19 NURSERY ST - BUILDING INSPECTION (2) � 112 �I< tlg
4
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
T / Massachusetts State Building Code, 780 CMR Revised-alur 2011
�- Building Permit Application To Construct, Repair, Renovate Or Demolish a o
_ One-or Two-Family Dwelling "' m
This Section For Official Use Onl
^ Building Permit Number: Date Applied:
J , �t
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Building Official(Print Name). Signature -L1
SECTION 1:SITE INFORMATION —
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers co
1.1 a Is this an accepted street?yes A no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
s log rAGfES
"tuning District Proposed Use Lot Area(sq R) Frontage(It)
LS Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Reyuircd Provided Required
Requirc= Provided Required Provided
1 Z Z5
1.6 Water Supply:(b1.G.L c.40,§Sd) 1.7 Fload Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipaj 6 On site disposal system ❑
Public Private❑ Check if es❑
SECTION2. PROPERTY OWNERSHIP"
2.1 Owner'of Record:
11eo ore 5vr, Sec)ff m
�me(Print) City.State,ZIP
19 La &:,rtl loan �g + 9a9 046.1 tJ er`r 24%N Lf
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) d Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work : < 1 -�at lL s&e- 444 ' + A t7 7 \/ :^ 6e-k
�GCP Flao WGI�^C' h��}L� +
lL v` b b �- r'• �
SECTION a: ESTIMATED CONSTRUCTION COSTS
Itctn Estimated Costs: Official Use Only
Labor and Materials)
1. Building S 3 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost?(Item 6)x multiplier x
3. Plumbing 1S S P Qther Fees: S
d.�Nlechannical (FIVAC) S - List:
S. \Mechanical (Fire ,S "total All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:
6. "rut:d Project Cost: S �� 00 d ❑Paid in Full ❑Outstanding Balance Due:
, l
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisoor Liic`ense(CSL) C-s-09 as(oa I)- ) 7
1 K eo ®b'4' e LT )m 1 r k .Y(Z— License Number Expiration Date
Name of CSL Holder List CSL Type(see below) U
19 Lou re' (-(71) 4a type Description
No. and Street
U Unrestricted DuilJin a to 35,000 cu. 11.
SW l� dh p5Lp ✓1'1A— C) I !7 R Restricted ILHF:unil Dwellin
City/fown,State,"ZIP M Masonry
RC Roaring Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
4-31 9 a-9 6.>2(ocl 4f614 S r1r f�Ce uti°On "_yy 1 Insulation
Telephone omit address . D I Demolition
5.2 Registered Home Improvement Contractor(HIC) 1 ,9a 9 9 a t
-r k e o d o f- 3 S Y-^ 4-1- v HIC Registration Number Expiration Date
I I IC Cump:my Name or IIIC Registrant Nunnd d y s .` � I_¢.l��1 QO gt) �'1.@VL°c'r Z4v� , ne
No.and Street Email address
9 e~t a »+03c atr+ tail- 019o'7 752 4a 9 oa Ke
City/town,State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L e.152.$25.0(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 Isluance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 70.OWNE .AUTHORIZATION.TO BE COMPLETED WHEN
OWNER'S AGENTORCONTRACTORAPPLIES FOR BUILDING PERMIT°
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.
`11' eodore T SMI " Tic— OLI-. / a, a0l S
Pont 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 NI.G.L.c. 142A. Other important information on the HIC Program can be found at
wwvv nMs,eov:'oca Information on the Construction Supervisor License can be found at wvow.mass.aov:! _
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) 'x .(including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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 ofcoolingSystem Enclosed Open
3. "I'otal Project Square Footage'may be substituted for"rotal Project Cost"
Lj CITY OF SALEA MMSACHUSE M
BmDING DEPAR7wNI
120 WASiM4GTONSUEET,3'0FLOOR
7kL(978)745-9595.
