8 SCENIC AVE - BUILDING INSPECTION ' S
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CY SAL MF
Massachusetts State Building Code, 780 CMR RevisedLEM2011
fut
Building Permit Application To Construct, Repair, Renovate Or Demolish a
�® One-or Two-Fancily Divelling
This Section For Official Use Only
Building Permit Nu beer/ Date Applied:
ULsy„ / eiGu,vr � ' fT/�i�ii iS� o2S �l
Building 011icial(Print Name) Signature Date
C i� SECTION 1: SITE INFORMATION
1.18Propert Addy ress: �U 1.2 Assessors Map& Parcel Numbers
L l a Is this an accepted street'?yes_QL_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Propos d Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(ID
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: �l �,�yn� -
l�i,r, 'C i✓ ?2� i J �9/!rf /� - O/Sr7G
Name(Print) C (C City,State,C.IP
No.mid Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) 4 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': //r/J'7/f�Z- �� L S
/� .'c✓i i'+,
f4L/a-CPm a...T Lc/.'Iy OGW
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item -(Labor and Materials) Official Use Only
I. Building $ �.S p _ 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cos[ (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ �/ /I _�
4. Mechanical (IIVAC) S List: Z!
5. Mechanical (Fire $
.Suppression) Total .All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S IS CAv-s' ❑ Paid in Full ❑Outstanding Balance Due:
rn (1c,� �
SECTION 5: CONSTRUCTION SERVICES
7—Street
n Supervisor License(CSL)
re 4"� �/y License Number F xpimtion Date
derList CSL'rype(see below)9w Type Description
U Unrestricted(Buildin�s u' to 35,000 cu. It.)
✓e l 0�1�.2 3 R Restricted I&2 Pmnil Dwelling
Ctty(f wn.State•ZIP M i Mason
ry
RC Roolin Covcnn
R WS Window and'Sing
in
SF Solid Fuel Burning Appliances
P I Insulation
Telephone Email-address D Demolition
5.2 egister'e/d Home Improvement Contractor(HIC)
A/L wO tin P.v e IIIC Registration Number Ispiration Date
IIIC'Compai ame or I IIC Registrant Name
N/o y�nd Street `����
�yeyz' /�//,� . '/9X? 9/,7f- 77y O�S9 Email address
City/Town, State,ZIP Telc 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 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 (�iy2'� r( . �s...� —e %71 I,
to act on my behalf,in all matters relative to work authorized by this buildin permit application.
Print Owner's Name(Electronic Si ature) Dale
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 b st of my knowledge and understanding. .
Print Owner's or Authorized Agent's Nam electronic 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
(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 can be found at
�}«yw maa oy'oca Information on the Construction Supervisor License can be found at totem tr_m_is
2. When substantial work is planned, provide the information below:
Total Floor area(sq. R.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half,'baths
Type of heating system Number of decks/porches_ ---
'rype of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"fol:d Project Cost" �-
° CITY OF S.U.&M. A-us.-ka-iUSETrS
• BL DLNG DEPART%MNT
120 WASHLNGTON STREET, Yo FLOOlt
M (978) 745-9595
FAX(978) 740-9846
Ki.%tHERLEY DRISCOLL
MAYOR 'I7iO.+teS ST.PIERRB
DIRECTOR OF comic PROPERTY/at:BDLYG co%wissrONER
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 t 1.5
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:
Z42-PI el-* /1>si 7T &Cle--
(nam of hauler)
The
debris
will be disposed of in
(name of facility)
S,oyLe.N
(address of facility)
signature of permit applicant
date
dabnaad,l,p
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.st Nt nl
12C WAHIINGIt^51xEk)' • inO+w, M.,>s.w.nt a I IvJI'/l�
frJ.: )7L?sivi'li •1',x. v7M•?tC•'18t6
1Yurkers' Compensation Insurance :vRtiavit: Builders/ContractorsiElectriciansr'Plumbers
%millcant Information Please Print Leeihly
Nit lflCllluene.sygrgant rJliaNlnJw miuul):
City.State,%ip.11 vP.z /�. elF a 7 Phone it;_9��
Are ou an culployer'!Check the appropriate box:
'Type of Project(required):
I I.❑ I;un a employer at ilh 4. ❑ I am a gcncml couUactor and 1
employees(full Jnd'ur port-time).• have hired the sub-contracturs is' ❑New construction
2.z1;un a sole propricux or partner. listed on the artachcd..sheer. : y ❑ Remodeling
ship and have no employees Then sub-contractors have S. Demolition
working for me in any capacity. workers'camp, insurance.
