40 NICHOLS ST - BUILDING INSPECTION (2) T `\r RE
v\ The Commonwealth of Massachusetts ONC T$ERViC S
Board of Building Regulations and Standards SALEM
j% Massachusetts State Building Code, 780 CMR 10�a S PRa&dPi4201f
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use OPLY
Building Permit Number: Date Applie
Building OtTicial(Print Name). Signature- Date
SECTION 1:SITE INFORMATION
1.1 Prop S/ 1.2 Assessors Map&Parcel Numbers
V-2Ti
1.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(11)
L5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Requimd Provided Required Provided
1.6 Water Supply:(b1.G.L c.40,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ p y
SECTION: PROPERTY OWNERSHIP,
2.1 Ownert of Record:
'T,�G �ar�s r �P0 W%
�thme( rint) City,State,ZIP
��n
NuNo.mu S,t Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Altemtion(s) Addition ❑
Demolition ❑ Accessory Bidg.❑ Number of Units_ Other ❑ Specify:
Brief Description.of Proposed Work-:
r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S P Other Fees: .S e` _
1
-1.Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees:S
Su «scion)
Check No._Chick Amount: Crash Amount:_
6.Tutai Project Cost: .S ❑Paid in Full ❑Outstanding Balance Due:
M Al l
A bey�'eouApu
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SECTION 5: CONSTRUCTION SERVICES 1
5.1 Construction Supervisor License(CSL)
1r, j1 elf�1��
License Number E.epvuti n Date
Name of CSL 1101der
/� List CSL'fype(see below) /lnri-s�ri ��+'-Gl
/q ,/�IAgat�/olot/ TYPe - Description
No. ;aid Street' Unrestricted(Buildings tip to 35,000 cu. 11.
--i- •- 0 9 / z - R Restricted 1&2 Family Dwelling
Cilyll'uwn,State,ZIP Ni Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
7 1 insulation
Telephone mail address U Demolition
5.2 Registered Home Improvement Contractor(111C) 7� Q y/ndb D l/ - HIC Registration Number 'Expliration Dane
HI Cump:mfy Name or HIC egislra tl Name )
/'r.c, 'mil�. -. „I,,I s �i Slid /l..Yi/ %P StLC ✓() .179//df. i
U.and Street • L Email address
City/Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 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..........❑ No........... ❑
SECTION 72:OWNER AUTHORIZATION,TO BE COMPLETED WHEN.;
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERNIIT`
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED 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.
Print Owner's or Authorized Agent's Name(Electronic Signature) Dale
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 Home Improvement Contractor(HIC) Program),will nit have access to the arbitration
program or guaranty, fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
wwvv.mass.��ov:'oea Information on the Construction Supervisor License can be found at vvww.nr is,;�,ov:'d� _
2. When substantial work is planned,provide the information below:
Total tloor area(sq. R-) ' ;(including garage, finished basement/attics,decks or porch)
Gross living area(sq. tt.) 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_
1. "I'oial Project Square Foota,ge"may be,ubstituted for"fond Project Cost"
CITY OF SM.EM, NWSACHUSETTS
t BCIlDING DEP.�RT>IEINT
i1 a�l 120 WASHLNGTON STREET, 3se FLOOR
T EL (978) 745-9595
F.-.x(978) 740-984,5
KI)IBE LF-Y DRISCOLL THOh41SST.PIIFARH
r:,L1YOR
DIRECTOR OF PUBLIC PROPERTY/BCILOCVG CONNISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informatinn / ) Please Print Legibly
V;1111C Inusimssgrg�nirarinn,'InJividual):Address: �II� c(4,/re.
4�_r-ar oQt6� �,
City/State/Zip: �2!'2/ 'Phone W 93
Are y 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 pan-lima).• have hired the sub-contractors
2.❑ I sun a sole proprietor or partner. listed on the attached sheet. l 7. Remodeling
;hip and have no employees These sub-contractors have S. C]Demolition
working for me in any capacity, workers'comp.insurance. y. El Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and iu
required.] officers have exercised their l0.0 Electrical repairs or additions
J.El am a homeowner doing all work right of exemption per MGL i I.C] Plumbing repairs or additions
myself.(No workers'Gump. c. 152, ¢1(4),and we have no 12.❑Roof repairs
insurance required.) t employees.INo workers' 13.❑Other
comp. insurance required.]
-Any upplie:un oral chucks bus f l mwt also fill uul the section betowshowing their W14W compensation puliiy inilumattan.
