17 SAVOY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
J Massachusetts State Building Code, 780 CMR, 7 h edition OF SALEM
Revised Jamitary
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008008
One-or Two-Family Dwelling
Th Section For Official Use Only
Building Permit N r: Date Applied: O
Signature:
Buil ' g Commissi n /lAspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pro'perty Address: 1.2 Assessors Map&Parcel Numbers
1.la Is this an accepted treet?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 Waateerrjaupp►y: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public L9' Private❑ Zone: _ Outside Flood Zone? Municipal fyOn site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Ownerl of Record:
G * w"� tJ A_t+ k r S 7 Sq vo y $ 7_
Name(Print) Address for Service:
Signature Telephone
SECTION 3.DESCRIPTION OF PROPOSED W ORIO(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': Xr M u v a Tv-..., 5 D..0 FIL t
/ ! 'I /oG � /VD ✓ 1 IRJ 2'
t�✓I/Q/ Y /4 e se A t/ Al e,w 6.g X-•x 'Tv as.e C _
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item (Labor and Materials) Official Use Only
1. Building $ G" I. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ v ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ z�4" 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees: $
`/ Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ d xp G "Or 13 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) �
i( /✓ O T<N a License Number Expiration Date
Name of CSL-Holder
�, r / -5 i e( List CSL Type(see below)
Addre ERC
Description
Unrestricted(u to 35,000 Cu.Ft.)
"�'� Restricted 1&2 FamilyDwelling
Signatur l� Mason Only
V Residential Roofin CwermTelephone Residential Window and SidinResidential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2,Regaste d Home Imp em!t��tractor(HIC) /�O 9 J
HIC Company Name ror HIC Registrant Name Registration Number
re. T ST.. &G A /G /7 /C
Add sf
�7i" � Expiration ate
grgliature 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 .......... Eider 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 matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, x � 0 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
/1,77t,d C2
Print N
/I t v _
. tare of Owner 16r Authorized Agent Date
(Signed under the pains and penalties of 'u )
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 arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(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"
CITY OF S.u.E:ti4 X'LNSSACHusETTS
a
BumniNG DEPAR• im-4T
120 WASHINGTON STREET,3'a FLOOR
Ti L 97 745-9595
FAX(978) 740-9846
KINIBFRr EY DRFSCOl I
MAYORTHOMAS Si.PIERR&
DIRECTOR OF P(BLIC PROPERTY/BUILDING CONLSBSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busimss.Orstnizationtlndividual): //2 iL/ �lee7 1"r P
i
Address: I G r to S T S
City/State/Zip: ?/�O ( Phone I/: Zel' 3 95 3 y a—
Are you an employer?Check the appropriate box: Type of project(required):
I. [am a employer with 4. [1 I am a general contractor and I 6. ❑New construction
,piployees(full and/or part-time).• have hired the sub-contractors
2. 1 am a sole proprietor or partner-
listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers'comp. insurance. 9, 0 Building addition
]No workers' comp. insurance 5. 0 We are a corporation and its 10.❑Electrical repairs to additions
required.] officers have exercised thew
3.0 1 am a homeowner doing all work right of exemption per MGL I l.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.[] Roof repairs
insurance required.]t employees.[Teo workers' 13.0 Other
comp. insurance required.]
Any applicant that checks box BI must also roll out the section below showing tbcir workers'wmpentation policy information.
'll.mnuwacn who submit this affidavit indicating they on,doing all work and then hits outside cotmaums must suinnit a new amdavit indicating suck
=Cotataclon that chuck this box most anached an additional sheer showing The rautw of ate sub-contractor;and their workers'comp.policy infom nation.
I am an employer that Is providing workers'compensation insurance for my employeex. Belaw/s the policy and fob sUe
information:
Insurance Company Name:
Policy Nor Self-ins. Lie. #: Expiration Date:: j Job Site Address: ! Z 5.4 ViG City/Staw/zip: 7 4/>dw[ IU 4,55�71 /Q
,�,e;7
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 S 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 S250.00 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.
