5 PURCHASE ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR
J Revised Mar 2011
(y�U Building Permit Application To Construct, Repair, Renovate Or Demolish a
aOne-or Ttivo-Family Dhvelling
'[his SectionForOfficial Use Only. /.
Building Permit Number: Date Applied",
Building Official(Print Name) Srgnature - Date
SECTION 1: SITEINFORbLaT[ON
1.1 Pro(�erty Address: 1.2 Assessors Map& Pare ll mbers
Is19/�C�� 'EA .
1.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks (ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.O.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Nlunicipal❑ On site disposal system ❑
Check if yes13
SECTION 2:; PROPERTY OWNERSHIPL
2.1 OwnertofRecord: ,\n A 01`9�O
rci�� Z7 Sh�e�tic� /`�1 �-1
Name(Print City,State,ZIP
5 � . C-Sht'(!RgAr ' P Katir:o.
No. and Street Telephone mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Cl Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Propo ed Worka: 7N5 ( N��� v i`W t5 e
� [.Y iS P-5•eY�hQ-Y
SECTION 4: ESTIMATED CONSTRUCTION COSTS .
Item Estimated Costs: Official Use Only,..
Labor and Nfaterials
I. Building .3 I. Building Permit Fee $' Indicate how fee is determined:
❑ Standard City/CotynApplication Fee.
2. Electrical S
❑"Cola!Project Cost (Item b)s multiplier x
3. Plumbing S 2. Other Fees: S 9
4. Mechanical (1IVAC) S List:
5. Mechanical (Fire $
Su � res;ion) _ "Cola!:\Il Eczs.S
Check No. Check Amount: Cash Amount: i
fi. TWA Project Cost 3 ('(� ❑ Paid in Full [IOutstanding 13Aince Dua:
SECTION 5: CoNSTRUCrION SERVICES
5.1 Coatstructiou Supervisor License(CSL)
License Number E.cpi rat ian Date
Name of CSL I[older
List CSL Type(set below)
No. and Street TyMInsulation
Description
Ucted Buildin s u to 7J,Doo cu. tt.
Red Lg2 Famil Dwallin
City/Town,State,ZIP bI
RCCovering
W and Sidi-
SFel Burning Appliances
In
Nle hone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
H1C Registration Number Expiration Date
I IIC Company Name or IIIC Registrant Name
No.and Street Entail address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit mast 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
1, as Owner of the subject property,hereby authorize 5p7p
to act on my behalf, in all niattqFs relative to work authorized by this building permit a plication.
h
Print Ow er's Nan e�(Electr is Signature Date'
SF. TION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering illy name below, I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true nd accurate to the best of my knowledge and understanding.[
�
I`rl-[l)1Y 11 'S or Au horned:\ nt's N;une(Flee 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
(nut registered in the Houle Improvement Contractor(HIC) Program), will Pint have access to the arbitration
program or guaranty find under NLG.L. c. 112A. Other important information on the HIC Program can be found at
www.m:ss.eov oca Information on the Construction Supervisor License Can be found at teww.maSS.,ro�.'dL
2. When substantial work is planned, provide the information below:
Total floor area(Sq. 11.)— _ _(including garage, finished basement/attics, decks or porch)
tiro;; living area(sq. III — __ Habitable room count
Number of fit eplaCCs._ -- Number of bedrooms -- —
-------_—_--
Nunnherofbachrooills _ -- Numberofhalfbaths _ — -
fvpe of heating system ._. -. -_ ------_-- Number of decks/ porches
----------
fti pe of cooling System-------_--- ---- Enclosed- - --- -_Open _--
}. f',i.il I t,yect Square Pu„la,e inay be iub;ututcd t;,r I'rulect('oil"
CITY OF S.U.E%vf
PUBLIC PROPERTY
DEPARTMENT
u�u..aar o•uaus�
awe I b 7Uww6-WW fMtar• ULM*.VANA04 MM at9-e
ML 9-9-741.91" •M%c f7s.74a.164
HOMEOWNER LICENSE E.XS.MFrloN
Pteaw Tr1st
Date l I
lob Loeadon
Home Owner Address So vv e—
Home Owner Telephone! 7 S t
Prev"Mailing Address 5ovr
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings ottwro Units or few and to allow such homeowners to engage an individual for
hire who does not possess a licensed provided that the owner acts as auparviaor.