l No wotitcrs'cut' insurance S. �• ❑ OuiWing addition
p• ❑ We are a corporation and its
required.) O04cen have excmixcd their 10.Q Electrical repairs or additions
3.❑ I ant a hnnleuwner doing all work right of exemption per bI L I t.0 Plumbing repairs or additiona
myself. (No workers'cunip. c. 152,§1(3),anJ we have no 12,0 Ruufrepuirs
insurance required.j I - cmployecs. (No workers'
comp, insurance mquinJ.) 13•0 Other. I'U �57
•bq.,iythcaa that checks bw el moat:Jw till In,,the w:rumn heluw awwinx Iheir wwkwit cum ntmiun
'I lumwuwnen-he vtdhmit this affidavit indiaatinx thu)Jn duinx all wurk and Ihee hire moide cu rmaon main.utmit 4It"1111dawil indict .na vhtck.
"a"chuck this bw mu"Joshed un additiurul sheet.huwinx'be name o(Ihe subremractm and the,uwiterv,emmy.pldlcy mq,matme.
/der an earplayer that le pruvldinX Ivulkers'rompensadon hhtarrureo/or ury rfnp/uprrs. Below/if rhr pullay and yaks lue
iulwmuliuha /
Insurance C•umpmty Name: 6/lifn,. f f •ST/�7-{' _... __._..---
I'ulicy 4 ur Sclr-ins. l.ie.d: 6 Y�S�r 9< Expiration Date:
iul)$ite :\tldfeax: O y CII islutelzi
y p;_Sm
Attach a ahpy of the workers'cumpensatlon p'licY declaration page(showing the policy nurnbur and expiration data).
hJilurn to score cuyemge as required under Scctiun 25A ul'SIGI c. 152 eau lead to rite imposition of criminal penalties Otis
fine up to SI.500,00 antl/ur use-year imprisunmunt. Js well as civil pcnallics in the 1•urm of a STUD WORK ORDER and a fine
Of up to S250.00 it day against file violator. Ilc advi.+cd lhut a copy urlhis stalcment may be iurwarded to the Ullice of
Itl\'�ah�Jllnlla UI lhu Ul.\ I9f❑1Hhf:11•ee Glivefa�e \el'IneJlnln.
/du hereby t rrti y under rhr paint Imd prnahiex uj-pe/rjuury rhar the iajurmuflon provided above is true turd correct
in.: , b,r•- . o.-iG% ice C.' � ��y
UJtt. 7— 1;- //
Oniviu!tar mtly. Dd ndt'•rife in this urea, to he cuuhpltted by city up town d//iriaL
('ity ur 'fnwn: Pcroto"' lcense rt, ..
1%%uing.\ulhurity(circle one):
I. Il'Jrd -if 2. Ilulldin� Dcparlmcol 1. (:il):'fuun Clerk J. Electrical Inspector i, plumbing llnpector 6. Other
linttacl l'cnmh: _ Phone IT
{ eh
Information and Instructions
\I:lai.lCliU�Clls General LJWS Chapter I J2 1'equlres all elllployers to provide workers' Compensation for their el"PIOYtes.
d",,—every person in the service of another under ally Contract of hire,
I'ursu:uit to this statute,an rmplerrs is Define .,
a�preas or unpile), oral or written."
of
%n eurplopet is dcfincd as"an Individual,Purtillt'n -.IYatKl ltWn,corporation or ndter legal entity.ed many two r t more
u the Gneguing engaged in a lumt enterprise, and including the legal cc I e city,ems lO a de`n'slo ees.INowever the
Iecmver or Irustee u1',u individual, pumershiP,association or other legal ennty,employing ' p Y'
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 a appurtenant Persons
sh to all not because of such employment be ds meJ to be an employetcriance.construction Of repair work on such dwelling r."
or till the grounds or building
MGL chapter 152. §25C(6)also states that"every state or,local licensing agency shag withhold the Issuance or
renewal of r license or per to operate a business or to construct buildings In the lerttmlanw'eultb for any
:rpplicrnt who has not produced acceptable evidence otcumpgaact with the insurance coverage required."