/do hereby rrrt uder Urr Ins and ygnalti a perjury that the information provided ab a is r e and eorrrea
// q
4irn� Date:
l 6 � �
Phone
O)rriel use only. Do not write in this area,to be completed by city or town oriciai_
City or Town: Permitd.1cense#
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other _
Contact Person: __ ____ Phone it•
/
Massachusetts- Department of Public S"fety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 20261
Restricted to: 00
ANTHONY R PETINO I
1 FIRST ST ' o
MEDFORD, MA 02155
Expiration: 5/16/2012
('ommisioncr Tr#: 23931
p� & '�om�rlo�+�*�ra�� ° ✓r'�p40a`'�'A`de License or registration valid for individul use only
Office of Consumer Affairs&Business Regulation
before the expiration date. If found return to:
- HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
Registration `.120096 10 Park Plaza-Suite 5170
Expiration 101-17/2011 Tr# 287902 Boston,MA 02116
Type: Individual,_
ANTHONY PETINO -
ANTHONY PETINO '- '� '
1 FIRST ST --
MEDFORD,MA 02155 - Undersecretary kw�—wi�otout h signature.
ANTHONY PETINO D/B/A FIELD COAST SERVICES PAGE 1
1 FIRST STREET.
MEDFORD, MASS. 02155 October 11 2010
781- 395- 3442 x 781 - 389 - 0330 cell
Karen Kapsourakis
17 Savoy Rd.
Salem Mass. 01970
We propose to furnish all labor, material, supervision,insurance,permits
for the following work at the above address.
Bath Renovation $ 8,000.00
1 Remove existing fixtures in the bathroom.
2 Remove all paneling from bath area.
3 Remove existing old plaster in the new bath area.
4 Build and install a new bath & shower unit.
5 Relocate the toilet to a fitting location.
6 Install one vanity purchased by owner.
7 Install new electric plugs and switches to meet code.
8 Install a total of 3 light fixtures purchased by owner.
9 Remove flooring as needed for the new bath area.
10 Install new blue board and plaster for new construction area.
1 l Install a new door to attic storage area by reusing existing door.
12 Install new the for the bath & shower walls and ceiling.
13 Paint existing bath area paint to be purchased by owner.
14 Remove debris from site.
15 Remove existing gas line.
16 Install bath fan to the outside.
17 Install bath accessories only. To be purchased by owner.
w
PAGE 2
Not included:
1 Bath fixtures
2 Electrical fixtures
3 Permit fee.
4 Purchase the floor and wall tiles
5 Shower doors.
6 Bath accessories towel bars soap dishes etc.
7 Heat
All material is guaranteed to be as specified. All work to be completed in a
substantial workmanlike manner according to specifications submitted, per
standard practices. Any alteration or deviation from above specifications involving
extra costs will become an extra charge over and above the estimate.
All work and material shall be guaranteed for 1 year from occupancy certificate.
nthony P tino General Contractor Karen Kapsourakis Owner Date `
STATE LIC # 020261/ HI#120096
PAYMENT SCHEDULE
Down $ 2 000.00
payment / o
Demolition complete start framing $ 1,000.00
Start plumbing & electrical $ 1,000.00
Start blue board & plaster $ 1,000.00
Start the $ 1,000.00
Start paint $ 1,000.00
Completion $ 1,000.00
TOTAL $ 8,000.00
,. CITY OF S�U.Etit, AkSSACHUSETTS
• BVILDIING DEPARTMENT
• 120 WASHNGTON STREET, Yo FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KI.NIBERLHY DRISCOLL
.MAYORTHOMAS ST.PtERas
DIRECTOR OF PCBLIC PROPERTY/BUUM NG COMMISSIONER
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 MGL c 40, S 54;
Building Permit# is issued with tFiecoadiiion 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:
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signs n e of permit applicant
/ 19 A LO
date