The URL can be used to link to this page

96 NORTH ST - BUILDING INSPECTION (3) W The Commonwealth of Massachusetts Department of Public Safety Massachusetts State Budding Code(780 CMR) Building Permit Application for any Building other than a One-or Two-Family Dwelling. , 1�. (This Section For Official Use Only) m '" Building Permit Number: Date Applied: Building Official: o� _ ' SECTION 1:LOCATION(Please indicate Block S and Lot p for locations for which a street address is not ava le) -Q &=QA SE No.and Street City/Town Zip Code Name of Building(if applicable ' 1 SECTION 2:PROPOSED WORK. _ �y Edition of MA State Code used If New Construction check here❑or check all that apply in the two rows elow Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ 1 Demolition ❑ (Please fill out and submit AppendtC I) Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineertn Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: I (] 21= A'1,12 SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION 4:BUILDING HEIGHT AND AREA - Existing Proposed No.of Floors/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-2❑ Nightclub ❑ A-3 ❑ A-1❑ A-5❑ B: Business ❑ E. Educational ❑ F: Facto F-1❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H-4❑ H-5❑ 1: Institutional 1-1❑ I-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4❑ S: Storage 5-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ HA ❑ 111313 1 IIIA0 IIIB ❑ 1 IV ❑ 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❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑ Private❑ or indentity required❑or trench or specify:Zone: or on site system❑ permit is enclosed❑ Railroad right-of-way: Hazards to Air Navigation: Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building con Lain an Sprinkler System?: Special Stipulations: -sa,3 o -t--0 M�rz� W OOSX DC(L SECTION 9: PROPERTY OWNER AUTHORIZATION , Name and Address of Property Owner H1.42y 11 p<oCk 96 elfgi rSr� w. .. Name(�t) No.and Stre City/Town Zip Property Owner Contact Information: 5 Title - Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit application. .t r SECTION.10:CONSTRUCTION CONTROL(Please fill out Appendix, - f bui din is less than35,000 cu.ft.of enclosed space and or,not under Construction Control then check here O and skip Section 10.1 10.1 Registered Professional Responsible for Construction Control - ``- ;`dg/IV() 857-26t 36 /%OEr�Ji /gaijlo7l® �C S - . 0 � g`✓" O Nmne(Registrant) Icphone No. e-mail address Registration Number Z6 /cfi/n/6ToN sr ✓ R�2��0 m4 ©zW /2- 92-ZO b Street Address City/Town State Zip Discipline Expiration Date 10.2 General Contractor Company Name Name of Person Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip Telephone No. business Telephone No. cell e-mail address SECTION 11:4VOI:KFRS'COIvIPF:NSA""PION INSUItANCti AFF'IDAVI'1' M.G.L,c.152.9 25C 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 13 No ❑ SECTION 12:.CONSTRUCTION COSTS AND PERMIT FEE. - Item Estimated Costs:(Labor and Materials) Total Construction Cost(from Rem 6)_$ 1. Building $ Building Permit Fee=Total Construction Cost x_(Insert here 2.Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical (FfVAC) $ Note: Minimum fee=$ (contact municipality) X 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ C) lr#4djoct municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT 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. N d ,671Zj/ Please prin I ign n. t - Title Telephone No Date m S?Mtcet AlIllres�( S ] ./' CityiTown w4 fate f?z G L t.v A � , —1 Municipal Inspector to fill out this section upon application approval: /� � -� / Name VDate b Massachusetts g � 4 s Department of Public ®- .Board Of Building R safety _F g Regulations and Standards License: CS-101850 Construction Supervisor ADEMI SABINO 26 LEXINGTON ST. WATERTOWN MA 6472. )Ur . `r Expiration: iration: Commi ss�oner 12/72/2076 Couto Painting and Carpentry 4 Hudson St#1 Lynn, MA 01904 (978) 979-1007 moisescouto2014@gmaif.com www.coutofinest.com ESTIMATE ADDRESS ESTIMATE# 1152 Leonid Deych DATE 07/12/2016 4 North st Salem, MA 01970 ACTIVITY AMOUNT Exterior Paint&Carpentry Repair Wood repairsemove and replaced all rotted wood around of the house.(front:around of the Bay window molding and trim boards,front siding remove &replaced wood shingles(with new white Cedar wood shingles=to 3 square of siding). Back of the house:remove& replaced =to 1 square of wood shingles . scrape all loose and peeling paint from all surface on the house,sand all areas and vacuum all the areas Apply house washing cleaner and pressure wash all the exterior Apply 1 coat of oil base tint primer on the Body and all trims Apply 1 coat of Exterior finish paint Body and all Trims on the house Couto painting will provide all the material for Carpentry repair and finish the job. OBS:Costumer will provide all the paint material to finish the job. Services 4,000.00 1 st payment:$4,000 Services 4,000.00 2nd payment:$4,000 Services 3,500.00 3rd payment:$3,500 Leonid Deych Moises Couto A/ __.._... - ..................................._.. ......... ................... ...l�y �. y .