\dJitionally, bIGL chapter li?. §-5C(7)states"Neither the commonwealth not any o1•its political.subdivisions shall
I' work until acceptable evidence ofcunipliance with the insurance
enter into any Contract for the Performance ul'pub
requirements of this chupter have been presented to the contracting authority."
Applicants to our situation and, if
in ills boxes that apply Y
Plaice rill out the workers' compensation affidavit completely,by checking on with their ceaificatc(s).Of_
' newss:uy,supply
sub-contractors)n une(.$),aJdkeLimit and Phone Partnerships
along with no employees
insurance. Limited Liability Companies(LLC)or Limited Liability Pannerrasnce(If an)LLC or LLP does have
than the
membe
partners, are not required to cury workers' con'Paffidavit
may
be to the Department of Industrial
Inelnben or p be submitted P
v't Inc
oniplyces,a policy is required Bs advised that this alTida 1 Y
Xccidents for confirmation of insuranco coverage. Ago be sure the pennit r sign and dote The u requested,
n The Depart it should
be leltrnmeJ to the city or town that the upplication
s Qf�rep rdrrig the law or it''you is lnare required to obtain ot the tu workcrs't of
Industrial Accidents. Should you have any y
Compensation policy,please call the Department st the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or•Cowin Officials
Please he sure that the affidavit is complete and printed legibly. The Department hus provided u space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
I'I.aae be arc to till in the PC number which will be used:Is a reference number. In addition,an applicant
that moat submit multiple Pe appliculions in any given year,need only submit one afidavn indicating (citycurr O
Policy infoubmitn(lf necessary) and under"Job Site Address"the applicant should write"all locations in (City ur
town), ,�copy of the unldavit that has been officially stamped or marked by the city or town [nay be provided to the
applicant as proof that a valid afftduvit is on file for future permits or licenses. A new affidavit must be filled out each
year. w'herc a home owner or Citizen is obtaining a license or pennit not related to any business or Commercial venture
t i.e. :1 Jug license of permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I hC )t lice tit Investigations wvould like to thank you in adv:ulec fur your Cooperation and Should you have:uiy questions,
please do not hesitate to give us a Cali.
fhe UCparunenl's address, telephone and fax number:
