1 PERSHING RD - BUILDING INSPECTION (6) ' �j � (0- 1 � ��03 �� 8
y� The Commonwea(th of Massachusetts CITY OF
` ��a � Board of Building Regulations and Standards SALEM
�,\��J/� Massacliusetts State Building Code, 780 CMR Revised Mar 2011
�u�
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
? �This Section For Official Use Onlq ' , '` �
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BuildingPermitNumber,� '< r _� rt Date"tYppl�ed �
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BuuldtngOffic�aC,(PnntNeme)�.h `-' �`.t ' Signature� k ; , bate
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,';$EGTION:L 5TTE INFORMAT 0 , ' 1 � � . -' ,"
11 Pro ert Address: 1.2 Assessors Ma & Parcel Nambers
p Y ��,�s!„��� R� �
I.1 a Is this an accepted street?yes n� Map Number ' 'Parcel Number �
13 7oning Information: 1.4 Proper!y Dimensions:
Zoning District Proposed Use Lot Area(sq ft) , •�,;Erontage(ft)
1.5 Building Setbaci<s(ft)
� Fron[Yard Side Yuds Reaz Yard
� Required Provided Required Provided Required Provided �
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: I.S Sewage Disposal System:
� Zone: Outside Flood Zone? Munici al 0 On site dis osal system ❑
Public❑ Private❑ Check if yes❑ P P
" �`' "> ' , ��S�'GTION 2'�;�ROPERTY OWNERSHIk' .>°��� a ;� ' �� "
,..,
Ownerl ecord:
�P �, °�o�� � lh�k H���c.�a�t- �.\e�. I�(� o����
� Name rint) City,State,ZIP �'�+.%
� Pecsh��e. R� �1�-sqy-4311 �e�,l,,,.,���cbe _��, � cn
No. and S—treet � Telephone —J�-� Email Address
:SECTION3zDESCRIPTION_QFPROPOSEDWOBK=,(checka,llthatapply) �, ,.
New Construction❑ ExisCing Building❑ Owner-Occupied 0 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brie:D,e�^c;;pt;on o`Propesed\a/o�-4yZ-:
_/�)-0lvl�� C�X/SW//9��In� 9ldO/�9 r7ttiil� ��(t�J���.i�.n
SECTI6N 4 ESTIIVIATED.CONSTRUCTION COSTS �i�
, . v . �
Item Estimated Costs = �� i 'x ' ^ > � ' `� $� .,
Labor and Materials ' �x � ���;x�" � ,:Offictal IIse Only u.
1. Building $ �'��. �j�f-. i`l� Build�g PermitFee $ �` Indicatehowfee is determmed. .
�� �_ :�Standaid Ctty/Town Apphcatiqn Fee
2.Electricat $ ? x 3 t'•`
�Total-Piro�ect Cqst,_(Item 6)x.mulhphex �- x `
3. Plumbing $ �/00 .(J�f. 2'OtherFees $ � �
, '
4. Mechanical (HVAC) $ �List � ' `,'� � � �
s .
5. Mechanical (Fire � Total All Fees $ � ^
S❑ ression � : ._ � � ,.'�' �' � ��
Check No: Ch2ck Ainount 'Cash Amount
6. Total Project Cost: � �3� �i�(�),(�l ',O Paid in:Full O Outstsnding Balarice Due `
�4Jd "R� GprJ'�"'{�.t�c.�.
SECTION 5: CONSTRUCTION SERVICES
�pervisor icense (C L)
AQ5� 7 `S
l t ('r��Gi(,t
rd
License Number Expiration Date
ev C'7"'List
J /
CSL Type (see below) 1//
Type Description
�, /�
C.
U Unrestricted Buildin s u to 35,000 cu. ft.
R Restricted 1&2 Fal Dwellin
City/Town, State, ZIPmiM
Masonr
RC Roofin Coverin
WS Window and Sidin
SF Solid Fuel Burning Appliances
e7�f_ _ ?? ,Qp
����� �Jt7
I Insulation
•
Tele hone Email address
D I Demolition
egister d H ne Improvement Contractor (HIC)
%n3Olo.SHIC Registration Numbere
Qr HIC Regis t Name
gaa�0&9eet
L�Z�A 9 %y G p % p � I�'i�3d�
Email address
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
I, as Owner of the subject property, hereby authorize t7 t �'r '/ !"&lOd aCN
to act on my behalf, in all matters relative to work authorized by this building permit application.
0 l�
Print Okher's Name (Electronic Signature) 3Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION ,r
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
conta' ed in this�aappplicatio is true accurate to the best of my knowledge and understanding.
