6-8 POPE ST - BUILDING INSPECTION (2) • J
T - The ('onuuomceaIth of A9as sac III set(
1 t Board Of 13ulldiug Regulations and Standards Pt 112
� NI( .Nit III.ALJ I )
i %'IaSSachLISCttS State 13wlding Code. 7So (AIR. 71" edition
SI!
Building Permit Application To ( onsu'urt. Repair. Rcnu\ate Or Dcntulislt a It t n J lnntu t �
Cw Oar- to Tlrn-FllmiA Duelling 'rms
!'his Section For Official Use Oink,
Building Permit Nun /err: Date Applied:
Buddhtg Conunu+lolled Inspector of liuddt t Date
SECTION : SITE INFORMA HON
1.1 Pro erty 4ddress:l 1.2 Assessors Map & Parcel Numbers �
- ��o� Sfrzer
/ I ✓ Ala Nunher Panel ,Nunthcr
la Is this an accepted street Yes__ no__-_ p
1.3 Zoning Information: La Pro B erty Dimensions:
--
Zontng District Proposed Use [,.of Area(sq it) Fronmee (It)
1.5 Building Setbacks (ft)
Runt Yard Side lards Roar Y:ud
! Required Provided Required Provided Rcquued PnniJcJ __-
Lfi Water Supply: (M.G.L e. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
/ Zone: _ Outside Flood Zone' Municipal 011,011 site disposal s)aetn ❑
Public lS� Priest'❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of R r �f
,c.1a u ,
Name (Prim) 11nn Address for Service9 -71
Siena �� relephone
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction GriExisting Building ❑ Owner-Occupied ❑ ii Repaints) ❑ Al ter:ltion(s) ❑ Additilm ❑
Demolition El Accessory Bldg. ❑ Number of Units Z Other ❑ Spee ry _
Brie(Descr�t pion of Proposed Work'':
SECTION J: ESTIMATED CONSTRUCT ON COSTS
Estimated Costs:
Ve n Official Use Only
1!_abut and Nlateriahl
I. 13uilJine S I. Building Permit Fee: $ Indicate how tee is Jet,:[nu tied:
❑ Standard Cilyfrown :Application Fee I
2. Electrical ❑S T t
utu! Project Glar (Item 6) x multiplier e
1. Plumbing I 2. Other Fees: S
4. Mechanical (FiV List:
:1C) S � ---- �
i. N-lechani"d (Fire Tolal All Fees: --
Sua resoion)
Check No. Check Amount: ('ash .AnuwnL
b. Total Project Cost: 'S $•Ol DUU ❑ Paid to Full ❑ Outsrtndine Balance Due:---
ors ; io s-
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor WSL) r
_ CGf� ` l_irrn.r :\'uinhcr F.>pir:won D;ue
Namr ul'C'SL- Iloldcr
Iasi C51_ "I'cpe (sce hrlov,)
\ re's n•
� - �f. c Dc. awn
C� l'nFln o�ilyd l n: 1;.I0
0 Cu Ft.)
i � Reslnclad I�_' F:muh Ds�rllima
,i_n:uure M AI:uonn Unlv
RC Rc,ldcnual Roollne (oNcnne,
Trlephunc N'.S ILCsidenu,d %1 HLIMI .md S:shn_-
SF RiII&M:al Solid I uel Burring A : di,InCC In.1A1,W'.11
D RC>idrnlyd DC111011n:,n
5.2 Registered Ilome Itnprurement Contractor (HIC)
HIC Company Nome or HIC RL rn naril Nunle RCgutr:nion Nmuhrr
Address
F cpira[ion Ualc
Signature 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 app Gcation. Fulure 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
1, as Owner of the Subject property hereby
authorize to act on my behalf. in all nmtcrs
relative to work authorized by this building permit application.
Signature of Owner Dale
SECTION
7b: OWNEW OR AUTHORIZED AGENT DECLARATION
)• /�.�D e/ CJ as Owner or Authorized Agent hereby declare
that the statements and information t the foregoing application are true and accurate, to the best of my knowledge and
� behalf.
Pant .Name
Signature of Owner or Authorized Agent Date
1 Si med under the gins and enaltics of e(urvl
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 tubitr:uion
program or guaranty find under M.G.L. c. 142A. Other important information on the HIC Prour:un and
Construction Supervisor Licensing (CSL) can be found in 780 CNIR Regulations I IO.RG and 110,R5. respectively.