The Commonwealth of Masmchusetts
DepaMnent of Industrial Accidents
Office of fsvesidpilons
600 Washington Street
Boston, MA 02111
•Ce1. q 617-727-4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
www.man.gov/dia
.4 ORO� CERTIFICATE OF LIABILITY INSURANCE OPID DH °A'EtxAL1°O1 Y
06/24 10
DDD R EOTT
nRCATE IS ISSUED AS A YATn3R; ORFORMAnON
Dan Hurley Insurance Agency CONFER$No RIGHTS UPON THE TE
Chestnut Greece, Suite 24 TH S COMFICATE DOES NOT D,EXTEND OR
Seven Fe ez-a Street HE COVERAGE AFFORDED BY THE I OUCIES BELOW
Danvers PA 01923-3620
Phone:978-777-9394 Fax:978-777-3306 ORSURERS AFFORDING COVERAGE ; NAU:A
INSURED
RSA- Preferred Dfntual _ - 15024
&il Le a
Brnthers Construction
Granite State
clomew Riley DBA
56 Conant Street _ E .
Danvers NA 01923 LNsatLSBLa
I D6IAt�@ -
COVERAGES
THE Pot>cEs w N+sINrANCE tLsrEOL�DwHAVE�+�mnaE waw®xa.®ae�wxnff Poucv Iwo omrA>Im.xotvinxsratmaic
ANY REQUIREMENT.TERM OR COtDRWNOFANY CONTRACT OR OTHER DOQ@x3R WIx RESPECTTO WHICH THE C9T11FCATE MAYBE ISSUED OR
MAY PEWAK THE INSLOIANCEAFFO)ID®6Y7HE POLICES DESCRIBED HER®16 SUB WrTO AU TLE T80M EICLUMONSANDCONO TIOIAS OF SUCH F
POLICIES.AGGREGATE L WFS SHOYNNYAYHAVE BEEN REDUCED BY PAW CLAIMS
' TTRR TYPEOFINSURJUM POLICY xIR®9t DATE OATE I q LIMITS
�+� �I� EAcHOmwREmcE? s_300000_
A X cMLSENEALLwau f CPP0170564252 20/16/09 10/16/10 PREMISES E9P I s 100000
CLAW UWE ®OCCUR - - .+ , MEOEXP(A W' pMe ) I s 5000
-- -
PecsDNa.aaovsNw s300000 -
GENERAL AGGREIGAJE 600000
C�RA[ TELwrAPMIE4P6t PRODUCTS- s 600000
POLICY MF—I LOC
AUTOMOU6E IL.vwm I
I COLWdard) E ]s
_ ANYAUTO (EH eaRetl) I
A OYHNIDAUTOS ! SODLLV IRIURY
SCHEDULEDAUTOS I IPPIPPIsaU i S
HIREDAUTOS
NONdMEDAIROS I IP!<emd0ll) s -
.. PROPERTY LVIMAGE .S
(PBdLP�LTY)
i laAWl(.'EIWBBJTY AUTO ONLY-EA •s
i _ -
�YA� OTHER THAN s
_ _
i ADTD ONLY:
I EIICESSIUxoovlw LMBQJTY IFAONoaamaacE IS
- -
acclsl CLAM MADE a[raEc,ATE s
i DEDUCTIBLE ---
s
RETENTION s -- I
NIOMMIMCWIPSSATION s
AND EMPLOYERS'LIABU.fiY YIx i % TORYLDA ER ___
B ANY PROttlVETORE 648459E I 016/20/10 06/120/11 FLEALpLACCDExT
OFFlCERIMa�9t atCLUDEDT y a100000___,
iM®10AIPIY bI NRR SB8 ATPAC66D NOTE I EL DZEASE-FA _ SIOOOOO_9 YM dmcnbPIMa ..
SPECIAL PROVISIONS mw ,EL DLSgISE-P Lcy $500000
ORTHI I I
� F
I
I i
OESCWPTIGN OF OPERAMONS/LOGATTONS IVEIRCLES I IDUCLUAONS ADDED BY BDORSBIBii) pL pROy19pN5
Sole proprietor not covered by workers ceDu%mMosatioa_ _
CERTIFICATE HOLDER CANCELLKTION
. _ - sRDlannxrOFT�AeaveDL�Paie�eE tl�TesEwxwTa
DATEINSEW.IMMSMGWMNMVM.LBMEMM 62ML 10 DAY9VxMRBN
• xOR7ETOT7gCHDDDgTE(CLOgtx'A®TOTTE GUTPINKUETOODSOSRAU
- RIpOSBxOO®D�ARNIIWIiT'OFANYIQmi1POtl� �iL51RE1�DSAb®liS Wt
Daniel L J ao t y'Q
Daniel Sprl7
U;ORD 25 L2tNI1W OM XWCORPORATIOU198
rvMassachusetts- Department of Public Safetj
Board of Building Regulations and -',tztndards-
Construction,Supervisor Specialty License
ticense: CS SL 98850+ .,,t..
Restricted to:, RF,WSIA
�„ ,
BARTHOLOMEW"KILEY'
56 CONANT ST
DANVERS, MA 01923
Expiration:. 1112012
f",immicarmer Tr#: 98850
OT
Office of Consumer Affairs&qRsine
' HOME IMPROVEMENT CO
Registration 124852Expiration Jt3l2Q]1
TYBarthol Barthol56 ConnDanvers.MA 01923�'�r;.
