30 NORTHEY ST - BUILDING INSPECTION (4) =Demolish�a
'rheCommonwealthofiviassachusetts INSBoard of Building Regulations and StandardsI�J 1 Massachusetts State Buildin Code, 780 CMRg i011Building Permit Application To Construct, Repair, Renovate O
One-or Tivo-Family Dwelling
This Section For Official Use Only .,
I Building Permit Number: Date Applied:
Building )ITIcial(Print Name). :: Signature- '- - Date
SECTION 1 SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map g Parcel Numbers
3a W12rL,"c- sT
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Properly Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required= Provided Required Provided Required Provided
1.6 Water Supply:(M.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 W y
SECTIONZ: PROPERTY OWNERSHIP!`
2.1 Owner'_0J2-.^ ToMTN A T__ -5b M ,o O 1 `i `I0
N� me(Print City,Slate,ZIP
�0 �o25'f.rG! sr `erg327
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK;(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory BIJg.❑ Number of Units_ Other ❑ Specify:
Brief Descriptions of Proposed Work : <t fu r r: .l /L6/ r o� [_� i✓E r / G LS .J6S
SECTION a:ESTIMATED CONSTRUCTION COSTS
Ilan Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ $ 5 I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S i O J ❑Total Project Cosh(Item 6)x multiplier s
3. Plumbing S r9 of P Qther Fees: S
d.M1lcchanical (11VAC) List:
5.Mechanical (Fire S Total All Fees:S
Suppression) '
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: .S 5r SO ❑Paid in Full ❑Outstanding Balance Due:
I��P \1.�17 ill Cp h /5
SECTION 5: CONS•rRUCTION SERVICES
5.1 Construction Supervisor Liccuse(CSL) CS—o 7 3 991 1 2l 16
G�GlLn Ls� W lJ % f License Number Expiration Date
Nmne of CSL[folder List CSI.Type(see below)
2-3 G-CC— Jon L,6 O/L .
Type •- - Description
No.and Street .
U Unrestricted(Buildings tip-to 33,000 cu. 11.)
0pr4vG2 S n''n O )5 Z 3 R Restricted 1&2 Family Dwelling
City/fuwn,State,ZIP M Masomy
RC Roolina Covering
WS Window and Sidinx
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 2 9 / 11/pir
�ionDate
GE/Ln W N r 5'� HIC Registration Number
HIC�n any Ntune o HIC Registrant Nar e
Cr �6.J r0 n L� n/L
No.pand Street Gnu fg
0
19 Z2 Email address
nr✓✓ M
_-___ _C.i �m,State ZIP Tel e hone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.152.$2SC(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 Is?uance of the building permit.
Signed Affidavit Attached? Yes ..........O 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 6A ( V W 6 )v h
t9 act on my beha f,in all in relative to work authorized by this building permit application.
2 / s
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERI 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.
u -F(ara —FO ATE /_-5-
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. 142A.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-.mass.sovhlos
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) 's ,(including garage, finished basementlattics,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
rype of cooling system Enclosed Open
.1. ."Total Project Square Footage may be substituted for"Total Project Cost'
The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
www.mass.gov/dia
Wrkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print a ibl
Name (Business/Organization/Individual): k) rGN E.✓Flu/L�C { GAO i./ �✓E N Mil �fC 7 n �f�
Address: 2 / A A e& hr / S r N N I fE
City/State/Zip: Mn a /9 , Phone#: 76 -7 I I S o
Are you an employer?Check the appropriate box:
Type of project(required):
1.F�I am a employer with employees(full and/or part-lime)." ], ❑New construction
2.X 1 am a sole proprietor or partnership and have no employees working for me in 8. ®Remodeling
any capacity.[No workers'comp.insurance required.]
9. ❑Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t
4.F-1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.[]Plumbing repairs or additions
5.F_j I am a general contractor and I have hired the subcontractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.l
6f�We are a corporation and its officers have exercised[heir right of exemption per MGL c.
14.Q Other
152,§1(4),and we have no employees.(No workers'comp.insurance required.]
-Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tConnacons that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and jab site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Sob Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
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.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Signature' C- Date rf /Z 1 1 S
Phone#: 'T7 8 7 6 -7 / IS D
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town 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 ajoint 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 building 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 issuance 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-contractor(s)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 appropriate 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 permit/license 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 must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial 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
Massachusetts-Department of Puhiic Safet'a
Board of Building Regulations and Stondards .
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License CS-073991 7r${tt
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stratlon: {29177.ration: 71191211115, Individual
Gerald White
Gerald WMe
23 Glendale Dr
Danvers.MA 01923 ..
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OSice of Consumer Affairs and Bu3ioess Regalatiod
10 Park Plana-Suite 5170
Boston,MA 02116
Nil
Not valid without signature
QTY OF SALEM, MASSAmUSEM
BUILDING DEPARTMENT
120 WASHINGTON STREET,31 mFLOOR
IkL.(978)745-9595
KIPMERLEYDRISCOLL FAX(978)740.9846
MAYOR THOMAS ST.PIERRE
DmECTOR OF PUBLIC PROPERTY/Bu[LDING 0DA&ffSSI0MR
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# z 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:
Co -xca
(name of hauler)
The debris will be disposed of in:
C ------------
O �cGO
(name of facility)
(address of facility)
C_
Signature of applicant
�2-
Date
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All dimensions size designations 7/'1 e'Ir1 j'�, This is an original design and must Designed:3/19/2015
given are subject to verification on ncnn 20P not be released or copied unless Printed:3/19/2015
job site and adjustment to fit job applicable fee has been paid or job
conditions, order placed.
Tisevich orthy wised All Drawing#: 1 I No Scale.
Kitchenworks
978 767 1150
21 A Pickman St,Salem,MA 01970
Flora Tomthat
30 Northey St
Salem
Kitchen project.
1. Remove existing kitchen cabinets, tops and splash, disconnect sink
and appliances and remove remainder of ceiling. $400
2. Remove linoleum from flooring and take up plywood subfloor and
install new insulation. Re-install sub floor where possible, allowed for
2 new sheets of plywood. Labor and materials $875
3. Remove kitchen window, install new shorter window, patch in siding
and install new trim and flashing. Labor and material $950
4. Install all new cabinets including all related cabinet trim including
island cabinets. Total labor $2,650
5. Frame in and duct out new fireplace including building soffit. Total
labor and materials $925
6. Blue board and plaster new ceiling and new fireplace area and patch
by new window. Total labor and materials $1,450
7. Prime and paint ceiling, walls and trim including cost of paint $1,275
8. Not included in above pricing, cabinets, counter tops, tile material or
labor, insulation material, fireplace or ducting materials, electrical,
plumbing or window cost.
Total estimate $8,525