' When +ribstantlal work is planned, provide the information below:
Toml floors area (Sy. Ft.l )including garage, finished basement/attics. decks :v porchi
Gross living area i Sy. Ft.) Habitable room count —
Number of fireplaces dumber or bed roorns
Number of bathroonts :Number of h:dObaths
TI pe of heating svLacin Number or dccke/ porchco
Fypc of cooling system Fneloscd ()pen _
z Total Project Square Footage• may be substituted firr 'Total Project Cost-
J
/5 O30G `]
05 - 03 ate) —1
CITY OF SALEM
ROUTING SLIP
NEW CONSTRUCTION
CEWMCATE OF OCCUPANCY
LOCATION: %�YN_ . Sfi GLf DATE
APPLICANT:
ASSESSORS -2 S'O 8
FRAM[ICiJLIY • DATE:
(93 wuhinpon Street) n/� n� 00
C awrry I e,,,0 Q r fM.f( � DATE: - .r-6
cI>$HE CI BRY Rn LAPO
(93 wuhingros Street)
PUBLICR SERVICES\ 1 _ DATE:
(1`bo Washington Street)4
WATER
DOTRIR THIBODEAU ATE: a
(i 20 Washington Street)4°Floor
CROSS CONNECT SUPERVISOR
BRIAN THIBODBAU ATE:
(S Jefferson Avenue) U
PLANNING - oj_L� f` DATE: oi z, b)
(I2u Washington Street)P Floar
CONSERVATION COMMISSION
DATE: 27
(120 Washington Str«q 3� oor
ELECTRICAL
JOHN GIARDI
(48 Lafayette Str«t
FIRE P O
ERIN GRIFFIN DATE:-='L
(29 Fors Avenue)
HEALTH
JOANNBSCOTT_ DATE:
(l20 Washington Str�; Floor, e
BUILDING 25J oP
THOMAS ST. PIERRE DATE:
(120 Washington Street) r
Oil
CITY OF SALEM
PUBLIC PROPRERTY
DEPARVvIENT
Construction Debris Disposal affidavit
(required for all demolition aiid renovation work)
In accordance with the sixth edition of the State Building Code, 7S0 C\IR section l 11.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit a _ is issued with the condition that the debris resulting from
;his work shall be disposed of in a properly licensed waste disposal facility as define by MGL c
1 l 1, S 150A.
The debris will be transported by:
— - (name of haular)
I'h.e ,!�:bris Dill be disposed of in
_� Vt. ').f S
CITY OF SALEM
3
PUBLIC PROPRERTY
DEPARTMENT
\1.\` `K I': \\'.\,I t;N� i, %'S IitIt I ♦ 5.\I i\t, \1 :19-:
l'Ihl . 9'8--.i -`h95 • F vS: 978
Workers' Compensation Insurance Afiida%it: Builders/Contraetors/Electricians/Plumbers
A t li\ant Information r� /` c Please Print I_e iJbly
F
11I11C t liusmras t trc:uuvaU/m lndl\t,luul l: 5 A S 1
�4
City, Statc:Lip:
I3 Lem � aPhone .#: ell S' " go-73� Cy
Are you an employer:' Check the appropriate box: "rvpe of project(required):
I.❑ I :tin a employer with 4. ❑ 1 am a general contractor and 1 6. ❑ New construction
employees (full andior part-time).' have hired the SUb-contract Ors
?.[,� I am a sole proprietor or partner-
listed on the attached sheet. 7. ❑ Remodeling
ship and have no employees -these sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. y. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ ! sun a homeowner doing all work b P n rht or exemption tion per NIGL l L❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, $t(4), and we have no 12.0 Roof repairs
insurance required.] employees. [No workers' 13.❑ Other
comp. insurance required-]
•:\uy epplicant that checks boz ill must also till out the section below showing their workers'compensation policy information
t l lonteowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
�('ontr,¢hrrs that check this boa must attached an additional sheet showing the name of the sub-contractors and their workers'comp. policy information.
l urn an employer that is providing workers'cntnpen.sution insurance for my employees. Below is the policy and job site
m y infor ation. �. ' '�' 3..+ • -I-�. -Z -T`5 pC c,&'
Insurance Company Name: N
Policy q or Self-ins. Lic. q: Expiration Date:
Job Site Address: G — O �t S '1A t e t City/State/Zip: G L�l 7 0
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to Segue coverage as required under Section 25A of bIGL c. 152 can lead to the imposition of criminal penalties of a
tine tip to S 1.illwi) ind'or one-year imprisonment. as well as civil penalties in the t*orm of a STOP WORK ORDER and a tine
of up to S250'00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
lu\c,tie;uions of AA ' r insurance cocerlge verification.
l do hereby c r ili' nt r die puin.s and penalties of perjury.—
but the infirrutation provided above is true and correct-
Cienentre: Date:
2 a�
Phone =
F[ollicialnly. Do not write in this urea, to be conquered by city ur town officiuL
: —_--__-----—--- Permit/Licenseority (circle one):eulth 2. 13nilding Department J. C'ity/Town Clerk4. Electrical Inspector 5. Plumbing Inspector Contact Person:- — --__ .— Phone q:—
r
Information and Instructions
\la>sac lit scns General Later chap Ier I>' rcgwres all cntplutcis to pro%ide t%orkcrs' r„in pensation for their cm ploy ces.