HIC #P 126-356
[a �C0[o�Ypuilaei5, {lint.
13 SEWALL STREET
PEABODY, MA 01960
OFFICE: 978-922-6120
SPECIFICATION SHEET �
Home Phone: .2 2W72 f.'(�33
. . . . . . . . .
Owners Name . . . . . . . . . . . . .J� . . . . . . . .Whrk Phalle: . . . . . . . . . . .
. . . . . . . . . . . . .�. . !?T. . . . . . .Qi�. . . . Citv .. . . . . . State . . . . . . . . . Zip . . . . . . . . .
Job Address . . . . . . . . . . . . . . ... . . . . . . . . . . . . . . . . . . . . . . . . . .
SIDING C r� d G p
I. Siding Type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .�.'.�.`%. . . . . . . . . . . . . . Width . . . . . . . . . . . Color
2. Area to be clone. Alain House .. . . . . . Brere7ewav . I eo.. . . Garage� a t!<sr . . . . . Additioac .
Dormers . . . . � . . 7
®. . . . . . . . Other . . .
c'c-[. .
c . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3. Insulation . .'
4. Trittt cover A-T"' ❑ No Color . .1/.f!X . . . . . . . . 7iitn ro be done: S'ofts �. . . . . Fascia - . . . . . . .
Rakes . . . / C'eilin /,t . ,.. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .i . . . . . . . .
i. Mind v and Door Frames .v„�4- .�� . . . . . . v �.�.P . '✓ y .. . . .
6. Gutters and�sp��outs m-Ws ❑No Use 11 ,avv gauge seandess . . . . . . . . . . . ._. . . . . . . . ./� . .�7.�.-. .olor4i -4 . . . . . . .
7. Shatters 6� �s 0 No . . . . �S`. . /1?eGfi .l�/!?�iaW12.4((�L� . . . . . . . . .
. . .
8. Windows and Doors l!�6 /
ROOFING
MaterialTvpe . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .lillolo
r . . . . . . . . . . . . . . .Areas to he done . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .Remove existing shit files O 1es ❑No 1S !b.felt. . . . . . . . . . . . . . . . . . . . . . . Aietal E . . . . . . . . . . . . . . . . . . . . . . . . .
Chimnev a vent. etc. . . . . . . .y/y . . . . . . . . . �.}.'. . . . . . . . . . . . . . . . . . . . . . . . . . .
NOTES . . . . . . . C`. . . . . . . ��7-1./. . . . . ..U '�/l : .c�/ . . .
�. G-�a . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . .
. . . . .
. . . . . . . . . . . . . . . . . . . . .`� � : : : : : : : : : : : . . . .
.. . . . . . . . . .
. ,
.-Deposit
Material and labor to cost$ ...Q... . . . . . . . . . . . .payable as folloiv.r: ,�. . . .J�. . .I st Installment
DO NOT SIGN THIS DOCUMENT IF THERE ARE ANY BLANK SPACES. $. . . . . . . . . . . . .2nd Installment
oa
S.� ,ZS OG ,Balance on completion
C'snar'uctur iril(do aR suidmork iu a good workmanship manner. You rnur rdttal this ngreernrnf it it has hero nnisuu�n+ated 6e a purtY thereto a1 a plan
ether than-an oddreu 0J the seller. rvhi<It man-he his nude glfice or brunch Thereof.provided you noble the seller in avritinq al liic main uJjicr nr hnnq lr
be nrdindp,mail posted. be telegram sent or by delivem not latter than midnigha of the ihlrd hu,mec.s day fbl/mvin.g the craning of this ai,tvremrtu. /J
[n' NITNES MEREO? the,parties hurt.hr,rruntu 'ipned Jew ml aes rhis. . . . . . . . . . . . . . . . . . f,�-
;1! ellt, I Signed 'r
lD u o 01tp All Pt•5, .Aril•
Repro unnti re
�Inrea lab ,r.�i ailsa, irnJrm au whtlhrr. _o'nmi,rill rnpplirr Jahn a r'eau77L�, in m/ mv.