2 OLIVER ST - BUILDING INSPECTION I The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM'Ol!
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised alur_
One-or Two-Enmity Dwelling
This Secti n For Official Use Only
Building Perini[Number: I - I Date Applied:
C
Building 0 icial(Prin Name) Signatures
SECTION 1:SITE INFORMATION
1.1 Property Address: 2 a4vER S7 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accep ed 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 O n t o{Record•
U! t) �(JNeS fflhelliI -
Nwne(Print) LL City,State,ZIP ^1
� � �AIfCSh�N�JO/✓ SG!/G�f'� (e�"]'3S`I"�633 T
No. mid Street T Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) �❑/Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other CYSpecity:
Brief Description of Proposed Work': cello&Xfg ��✓ ��� J t i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4—Mechanical (11VAC) S List:
5. Mechanical (Fire S Total All Fees:$
Su ression)
7so� Check No._Check Amount: Cash Amount:
6. Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
h1v
i��r;'�e le� , aa
r rn/r a ou,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
��/L!y� / /0.�lo.Z 7D%'O,
G Ake"j d� License Number Name ol'CSL Ilolder.fTT� G✓O/G/(/LL`/ S'` List CSL Type(see below)No. and Street 'Tv��11Unrestricted B000 cu. It.6dv,0%%n,.�17 //9�9" /S.�l/ R Restricted 1&2
City/Town,State.ZIP km
Mason
RC Rootin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tcle Iwne Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) / !Y / //
/ "it— sP0/��6�//Y
HIC Registration Number Expiration Date
1 TIC' ompany Name or I IIC Registrant ame
No. and Street Email address
City/Town, State,ZIP Telc hone
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
I, as Owner o ubject property, hereby authorize_ �/Ci�
to a my be If,it matters re ' to work authorized by this building permit application.
Print ner's Na (Electr t tc Signature) oDute
SECTION 7b:OWNEW OR AUTHORIZED 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.
Pnnt Owner s or Authonzed Agent's Name(Electronic Signature) pale
NOTES:
1. 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 riot 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
>«�g_rn>u,��•os_'ogi Information on the Construction Supervisor License can be found at to�tw.iiia s.guv41L
2. When substmttial work is planned, provide the information below:
Total Floor area(sq. ff.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths _
T%pe of heating system Number ofdecks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost" --
II
M�� CITY OF SALEM
� PUBLIC PROPRERTY
DEPARTMENT
.i tea a:1 r:,a1N 011
\Itstnt
12:\trTMITI l l�ilxfL•T • inI B.N,M.1i5A1.111 d 1 Iv J197v
11:1:77b71i'Ji•fi a 1'.ts. 1711•74C•'1x46
Workers' Cumpenaallon Insurance AtOdavit: Builders/Cuntracturs/Electricians/Plumbers
%Q011cant Infnrin'ation Please Print Le -My
NOITIe �d $Y/J'9'G 6f1W�0' ✓/:p,
r
Address: G ,?:Gydv ,Cif
Cily,Sf.uc.7.ip: >•/ Montt
\re I t an employer:'Check the appropriate boa:
II. I ;Im it employer wish_-D, 4. ❑ 1 am a general contractor and 1 I>Pa air prvljoct(required):
cnlPluyccs(lull and/ur part-time).• huve hired the sub-comracturs 6. O New construction
2.C I am a sale pmpricntr or partner- listed on the anachcd sheet. 7• ❑ Remodeling
ship and have no cmpluyccs These sub-contractors have 11. C Demolition
working Iilr was:in any capacity, workers'comp. insurance.