KINDERLEYDRISCOLL FAX(978)740-9846
MAYOR 7�r STAEM
DntEcrcRoppLmijcpjtopERTY/Bu[LD=cmausgomR
Construction Debris Disposa/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:
Co yr S
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
r9t i Z, uJ s
Date
( The Commonwealth ofMassaehuseM
Department oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
UW www.massgov/din
Workers'Compensation Insurance Affidavit:Builders/Contractors/Elechicians/Plumbers.
TO BE FfLED R'ITH THE PERAffrn VG AUTHORITY.
Applicant Information Please Print Leeibly
Name(Business/organmtion/fndividual): I/1 ed d P<'e 7 S{/hi Tyr .Tte—
Address: 19 Lta Lc 0e t 4d 4O
City/State/Zip: SuJt4✓Y1 PSCD l�Y/ff Phone#: S/I 7j9 Qa (p 01
Are you an employerr Cheek the appropriate box: '
L14.00ther
Project(requhred):
I.❑I am a employer with creploym(full end/orpart-time).' -
ewconsWction
2. mg
�/]I am a sole pnquietoror partnership and have no empbyaa wol)<tng forme m Pmode,
Puy capacity.[No workers'comp.iosmsrice required) -"...
3. I am a homeowner as work 1 emolition
Q. gbasg myself.[No workers'coup-insumoce required.]
uilding addition.
4.O I am a homeowner and wID be hiring contractors to coat all work on my property. I wall
emme that all contractors either have workers'compensation insurance or are tole ectrical repairs or additions
proprietors with ao employees.
5.�7®a general contractor and l have hired the sub-contractors listed on the attached sheet Plumbing repairs of additions
these sub-contractors have employees and have worker's'comp,imnrarce} of repairs.
6.Q We are a corporation and its officers have exercised fink right of exemption par MGL c. her -
15Z§I(4),and we have no employm.[No workers'camp:mwusnce required.]
-Any applicant that checks box ell must also 6a end the sermon below showing theft workers'compensation policy iafoimetion.- -
t Homeowners who submit this affidavit ihdia�g they art doing all work and then hire outside contractors most robin@ a chew affidavit indicating such.
tContreclon that check this box most attached an additional sheet showing the name of the sub-cohtractma and state whether or not those entries;have
employm. If the subcontractor have employees,they must provide thea.wmkas'. oli comber.
comp•P cr .
I am an employer that isproviding tvorhers'compensation insaraacejm my employees. Below is thepolicy and job site
inforina&IL
Insurance Company Name:
Policy#or Self-his.Lic.M Expiration Date: -
Job 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 certi der epainsandpetfiftles ofperjury that the information provided``above is true and eorrec
-4 t
Signal... Date: OC . �a o9
y
Phone#: TS I 949 040 J\
Official use only. Do not write in this area,to he completed by city or town offteial
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 wrium."
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 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 i wUrance
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 perrint/liccose 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 roust 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 dqg 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. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Commonwealth of Massachusetts
City of Salem
120 Washington St,3rd Floor Salem,MA 01970 978 745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Permit No. B-15-844
FEE PAID: $357.00 PERMIT TO BOUBILOUO4"
DATE ISSUED: 8120/2015
This certifies that SMITH THEODORE J SMITH KATHERINE V
has permission to erect, alter, or demolish a building ,�',19.NURSERY STREET Map/Lot: 270158-0
k s
as follows: Renovation GUT KITCHEN &'BATHROOM, SAND FLOORS;,PAINT, NEW WINDOWS
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Contractor Name: THEODORE J. SMITH JR
Contractor License No: 092562
$ rt
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I�RI .'ryes t �pd 8/20/2015
qrtym
r ,I Building Off�i[c[ialq " ,. Date
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This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request ,
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All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
All construction,alterations and changes of use of any'bulld�ing and structures shall be in compliance with the local zoning,by-laws and codes.
This permit shall be displayed in a location clearly visiblem�fro access street or road and shall be maintained open forr
public inspection for the entire duration of the
work until the completion of the same. I'1�'�
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit. _
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'wo,
HIC.#: Persons contracting with unregistered contractors do not Faye access to the guaranty fund"(asset forth in MGL c.142A).
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Restrictions: n � a . ;
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Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.