-..�1.-....-...... It would be a pleasure to do business together) TOTAL $114500 00 r City Of Salem, Massachusetts Board of Health 120 Washington Street,4th Floor,Salem, MA 01970 Iamberley Driscoll TEL. (978) 741-1800 FAX. (978) 745-0343 Larry Ramdin,MPH,REHS,CHO Mayor health@salem.com Health Agent GENERAL HEALTH PERMIT Permit# GHL•16-238 License For: Exterior Paint Removal Date of Print 7113/2016 Granted To: Mary Woodcock Permit Issued 7113/2016 Address: 19 Foster Street Salem MA 01970 Permit Expires Permit 2018 Location of Establishment: 96 NORTH STREET Permit Fee $35.00 Restrictions: no electric sanding Late Fee $0.00 Notes: This permit or license is granted in conformity with the statues and ordinances relating thereto, and expires on 12/3112016, unless sooner revoked or suspended. The Commonwealth ofMassachuse&S Department oflndus'trfalAccidents I Congress Street,Suite l00 Boston,MA 02114--2017 wwwmassgov/dia WWorkers'Compensation Insurance Affidavit:Builders/Contractors/Electridans/Plumbers, Applicant Information FIL TO BE FILED WITH THE PEPIArrr1NG AUTHORITY. Name(Buser Please Print I e�b1v ess/OrgamzatiomRndivitival): _ t�O(J / O Address: .� 1�.ifb�at/ St t Ly�w rr/,�� 019�i City/state/Zip: L you am empbyer7 Clerk the appropriate box.- not a employer with mgrloyeea(tali aror . T3�of project(required): -une 7. ❑New construction m a sole PY0Pnn1 r or Parorership and havemY capacity.[No workers' Io working formein 8. R®odelin comp.somm ne, "mo&J ❑ 8 a homeowner doing all work myself[No workers'comp.mymance regUhW.)1 9. ❑Demolition a homeownerandwillbehimrgcontactors m conduct au work m myproperty. 1will 10❑Building addition ure that all contractors either hate workers'compensation msmance or ue soleIl. Electricalx;emra win inn employces. ❑ repairs Or additions a 12.❑Plumbing repairs oradditions general Connector and I have hired the sub-coffiactors listed on theattached sheet.se subcmtacmrshave employees end have workers'comp.msonsom,t 13.❑Roof repairs e a corpoatim and its officers have exercised theksight of eaempdion perMGL c. 14.15Other§1(4),and we have on employees.[No workers'mtryr i repim&j ;My applicant thin checle box#1 must also as out the section below showing rhea workers'm opmmtlon policy mtmmmion. Hommwners who subrmt this affidwh indicating they as doing all work end them hire oumde contractors must milaw a new affidavit indicating such 101Mtrac10rs that check this box must attached m additional ahem showing the mama of the mbtmtraams and state whether or not those entities heve employees. Ifthesub<ormactorshaveempioyas,theymnatprovidethefr workers• comp-polieymonber. I am an employer,that is providing workers'compensation insurance for my eMpfoyees Below is the policy and job she informadoiL / Q Insurance Company Name: �. SfL✓,.Q/`�J �,.�j1�! 1 r NC / / Policy#or Self-ins.Lic.#: S 3 S(r ,3 0 0 �O /,S Expiration Date: I Z t / af Job Site Address: l Q"s'2�vt / ( .0�1 �(� p� sty/��ip: .y Attach a copy of the workers'Compensation"Hey declaratio page(showing the Policy number and piration date) 7T✓ Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine 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. t ao hereby cergfy under the ants andpen es ofperJury that the mformahon prommmvided above is&ue/and correct. Si®ature'i�i�a�%�� y� Date ,p Phone#: 77 _9 Official use onlys Do not write in this area,to be completed by city or town oj)iciaL City or Town: Permlt/Ljcense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5.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 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 buildmg 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 tRananee 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(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 approphate 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 permullicense 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 rrnrst be filled out each year.Where a home owner or citizen is obtaining a license or permit not related to any business or cormmercial venture (i.e.a dog license or permit to burn 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 Q'7Y OF SALFJK MASSAa*EETP BU DMDBPAlMdW 120 W/ASIOM ntS"MET,3IDFioax 7kL PM)745-9595. PAY MT)%DAERIZYDRi5100ZL MAYCR 1? OAMST.PM DBtBCWaCFPUBUICPXOFMY/BiLUMQ t Construction Debris Disposa/Af rdavit (required for all demolition and,-renovation work) In wcordame with the sixth edition of the State Building Code, 7B0 CMR, Section 111.5 Debit, and the provisions of MGL 040,S 54; Building Permit R is issued with the condition that the debris resulting from this work shall be disposed of in a properiy ikensed waste deposit facility as defined by MGL c 111,S JSOA The debris will be transported 6 . Po y (name of hauler) The debris will be disposed of in: (name of facility) (address of facility) Signature of applicant Date