DEFINMON OF HOMEOWNER
lscmn(s) wbs owns a parcel of land oil which hdrbs resides or intends to«sids4 on
which there i; or is intended to be,a one or two f&Wfy dwelling, attached or detached
structttra accessory to such use and/or farm structure, A person who constructs more
than one hams in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Ot7fW4 an a form acceptable to the Building
Oflfcial, that he/she be responsible for all such work performed under the Building
Permit
The undersigned "homeowner"assume responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"cert ffa that he/she understands the City of Salem
Building Department minimum inspeetio,p procedure and requirements and that he/she
viIf comply with said procedures rebuirements.
HOMEOWNERS SIGNATLM �
APPROVAL OF SUILDNG ' EC
Sce other side far state code
f(i _
p • y
f'
i.
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CITY OF SiU ENM) M-uSACHUSETI'S
I' •1,.j� '' t „ l�, F3l:tLDL\GDEP.1AIllE.�iT
120 WASHNGTON STREET, 3" FLOOR
'I-L (978) 7d5-9595
Iua0ExLEy DRiscoLL
F.tie(978) 740-9846
AWOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSISIISSIONER
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 111.5
Debris, and the provisions of i'v1GL 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:
(namc orliauler)
The debris will be disposed of in
(namc ot•facility)
(address of racility)
4re ofAmutc-applicnt
� � Zil13
date
i
i
� t 1
Contractor Information: 4/3 /13 Proposal
MA. LIC. # 149286
?' Craig & Heather Shupenko
C.S.I. Home Improvement Services 5 Purchase St,
18 QUAIL RD. Salem, Ma. 01970
PEABODY, MA. 01960 (781) 392-7880
Tel. (978) 764-7276
Email: CSISERVICES65@GMAIL.com cshupenko@yahoo.com
T Christopher Scott Ingemi
All bids valid for 90 days unless chemise specified
Details of Work to be performed:
CSI will rehab and or remodel and existing finished basement space approximately 500'Sqr. Ft.
CSI will include a new bathroom including new 1/z moon shower enclosure, new basin, new sink, washer and drier
hookups, and all necessary plumbing including a new pump up system from the basement.
CSI will relocate most of the existing plumbing in front of the window.That window will be incorporated into new
bath.We will also supply all plumbing for new project up to code.
CSI will supply new Electrical in bathroom to bring up to code. GFI outlet and vent fan.
We will also install 18'electric base board in main room, 1 4'base bb in office area,and 1 4'bb in bathroom,with two
thermostats. We will also install 4 new 6"recessed lights in the main room,and 2 in the office area.
CSI will install new outlets per code.
CSI will cover all Walls new with 3/8 blue boards and plaster.
We will build new chases around existing plumbing,where necessary,and install all new baseboards and moldings.
CSI will install new doors in bathroom and back room near basement bulkhead,and near front stairs. We will also
install new vent panels in walls for furnace room. Per code.
CSI will frame for new closets in office area,and install new by-fold doors.
CSI will install new ALLUR flooring in bath, main and office rooms.
CSI will supply paint,(one color) and apply it to walls and moldings.
CSI will remove suspended ceiling, and replace it with a new ceiling,and install 6 new recessed lights.
CSI will 'install new carpeting for stairs from 1 t floor interior entrance to the sub level.
CSI will supply all materials and tabor to complete the job unless otherwise stated.
CSI will coordinate all if any sub contractors.
Any and all work not defined on this contract will be considered an Extra and will billed separately.
CSI will not supply any light fixtures,(other that the recessed lights and bath vent light),faucets or vanities. But all
other materials are included.
All materials and labor will be included in this price, pp
All dump fees Approx. $475. and permit fees(?)are additional,and will be billed separately. _l- Initials
IL j1<3 = {�} Total Contact Price and Payment Schedule
The contractor agrees to perform the work, furnish material and labor specified above in th total sum of$27,500 plus
any taxes or permit fees if applicable.
Payments will be made according to the following SCHEDULE.: approx 1/3—approx 1/3—balance due.
9,000.00 1/3 upon signing contrac&o
$9,000.00 113 after demo is complete or after the first week. (Whichever comes first?)
$9,000.00 1/3 upon completion of the contract
i _
[c=
ce of Proposal the above prices,specifications and Customer signature:=.��.
re satisfactory and hereb acce ted. You areY Pto do the work as specified. Payment will he made CST Signature:above. This agreement may be canceled in writing the third business day following the signing ofthis Date