PI II 5U.11it to III IS >ruute, an rmpf✓tee is dc1mcd as "...accn persan in the sett ice of:nnot het Under any contract of hire.
c%prc,s or innphed. oral or tt ri ttcn."
.\n :urphner is dclined as 'an iudit;dual. pdrn;crship. ssociatiun. corporation or other legal cntity, or any two or inure
,,I the liurgaing engaged in a joint enterprise, and inclu.ling the legal rcpresrntatit eS of a deccseJ eutpluyer, or the
rcccitcr or tru5lCe of an indmdual, partnership, association or other legal cntity, employing cntployroes. I luwet er the
,�tt nar of a dwelling house hating not more than three :tparttnents and is ho resides therein, or the occupant of the
dtt clling house of:another who cntplocs persons to do maintenance, construction or repair work off such dwelfing house
of ,)It the _rounds or building appurtenant thereto shall not because of Sit,:hjeny)lutnlent be deemed to he an cntplover."
\IC It. chapter 152, ,s25C(6) also slates that "every state or local,licensing ageneylshalf withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the i:onirtinssealtth for any
applicant,ish'o ha's,`not produced,acceptable evidence of compliance with the insurance coverage required."
Additionally, \IGL chapter 152, §25C(7) states "Neither the cumuonwealth nor try Of its pLlitical Subdivisions shall
enter into any contract fix the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter !lave 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-contractors) naane(s)• address(es) and phone nuntber(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 he sure that the affidavit is ct7niplete and printed legibly. The Department has provided a space at the bottom
t
of the affidavit 66rybu'to till'out in'the event the Off ie uf`lhd cstigationslhas toicontact you regarding the applicant.
Please he sure to fill in the penniulicense 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 informatign (if necessary) and under"Job Site Address"the applicantshouldwrite,Fall locations in (city or
own)." A copy of the affidavit that has been officially stantped`or"m'jrked 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 tilled 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 ctc.) said person is Xo,r required to complete this affidavit. _
The i)Rice 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
t
I lie D) f)artntuu's address, telephone and tax number
t• r. The Commonwealth of Massachusetts `
i Department of Industrial Accidents
Office of Investigations
60
0 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Itetised �-'b-OS
Fax # 617-727-7749
www.mass.gov/dia
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1 x a Collar Ties fil 4�0" O.C. Roof-Rafter 3W
Roof Rafters
Maintain° nfn cleararoee
::Z ir' �•
Fascia Board
-- _ Ceiling Joist Overhanging soffit
-_- _- ___.___-_ s_ with venting
Rldge Detall in' 1'0' B Sorrit Detall 1 „
2 x 4 Bottvm'Plate
0 - 2 x 4 Bottom Plate 2x Fire_Blocking
Floor Sheathing /0
a boo Otj
R2D insulation
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2x 2x Floor Joist x l2ecenter.Beam
Lally Column Cap;Plate
2-2 x 4 Top Plate fasten to Center t3eam
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2x Floor Joist P T
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2x Band Joist Decking
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2x Floor Joist _ =—�-2x Deck framttig-Q'.Ta
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Contlruous Barried Ridge vent
12 2 x 1PRldge Board
l I x g Collar Tree at d'O° O.C. ROOFING
Conposlte Roaring
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F SBulld hg Paper
2x OC.
�. 2,X .g l6r�OCr
Fawla Board
CEILING
2x801600,C.
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P Vapor Barrier Board. OverhangN soffit
3 with venting
to
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3/4' Sheathing WL
2 X 10 9 160 O.C. Sidgg��,,Air Barrier
Shea�bg,2 x 4 9 16104,
Rill Insulation,vapor BaMer
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FLOOR
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s 2 X 10 9 16' .C. -
R20 Iroulatbn 1 -2 x b P.T,1 -2 x b KD. 13402
Continuous all Gasket
2X Firm Blocking in" 61L x 12' Lg,Anchor Bolts Lis
2 x @Center Bean
9 8,0" O C.(max) u " -
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3 Irl Die.Lally Columrq
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