'I tameuwr r%who submit this atnrinvit indicating They ate doing all work and then hoc outsida comactors matt submit*new 3MJavit indicting such
$lnnmuron that chvck Ibis box mrot mtachd'an a.Waiurul sh>t showing Ilw natnc olthc aub•tanlra0on anJ Ihclt wurkm'camp.pulley information.
f unt un eurptoyer shut is providing workers'c•otnpenration htsuruncefor my employees. ffeluty is the policy ernapts site
infururalion.
Insurance Company Name:, rD�3
Policy 4 or Self-ism. Lie.d: EQ40-/05?a[w�, --Q—!T Enpiration Date:
Job Site Adckess:�/� ,L�: /S Uli City/Slutc/Zip:
Attach a copy of the n'orlecn'compensations policy declarallon page(showing the policy number and expiration date).
I,'ai lure to secure coverage as required under Section 23A or NIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisnnmcnt,as well as civil penalties in the form of a STOP WORK ORDER and a line
nrup to S25000 a day against the violator. Ile advised that a copy of This statement may be furwarded to the Office of
Investigations nl'Ihe DIA for insurance coverage verification: -
l du hereby c•erlify under the puiats and penuilles of perjury shut the information provided ubuve is true and correct.
t.
Phone
n
Official use rnlly. Du not write in this oreu,to be completed by city ur lown off eAsit
City or rown: __- I'ermit/1.Ic°nsctil—
issuing Authority(circle one):
1. Buurd ul Ilcvllh Z. Iluildlnq Ilepartnleut .l.City/rorvn clerk J. Electrical luspecfor 5. Plonlbing luapeeror
6. Other
Contact l'cvcnn:.,.
/ QTY OF SALEM, MASSAaRJSETTS
n BUILDING DEPARTMENT
�`St Ir ail
`u- ti✓ 120 WASMNGTON STREET,3m FLoOR
TEL.(978) 745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
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 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:
(name of hauler)
The debris will be disposed of in:
(name of facility) Chel/seg�,164
(address of facility)
Signature of applicant
Date
JB Sash & Door Co., Inc. CHARGE COPY
SASH
JB
Ord #: 180997-0 f
�2uiutzcm.en&Discibnten
DOOR-WINDOWS �LLW0Rk
28D Second Siren+ Chelsea'AA 02150 Route: NONE
&DOOR (617)884-9940 1-800-648 93?9 Fay ff(61.7)$84-9288 Page: 1 of 2
HOME OFTE�E WINDOW BOYS Rya=���
Order: 07/30/14
To: CON142 Ship To: Sched:
JOHN CONNORS INSTALLATION
40 NICHOLS ST 40 NICHOLS ST Printed
SALEM MA 01970 SALEM MA 01970 Date: 09/17/14
Time: 10:21 AM
Phone: (978) 210-4319- Phone:
ti
Entd: EOD In: 15 / Out: 15 I Terms: COD ; Cust PO#:
Customer Instructions
ohn.connorslO@verizon,net j
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Line #0 Remark:N IST FLOOR '_ _ .._. _L.Quantity_ ._.. Shipped Comments
Line # -- Item Number , Description
_
BEDROOM I
..». .
0002 00 j *180997002--,-00 �, ANDERSEN_ TERRATDNE. —, PERMASHIT -
ELD
CASEMENT FOUR SECTION BOW
WINDOW UNIT-C445 BOWL-S-S-R)
R/0=97 3/8" X 54 7/8"
j CLEAR PINE INTERIOR
I H/P LOW E-4 INSULATING GLASS i
5 114" CLEAR PINE EXTENSION
JAMB/HEAD AND SEATBOARD i
STONE SCREENS I
STONE CLASSIC HARDWARE
1 X 6 AZEK EXTERIOR CASING
APPLIED AT JOBSITE
2. 112" CLEAR PINE COLONIAL
INTERIOR CASING
NEW ROOF TO BE CONSTRUCTED
AT JOBSITE AND SHINGLED WITH
BLACK/GRAY ASPHALT SHINGLES
(EXISTING 5 SECTION WOOD BOW- '
l R/0=100 1/2" X 55 7/8"-WOOD
ISHINGLES)
- - -- ---------------------___..- --
0003 00 INSTALL ; INSTALLATION OF ABOVE 1.00
j ! INCLUDING REMOVAL OF DEBRIS
FROM JOBSITE
10004.00 1INSTALL ( BUILDING PERMIT FEE 1.00
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