I Na workers'cutup. insurance I C We Willa ew 9• ❑ OuiWing aJJititm
porstinn and is
required.) 011''Icen have cxereisc•J Ihcir IO.0 Elecrrteal«pain or additions
3.C I and it homcanvner doing all work right of exemption per h1 a 11.0 Plumbing repairs or additions
myself. [No workers'comp, c. 157,§1(4),anJ we have nil 12.0 Ruul'apaid insurance required.j t cmpluyccs.(No worked'
comp, insurance r apair d.J 13.0 Other
•111y.,phcal dial Owcha bw of mu4 alw rill uW the v:ebdn hvluw aluwina'heir wwhow,cunlpetts,I policy iofurtrtmiuta
'I lumm,wmn who sta,mit this an7davir indiuiins they are doing all wurk and'hen Ain twnide cu,nrnuon mwI.Mmol a now a rldlivit ir,Jivalmy vtall.
•r„ntrwnwv thm eA.xk this boa,tart anand an aaditiuwl shaW,M,wina llle name ortlar etb.eenraelallat-nd rhea wu,4an'tvmy.p>,drey tntbrmanue,
/tun an earptoyer thut Ir pruvld/nx workers,rompetarndon lnturance jar/try e/npluyenr. Be/aly!s/he par/!sy and/ub site
/a/drrnutinn
Insurance Crimpany Valne: 4 /AN2*wd /z-^'T �O
_.Expiration Date: 2 /L_ .
JubSiWAddress: 33 Was�tr>r S9-� C'u YState/LI p:—St-1e 0,*1--
Attach a copy of Ilto workars' cumponsation pulley declarationpuKe(showing the policy number end explraNun date).
Failure to securo cavtmge as required uoJcr Section 25A ul'SIGL c. 152 can lead to the imposition ot'eriminal penalties of a
line up nI s 1.500.01)and/or one-year imprisonment, as well as civil pcnulncs in the 1'unn of a STOP WORK GIRDER and a fine
of up ro S250 00"Jay.Igainst flit violahv. Ile advised that 4 copy orthis wutemuttt may be STOP W w Ihu ORDER
a
I IIP��IhJIIOIIa ul fllu DIA par Ithtl(:11:ee piY eft- •L'\el'1nGJl(aln.
/du hereby.rr/i/y udder Ihr p arJ pep is ' v/per"ry thW d#e"Our"uNon provided above is true and correr6
ant a'uurc
y
(411ial rr.st dilly. Donal write in thin urea,/u be ruotp/rted by city or town a//JriuL
l
('ity or 1'11trn: _. Pcnnit/LItt•nse tl. I
Issuing Atilhurily (circlo onc):
I, lh,ard of Ilvalth 2. I11liWiu•4 M13.4runcut I, l:il1:'I•utut Clerk 4• l•'Icctrical lnspector S. Plumbing Inspector i
6. Other
l'�nuael t'c nuu:
. _._ Phone '!:
I
Information and Instructions
\I:Iii.1e1lusells(JCOeral Laws chaptef 1 J2 1'equlres all C111ploye s to prov l.jon In the 3Cry LC of another W1 pelflolly c ntmct fk)f their loflhire.s•
1'arsuan,to This aalune, an emplus•rr is de ined as"..every pe
c%preas or unplieJ, oral or written."
\n employer Is defined as"an individual,purtncrship,association,corporation or other legal nary,or any two f' more
t ihu IJfeSJing engaged In a Joint enterprise, and inciulktlg the legal representatives Of a dcetased employer,Jr he
of th V t e uilli; a nl•engaged
individual,)dual, pantmenhip,At his
or other legal entity,employing employees. However the
-in
owner of a dwelling house having not more than three d w
to o maintenance,ents unhtru�resides
repair work nerain.or the nsw h Jwcupant alling house
.hvclhng Iwusd of another who employ. persons
or on the grounds Jr building
appurtenant thereto shall not because of such employment be deemeJ to be an employer.'
�IGL chapter 152, Q'_SC(6) also states that"every state or local licensing agency shag withhold the Issuance or
renewal of a license or per to operate a business or to construct buildings In the commonwealth for any
Ippllcunt oils has not prndu�ed acceptable Neithece r hen commonwealth alth not any of its political Ills the insurance giubdiv stuns ihall
\ddiliunally,MGL chupter I S_, �. l )
enter into any contract for the pertomwnce ul'public work until acceptlble widence of wnlpli sue with the insurance
requiremcnls of his chapter have been presented to the contracting authority."
Appincanls
please till.wt the worker' compensation afidavit cacyplaentdelyhone numbers)along with Chair rtiticrte(s)of situationing ilia boxes that apply to your and,if
necessary,supply sub-contraclor(s)nume(s), address( ) P with
insurance. Limited Liability Companies(LLCworkers'Limitcom ced ompensation oility n insurance.(If an)LLC oroLLP does have
er than the
member or partners, are not required to carry
employees,u policy is required. Be advised that this affidavit nosy be submitted tand o the he uMdaviL li industrial
he Accidents
ider s for confirmationile ry town thatah ce covrgrago. Also be apon cation for the permiteoroli its is beinglrequested,rnot he lhpartment of should
Industrial Accidenu. Should you have any questions regarding the low or if you ace required to obtain u workers'
industrial
Acompensation policy.please call the Department at the number listed below. Self-insumd companies should enter their
self-insurnce license number on the appro riuto lino.
City or Town Ofrlclals
Pcax-be sure that the affidavit is complete and printed legibly. The Department hus provided u space ut'the bottom
Of rile affidavit for you to fill out in rile event the Orrce of Investigations has to contact you regarding the applicant.
p ermitilicellse(lumbar which will be used as a reference uulilber. in
!'pause be sure to fill in he addition,an applicant
nnitllicallse applications in any given year,need only submit one
davit indicating current
that must submit multiple I
Policy inform y of he affidavit necessary)
has been offtc ully taice mped or mar the ked Ibyvthe city or town)may be provided to he or
Y P
town). d tinder"Job S
" A cJPY
applicant as proof that A vulid affidavit is on file for furor permits Of licenses. A now alTSdav$ must m tilled out each
venture
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venter
tie it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
1 he 1)11icc u(Investigations wuuld like to drank you in advance fur your cooperation and shuuld you huec:my yucsuons,
picabe du nun hesitate to give us a call.
fhe Udp:lrtlneltl'isddress, felCphone and fax number.
The Commonwealth of M=achusetta
Department of Industrial Accidents
o lee of IsvesdQsdons
600 Washington Street
Boston, MA 02111
'rel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
(:1.1,,d :-'n-ns www.man.gov/dia
{i
° CITY OF S.U..E.NI, UxssikaiUSETTS
• BL DLNG DEPARTMENT
130 W.ASHLNGTON STREET, 3'FLOOR
TEL (978) 745-959S
FAX(978) 740.9846
KINMERLEY DRISCOLL
T
MAYOR Ttows StPtERas
Dtmcroa OF PCBLIc PROPERTY/MaXI YG COMMISSIONER
Construction Debris Disposal At'fidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 11.5
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
l 11, S 150A.
The debris will be transported by:
41-d v
(name of auler)
The debris will be disposed of in
j aS ..L�
(name of facility)
(address of facility)
atur o ermit applicant
slate
Jabna,Rd,q
••r' �`�rV�te.:.T00nvOta/t!iFG� �
h � x Board of Building Regulations tb
�S,
HOME IMPROVEMENT CONE-0
— "
r RegistraBn:or 163361
. Expiration -:61M011 Trll �,265
Type: Individual
tv
x1
K.D.GOODHUE 11
MARK GOODHUE 4
s� x '555 WQRCCESTER ST APT 905"
QUTHBRIDEGE,MA 01550 r AJrpmn,r.�M�'
, - Massnehusetts-dep:lrtmtnt of PuBlic Safct�
�; Bnard rf BuildinL Regnihl inn+and St:ln:* , 'f
J Construction Supervisor License
License: CS 102402 I
t
.�- Restricted to: 00 !` _
MARK GOODHUE
555 WORCESTER ST UNIT 105
SOUTHBRIDGE,MA 01550
y� Expiration: 3W"12l .�
��- /T Tr#: 102402