-and
.D✓ / �l � C�a.C�l
Pru's or Authorized Agent's Name (Electronic Signature) Date
NOTES:
ner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
istered in the Home Improvement Contractor (HIC) Program), will not have access to the arbitration
or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
P2.When
ass.govioca Information on the Construction Supervisor License can be found at www.mass uov/dos
ubstantial work is planned, provide therea
(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
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
"My applicant that checks box 41 must also fill out the section below showing thein 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.
(Contractors that check this box must attached an additional sheet showing the name of the sub -c
employees. If the sub -contractors have employeesontractors and state whether or not those entities have
, they must provide their workers' comp. policy number.
I am an employer that is providing workerscompensation insurance for my employees. Below is the
information. policy and job site
Insurance Company
Policy # or Self -ins. Lic. #: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby
ofperjury that the information provided above is true and correct
�_ Date: 1";7/d7 el Z
Official use only. Do not write in this area, to he 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
6, Other 5. Plumbing Inspector
Contact Person:
Phone
The Commonwealth of Massachusetts
Department of InduslrialAccidems,
Office of Investigations
600 Washington Street
Boston, MA 02111
Workers' Compensation Insurance
www mass.gov/dia
Affidavit: Builders/Contractors/l;lectricians/Plumhers
A licant Information
Please Print Legibly
Name (Business/organization/Individual):
/ Ic+t^
Address: /9�—
City/State/Zip: t
t 0 Phone
Are you an employer? Check the ap ropriate box:
1. ❑ I am a employer with
4. ❑ I am a general contractor and I
Type of project (required):
e�mployees (full and/or part-time).*
have hired the sub-contractors
6. ❑ New construction
2.)K
2• Blom a sole proprietor or partner-
vY
listed on the attached sheet.
7. ❑ Remodeling
ship and have no employees
These sub-contractors have
g, ❑ Demolition
working for me in any capacity.
employees and have workers'
[No workers' comp. insurance
comp. insurance.t
9. ❑ Building addition
required.]
3. ❑ I am a homeowner doing
5. ❑ We are a corporation and its
officers have
10. ❑ Electrical repairs or additions
all work
Myself. [No workers' comp.
exercised [her
right of exemption per MGL
11.0 Plumbing repairs or additions
insurance required.] f
C. 152, § 1(4), and we have no
12. ❑ Roof repairs
employees. [No workers'
13.❑ Other
comp, insurance required.]
"My applicant that checks box 41 must also fill out the section below showing thein 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.
(Contractors that check this box must attached an additional sheet showing the name of the sub -c
employees. If the sub -contractors have employeesontractors and state whether or not those entities have
, they must provide their workers' comp. policy number.
I am an employer that is providing workerscompensation insurance for my employees. Below is the
information. policy and job site
Insurance Company
Policy # or Self -ins. Lic. #: 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby
ofperjury that the information provided above is true and correct
�_ Date: 1";7/d7 el Z
Official use only. Do not write in this area, to he 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
6, Other 5. Plumbing Inspector
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 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, conshuction 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 contractfor the.performance of public work unfit 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 he.
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 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.
The 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
Revised 4-24-07 Fax # 617-727-7749
www.mass.gov/dia
KIMBERLEY DRISCOLL
MAYOR
CITY OF SM.E.NI, Axss.�musETTS
BC tLDLYG DEPARTMENT
120 W.•1sNLYGTON STREET, 3ia FLOOR
TPL (978) 745-9595
F.kX (978) 740-9846
THosw ST.PtERns
DIRECTOR OF PUBLIC PROPERTY/ Bt: ttDLNG CONNISSiONER
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 1 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
111, S 150A.
The debris will be transported by:
(flume of hauler)
The debris will be disposed of in :
(name of facility)
(addre of f�tciiay)
o
eigna re of permit applicant
�t,tte
tome. iU, J.N
Mass. Lic. 025745
Licensed
Insured
Meagan Forbes -Steven Howcroft
1 Pershing Rd.
Salem,Mass.01970
Proposal to remodel Bathroom.
PETER MICHAUD
CRAFTSMAN,
Fine Custom Carpentry
Windows & Doors
Phone # 978 744-2382
Fax # 978 744-4880
H.M. 103065
12 Bridge St
Salem, MA 01970
12/21/13
Obtain permit.
Demolish existing bathroom.
Insulate as needed
Supply plumber to install customers fixtures,tub shower valve,toilet sink and faucet.
Supply and replace baseboared heat.
Supply electrician to preform all necessary electrical work.
Supply and install electric heat on floor.
Install cement board on floor and shower area.
Install blueboard and plaster walls and ceiling.
Install customers tile and grout on floor and shower area.
Install vanity and all customers accessories in bathroom.
Install all necessary interior trim.
Remove and dispose of all job debris.
Payment terms
Estimate $13,600.00
Start of job $5,600.00
Upon rough inspections $4,000.00
Upon final inspections $4,000.00
Total $13,600.00
Thank You,