5 NORTHEY ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
�
Massachusetts State Building Code, 780 CMR S Revised,L/ar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official-Use Only
Building Permit Number: bate/Applied:
i�os�ras J. ST.f�tt=2rzr + �-� t ' 1�
Building Official(Print N:une). Signature Date
SECTION C:SITE INFORMATION '
1.1kow,!,y
O;Aidtz S"f ( 1.2 Assessors Map Sr Parcel Numbers
I.I a 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 It) Frontage(11)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.IfOwner{of Recor/d,: / {
tG�a^f Ov�' cV 9 yd✓'i1� �4-
N y me(� City,State,ZIP
41 '1 5019
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF:PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) '4i1 I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work-, P.� a .e {ti 4 .¢xr y t I'—J 1�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials) -
I. Building $ j 1r C)CJD 1. Building Permit Fee:$ - Indicate how fee is determined:
❑Standard City/Town Application Fee- -
2. Electrical $
❑Total Project Costa(Item 6)s multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) S List: /, �OU
5. iMechanical (Fire $
Suppression) Total All Fees:S
Check No. - Check Amount: Cash Amount:
6. Total Project Cost: s Gl/ = ❑ Paid in Full ❑Outstanding Balance Due:
SECTION 5i CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) S
License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
No. and Street Type ;; Description
U Unrestricted(Buildings tip to 35,000 cu. ttJ
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�n ^ -go
Y� SF Solid Fuel Burning Appliances
l ,J P✓ [ Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
e7 o✓ti ' — HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
No. and Street 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 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN,
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize
-t4 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nane(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION:
By entering my name below,1 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) 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 Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. I42A. Other important information on the HIC Program can be found at
www.mass.eov:'oca Information on the Construction Supervisor License can be found at www.nnassjgov:4lps
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
,rypeof cooling systeat Enclosed Open
3. "Total Project Square Footage"may be substituted for""rotal Project Cost"
_lit �.
��e �G onr,mnruuen�C�o�Plf�aed�ir�rme/Gi'
Office of CousumerAffairs&Business Regulation
=-ROME IMPROVEMENT CONTRACTOR
et/20155
egistration: 1.4 146495 Type:
xpiration =4@ Ltd Liability Corpo.
Am A
EBER80LE CONSTRUCTTION LLC�"!�
\UM p ,
ANDRE EBERSOLE
87 FLINT ST
SALEM,MA 01970 - Undersecretary
ent of public Safety
f Massachusetts -Departm
Board of Building Regulations and Standards
Construction Supervisor
License: CS-086.'"492
„
ANDRE L EBERS¢1LE
SALEM NIA 01940 }#
Expiration
O412212015
Commissioner
NOTICE NOTICE
m TOA
EMPLOYEES atia EMPLOYEES
QIy M1'�V,.
The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22, & 30, this will give you
notice that I (we) have provided payment to our injured employees under the above mentioned
chapter by insuring with:
Associated Employers Insurance Company
NAME OF INSURANCE COMPANY
P.O. Box 4070 Burlington, MA 01803-0970
ADDRESS OF INSURANCE COMPANY
WCC-500-5006255-2013A 04/20/2013 - 04/20/2014
POLICY NUMBER EFFECTIVE DATES
24 Federal Street, 4th Floor
Boston Insurance Brokerage Inc Boston, MA 02110 (617)556-7000
NAME OF INSURANCE AGENT ADDRESS PHONE
Andre Ebersole Ebersole Construction 87 Flint Street Salem, MA 01970
EMPLOYER ADDRESS
02/13/2013
DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of
employment to furnish adequate and reasonable hospital and medical services in accordance with the
provisions of the Workers Compensation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee may select his or her own physician. The reasonable cost of the services
provided by the treating physician will be paid by the insurer, if the treatment is necessary and
reasonably connected to the work related injury. In cases requiring hospital attention, employees are
hereby notified that the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL FACILITY
EMPLOYER ADDRESS
TO BE POSTED BY EMPLOYER
000
CITY OE sm-zm. NUNSSACHUSETTS
BL•ILDIDIG DEPARTMENT120 WASHINGTON STREET, 3'a FLOOR
TEL (978) 735-9595
F.ue(978) 740-9846
KIJiHERLEY DRISCOLL THOMAS ST.PtERRE
MAYOR DIRECTOR OF PUBLIC PROPERTY/Bt:ILDLNG COJLMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant infnrmatiols Please PrintLegibly
Name(BusiiaNs Orgmixatiurvindividual): (fL1l�� t ��IL /
Address: &9 f-- ((,- f
City/State/Zip: ����� M/.Y Phone 3: 570 L?10 7'5
Are you an employer?Check the appropriate box: 'Type of project(required):
1.0 i am a employer with 1 4. ❑ I am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time).* have hired the subcontractors
2.El am es sole proprietor or partner- listed on the attached sheer.t 7. El Remodeling;
ship and have no employees These sub-contractors have V. ❑ Demolition
working,for me in an capaci workers'comp.insurance. 9
any capacity. ❑ Building addition
(No workers comp.insurance 5.0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑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' it ❑Othtr
comp:insurance required.)
•Any appticara that chaka boa sl must also fill Out oho seeauo below showing their wmken'compaiwlan polluy information.
''1 hvneuwnom who submit this affidavit indicating they ass doing all work and than him outside commie t most submit anew affidavit indiaine such.
!(bmmcturs that chwk this box most anuhod an additfumt{short showing tho nema of the subM naacwrs and their workers'comp.pulley informneon.
l um an employer that is pruvfding workers'c ompeusadon Lasurancerfor my empluyeex Below/s the pulley and fob sire
inforarutlon.
insurance Company Name: �. C
� 0f
Policy U or Setf--ir>s�tLic. N (A/CC 500 5ci0G � 55- 34
Expiration Date: /
Job SitsAddruss: / ✓ dam' 7'r'7 City/Statr/Zip: ���'1�'�`�
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure:to sccuro coverage as required under Section 25A ofNfGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 31,500,00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S230.00 a day against ilia violator. Ile advised that a copy of this statement inay be forwarded to the Oflics of
I t vest igatiwrs ufdts D[A for insurance covcrago veri tiealiun.
/du hereby certify under the u a and peruldes of perjury thus the hifurinuilon provided above is true cord curreca
Sicnnnnre• Oats:
11hunc
U]1iciul use unly. Ou not write in drir area,to be cumpleldd by city or(omit gjjlciaz
t
i
City or Town: Pefmlt/f.1cerstc.4
Issuing,\uthurity (circle one):
1. Buurd of Ilealth 2, fluildinit Deparrnent 3.Cityi fawn Clerk 3. Electrical 6t5pectur 5. Plumbing fnspector
6. Other
Cunlucl Person: __ - „__ _ Phone it:
(
CITY OF S.3LEm, NL L-1SSACHL'SETTS
BU M DL\G DEPARTJIENT
120 WASHNGTON STREET,3w FLOOR
d TEL (978) 745-9595
FAx(978) 740-9846
KI,tBFRT F.Y DRISCOLL
MAYORTHOMAS ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BI IMNG COJ12,11SSIONER
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 a properly licensed waste disposal 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)
(address of facility)
I
asir;of permit applicant
date
Jcbrisalf dux: