20 OSBORNE ST - BUILDING INSPECTION I lie Coil' monwealIll of Massachusetts
Board of Building Regulations andStandards CI fl'OF
r c, Massachusetts State Building Code. 780 C'MR SALEM
Building Permit Application "ro Construct. Repair. Renovate Or Demolish a
C\\ One-or To -Family Du rlliu.C+
this Section For t p Use Only —
,�(Jl Building Permit Number: Date Appli•J: 20 It y
Building 011icial(Print Maine) Sign lure D Ic
SECTION 1:SITE INFO IATION
LI Property Address: 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes ✓ no Map Numhcr Parcel Numhcr
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District I'ropus (jUse Lot Area(sq II) Frontage(II)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Reyuircd Provided Reyuircd Provided
1.6 Water upply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
A / Public Private❑ zone: _ Outside Flood Zone? Municipal❑ On site disposal v Check it' es❑ p system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 wnerl of Record:
1-11 L ( �' �i • l�cNr�>>NI
Name(Print) City.Slate.ZIP t
No.and Street
Telephone Finail A •ss
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
NewConstruction❑ E.xistingBuilding wner-Occupied Gr Repairsts) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other tSSpccily: ':& g
Brief Description of Proposed Work-: Vtn;i SAIns Fro 'T O
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labur and \laterialsl Official Use Only
I. Building S —1/900. o O I. Building Permit Fee: S Indicate how fee is determined:
'_. Vlectrical S ❑Standard CityrTosvn Application Fee
❑Total Project Cost'(Item 6)x multiplier
1. Plumbing S ?. Other Fees: S -
J. \IMmilicat i li AC) S LisC_
S. .\Icchanicat tFire
tit+treesionl S Total .\II Fees: S
o. Total Project Crest: S q9pp Check Nu. _ _('hak :\nunuu: . __.--- l'sh:\nnnun:
900• ❑Paid in Full ❑Outstanding Bahmce Due:
SECTION 5: CONSTRUC'rION SERVICES
5.1 C'ottstructionSupervisort.icense(C'SI.) 1/-22-2013
I howr�S 5' Ii ertci Liceme Number fxpirnion Date
Nuntc ul'l'SLpI IolJcr
�( 1Ud'c.`•-WSe 5T Iisl Ctil. l')Ix l,Qc hcluol
Na. ,ilia Strst ------ --- ------'------- .I)Pe Description
U Unrestricted(lluildin n ti t» 11-500 nl. IT.)
R "ell *led I tt:2 Famil l Dsscllin
Cit)ifuwn.Sane,/IP N1I pLt6on
RC J Rooling Covering
_._._ WS W'Indotv;md.Sidin
SF I Solid Fuel flurning:lippliances
�F-�7Y�2YtF0 _ IjGC.O+sQ A 0 L I Insulation
fele hone Fntail address I D I Demolition
5.2 Registered Home Improvement Contractor(1111C) 1a$a92 3 zz ZrX3
omgg S t`vJCn q 11IC•Registration Numhcr Expiration Dale
I IIC'C'onlpan) Ni ror IIIC'Itegistruni Name
Si � �1woC, cT' TrGCOrxC tAOI. . Cor+1
Nu tJ Swet Email address
�,sCrs otg�3 R��-»v-zyvo
City/Town.State,ZIP talc 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 AI}idavil Attached? Yes ..........I No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 1 tI.r,w% SLC rtC%
to act on my behalf,in all matters relative to work authorized by this building permit application.
C-�0k) � c, iG a611
Print Owner's Nwne(Electronic Signature) Da
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.
/ riry -s S,�1/Z?-kQ /2-19-zoll
Print Owners or:\u0urriicd,\gcnt's Name I FIcciranic Sigmaure) Date
NOTES:
I. An Owner who obtains a building permit to do his,her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program),will no have access to the arbitration
program or guaranty fund under\I.G.L.c. 1 a_'A.Other important information on the HIC Program can be found at
\fait n,.r., \ "A Information on the Construction Supervisor License can be found at it%t tt wa,: �w II„
2. \Then substantial twrk is planned, provide the information below:
Total flour area(sq. fl.) _ 1 including garage. finished bascment attics,decks or porch)
Gross fiv ing area Isy. 11.1 _ _ Habitable room count
\unlherof fireplaces__. Number ofliedrooms -
iNunther tit bathrooms \untbcroflialfhalhs
I�pe of heating system _ . .. Number of decks, porches - -.
i
I l Ile of Cooling ]y i1e111 Fincloied 011en
t "Iotal Project Stluxe Footage"m;tv he substinncd tly'folal Project Cast.
