost: $ I (Qi ❑Paid in Full ❑Outstanding Balance Due.
C D 'T P,W S ( I tJ Ftx. -ram S GGtAvU I;CZ
(rnratt_� tufty
f
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 100531 Q a' �7
&C J Gr1 ay, License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) l)
\1 C2dss St
No.and Street - Type Description
ufi.`U 'M n lei 1S U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,Stat ,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 16,6522
(,
eb'^—W""' HIC Registration Number Expnauon Date
HIC Company Name or HIC Fftistrant Name
11 dStrA (:4v5ccc�"Srs I-
v^
No�nd Street ��^T J
�p`,"u t1.1MR Ai—Cti o Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 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 ...........r 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 gee J t.�tw
to ac m behalf, all matters relative to work authorized by this building permit application.
Al
`%/!�
Pn t wner'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 knowledge and understanding.
me j5a ��4cnr, W-L[4
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total 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
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
� ((( ��ie !prnnmwneoea�t a��a�aclu�aelt
{; Office of Consumer Affairs&Busmess Regulation
HOMEIMPROVEMENT CONTRACTOR
! Registration:nV522 Type:
Expirat�i-o •_ F2S1,. DBA
�. CHASE CONTRAC Ji!. - y
1
ERIC CHASE
11 CROSS ST
j BEVERLY,MA 01915 `'I-� Undersecretary !
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-100531
Construction Supervisor
-ERIC J CHASE
11 CROSS ST _
BEVERLY MA 01915
I
r '
Com
—M
missioner Expiration:
12/08/2017
!
e
CITY OF SM�E;NI i%LkSSACHUSETTS
BUILDING DEPARTmENNT
a 120 WASHiNGTON STREET,3w FLOOR
0'f TEL (978)745-9595
FAX(978)740-9946
KINfBERLEY DRISCOLL
tiiAYOR THobtAs ST.Pi-m
DIRECTOR OF PUBLIC PROPERTY/BUI DLNG COSMISSIONER
Workers' Compensation insurance Affidavit:Builders/ContractorsiElectricians/Plumbers
Applicant Information Please Print Legibly
Name(Business:Organization/Individual): l a!� ,L CN rnkd—AA'Yyt
Address: _lk Ccnss S�-
City/State/Zip: MN o 61,1� Phone li: g2-0910Y
Are you an employer?Check the appropriate fox:
I:� I am a employer with 3 4. ❑ 1 am a general contractor and 1 Tye of project r coon ):
employees(full and/or part-time).' have hired the subcontractors 6. ❑New construction
2.0 1 am a sole proprietor or partner- listed on the attached sheet.: 7• ®'Remodeling
ship and have no employees These sub-contmemrs have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL t L❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers' 13.0 Other
comp.insurance required.]
'Any applicant that clinch box ei must also fill Out the seciim below showing their work as,compensation policy information.
*I Inmeue n as who submit this affidavit indicating they am doing all werk and then him maide cmtraaort must submit a new affidavit indicating such
'Contractors that cheek this box must anachod an additional sheet showing the name of the subcontractors and their workers'comp,policy infomutim.
l am an employer that is providing workers'compensation insurance for my employees. Below is the pollay and fob site
information. (�
Insurance Company Name:_`^NWai ep �aV /ri5
Policy#or Self-ins.Lie.q: Expiration Date:,_
Job Site Addn ss: -Eq YY11 tnnf;Al. t)f,J City/State/Zip: &t.&� e"X y'7U
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expirationdat*
Failure to secure coverage as required under Section25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 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. He advised that a copy of this statement maybe forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby certify uu/nderr�thee�'°ins and penalties of perjury that the information provided above is true and correct
SiLnature: / / 1 ( �I, Date:
Phone x: S7tFgy�
Dgicial use only. Do not write in this area,to be completed by city or town official
City or Town: PermittLicense#
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 All:
CITY OF S.U.E;N1, 1Lxss kCHUSETTS
BuumLNG DEP.kRT%m,%T
120 WASHINGTON STREET,r FLOOR
a TEL (978) 745-9595
FA.r(978) 740-9846
KI\(BERLEY DRISCOLL
MAYOR THomAs ST.PIERRa
DIRECTOR OF PUBLIC PROPERTY/BUUMING COMMSIONER
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 aproperly licensed waste disposal facility as defined by MGL c
111, S 150A.
The
debris will be transported by:
apm
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
�n1211-
date
dennrisatr.dm
\ Estimate
CONTRACTING
11 Cross
Street
Beverly, MA
01915
978-578-8047
Date
www.chasecontracting.net 10/11/2016
Melisa Vacon
59 Memorial Dr
Salem Ma 01970
Item Description —J� Total
01.2 Building Permits Building Permits TBD 0.00
02.10 Demo Demo 4 500.00
Dumpster fee Demo um
1 700.00
Ob Floor Frame Framing Materials Allowance 9,740.00
06 Floor Frame Framing Labor 19,000.00
09 Roof Flashing Roofing, Flashing labor and materials 3,320.00
13 Windows &Trim Windows &Trim 18,000.00
13 Windows &Trim Windows &Trim labor in existing part of home 500.00
11 Siding Siding dormer only 0.00
,94
14 Plumbing Plumbing Allowance 2, 0.00
15 HVAC Heating & Cooling Allowance 1,500.00
16 Electrical & Lighti... Electrical & Lighting Allowance 8,110.00
17Insulation Insulation Allowance 2,500.00
Blue Board and Plast... Blue Bo
ard and Plaster Allowance 9,500.00
14 Plumbing Plumbing fixtures Allowance 2,500.00
16 Electrical & Lighti... Lighting Allowance 00.00
23 A Tile file Allowance labor 5,800.00
23 Floor Coverings Floor Coverings" hardwood 12sgft Allowance 6500.00 0.00
20 Millwork &Trim Millwork &Trim labor and materials 7,045.00
Dumpster fee Construction dumpsters and hauling 1,700.00
10 Exterior Trim & De... Exterior Trim & Decks including railings 1,500.00
Repairs to Existing Allowance for hidden repairs 3,500.00
Eric Chase Licenses Total $110,455.00
CSL 100531 Exp 12/08/17
H1C Reg 166522 Exp
6/09/16