CITY OF SALEM, Akss.ICHUSETI'S
BLMDLNG DEF.IRTtENT
120 W-ts' 4GTON STRERT, )10 FLOOR
nL (978) 745-9595
WM RI Y DRMOLL FVt(978) 740-984
MAYOR Tkosau ST.Pmus
❑IRE(17011t OF pLBL)C pROFHR7y/9Lp pL%,G COdL\I(SSIONER
Construction Debris Disposal Afttdavit
(required for all demolition and rcnovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.S
Debris, and the provisions of MOL c 40, S 54;
Building permit g is issued with the condition that the debris resulting from
this work shall be disposcd of in a properly licensed waste I.If. S ISOA. disposal facility as defined by(rICL c
The debris will be transported by:
(mane of hauler)
The debris will be disposed of in
., Tow vvva
(jddraua or•rjjy)
dn�mre ofpermrt ipphunt
CITY OF SM.E.Ms Alin ikCHUSETTS
` BUILDING DEPARTNLEINT
120 WASHINGTON STREET, 3'a FLOOR
T EL (978) 745-9595
F.+x(973) 740-9846
K1.tBFRi EY MUSCOLL
AYOR 7HONW ST.PIFARH
DIRECTOR OF PUBLIC PROPERTY/BUIMNG COMMISSIONER
1Yorkers' Compensation insurance Affidavit: Builders/Contraetorg/Electricians/Plumbers
Aoollcant Information Please Print Levihly
�1;II71C lnusitxis Organiraliom'Imlividuaf): 1 horWa S �,\Jcd'�ot
Address: -�Tl Pu"se_ S
City/State/Zip: 1Anver-S fvr� 019-IS Phonelt:
Are nu an employer?Check the appropriate box: Type of project(required):
1.LrJ I am a employer with�_ 4. El I am a general contractor and l 6. New construction
employees(full and/or part-time).' have hired the sutacontractorx
2.❑ I am a sole proprietor or partner- listed on the attached sheet. : 7• ❑Remodeling
ship and have no employees These sub-contmctors have g. Demolition
working for me in any capacity. workers'comp.insurance. y. Building addition
(No workers comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.LNo workers' t�
comp. insursncerequireJ.J 13.@-Olher aaalnca
Any appli,am dui checks box of most alau fill cut Ihv section below showing their waken'compenvdun policy inf amation.
t I v"eurnen whe,uhn it this ailldnvil indicating ihey am doing all work and than him outside contncmn mint suhmil anew atrdzvit indicating rush.
:('entrxtun thal chvsk this box meal anachod an additional ahesl showing aw nwna of the subtamracton and their wnrken'mmp.policy infennation.
fain un euployer that it providing worker'compeusatlon htsurance for myoyees; Below is!!u po!!cy and Jub site
inforarrutiaa _ LL i empl ,1
InsuranceConlpanyName: -J-aarT.� �A.. AIA CATuR,I `y �y.,S do .
Policy 4 or Sclf-ins. Lic. 0: r7�`,C &, (o g'S I 1 Expiration Date: 7 — Z 9 —2,0 1
Job Site Address; aD City/State/Zip: CD 0-70
.Attach a copy of the workers' compensation policy declaration page(showing the policy number and explratlon data).
Failure to secure coverage as required under Section 23A of VIOL c. 152 can lead to the imposition ofcriminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of ap to S250.00 a day against the violator. 13e advised that a copy Of this statement may be furwardcd to the Office of
Invcstigaliuns Ofdle DIA rar insurance coverage verification.
1 do hereby ceruy under a pa( ujperjury that the infurmwlou provide)above i.T true and correct.
ZZ
urC' pntd: _/2-Lo-i I
F[u nuour wrNe in this ureµ ro be completed by city or town aJJiiuL
rIatvn:,\ulhurily (circle unc):
rd Of lie-Ah ?. Building Deparuncnt .3.Ci(yitown Clerk 4. Electrical lnspector 5. Plumbing luspeetor
ft Person---- - . -_. Phanc,'l: — 1
I
Information and Instructions
\lassachusclts Gcneral 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, g25C(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)nume(s),address(es)and phone numbers)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 gown 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 till in the permittlicense 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 rile for future permits or licenses. A new affidavit must be filled out each
year. Where a(tome 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 bum leaves etc.)said person is NOT required to complete this affidavit.
The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
Re Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
Tel. #617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
2eviicd j-26-05 www.mass.gov/dia
I, < Office of Consumer rr�Affairs&Bfines Regulatioo�
HOME IMPROVEMENT CONTRACTOR
- = Registration , 128292 Type:
Expiration 3/22/2013 DBA ,
c c.m.-
T. VERIA PROPERTY.SERVIG $ .
h � 1,
THOMAS SILVERII
` 51 PURCHASE ST
DANVERS,MA 07923 Undersecretary
tiYl Massachusetts-Department Regulations and Standards
Board of Building
Gmstruc[iun Super,isur
License: CS-070245
T'jo"H SfLURL& r?:
SB STNiT
51 PURCM
DAIIVERS MA 0
y
�� [Hi•� Expiration .
Commissioner
11/22/2013