23 SOUTHWICK ST - BUILDING INSPECTION BF E
/9 3� PUBLIC PROPERTY
(�3! DEPARTMENT ��1 � 6 �ff
Kl.%BFJU.EY DRISCOLL / 4
MAYOR I-V WASHINGTON STREET•SAS�.0 X1,hSACHLSbT1S 01970
TEL-978-745-9595 0 FAX 97&740.99"
APPLICATION FOR THE REPAIR, RENOVATION, CONSTRUCTION,
DEMOLITION OR CHANGE OF USE OR OCCUPANCY, FOR R ANY EXISTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
Property Address: :2 ,3
Property is located in a; Conservation Area YIN Historic District Y/N
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name: ��1 iv .�, —• 'tl_, 2 `�
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition Existing Z
Renovation Number of Stories Renovated
Change in Use New 'Z
Demolition Existing S s--
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work:
rJ
T Z"
1�4toh-f S73 33Sr- 3 901 _ <cltr tltiP
MailPelmltto: S C ti� a/ dcl
What is the current use of the Building? S%rk /Z.S)dC^J4 1
Material of Building? "J— If dwelling, how many units? f
Will the Building Conform to Law? `f e-S Asbestos?
Architect's Name j)e e iV l A/ l,% - ec t S
Address and Phone
Mechanic's Name
Address and Phone S 7
Construction Supervisors License# 6`74 �7 9.) HIC Registration#
Estimated Cost of Project$ U 003 Perk Fee Calculation
Perk Fee$ Estimated Cost X$7/$1000 Residential
Estimated Cost X$11/$1000 Commercial
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
7 / / Date
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LOW-RISE RESIDENTIAL NEW CONSTRUCTION and ADDITIONS
780 CMR Appendix J
Applicant Name: mar)T z/n Site Address: � 3 ..Scu `\r ,'v� sy
Applicant Address: 2 ,3 ScxJ-N't sr City/Town:
SAIPrn 17 1 - Use Group:
Date of Application: /l
Applicant Phone: 91,S- 7L//- U 5 S/ Applicant Signature: ✓� �
U
Compliance Path(check one):
❑ Prescriptive Package(Limited to 1- or 2-family wood frame buildings heated with fossil fuels only)
Package(A through KK from Table J5.2.1b): Heating Degree Days (HDD.) from Table J5.2.1a:
(For items d.through i., fill in all values that apply from Table J5.2.Ib:)
a. Gross Wall Area sq.ft f. Wall R-value R-
b. Glazing Area' sq.ft. g. Floor R-value R-
c. Glazing % (100 x b a a) % h. Basement wall R-
d. Glazing U-value U- i. Slab Perimeter R-
e. Ceiling R-value R- j. Heating AFUE
❑ Component Performance: "Manual Trade-Off' (Limited to wood or metal framed buildings only)
Climate Zone (from Figure J6.2.2) ❑ Zone 12 ❑ Zone 13 ❑ Zone 14
Attach Trade-Off Worksheet from Appendix J, [and HVAC Trade-Off Worksheet, if applicable)
❑ MAScheck Software
Attach Compliance Report and Inspection Checklist printouts
❑ Home Energy Rating System Evaluation
Attach Home Energy Rating Certificate(HERS rating score must be 83 or higher)
❑ Systems Analysis OR ❑ Renewable Energy Sources
Attach Mass Registered Architect or Engineer Analysis
ALTERNATIVE FOR ADDITIONS ONLY:
a.Gross Wall+Ceiling Area //6.�sq.ft. b. Glazing Area' 9�_ q.ft. c. Glazing % (100 x b_a) _Ls %
4 ADDITION with Glazing % (c.) up to 40% may use 780 CMR Table J1.1.2.3.1 below:
MAXIMUM U-value 1 MINIMUM R-Values
Fenestration' I Ceiling' Wan Floor I Basement Wan Slab Perimeter Depth
0.39' R-37 R-13 R-19 R-10 R-10 4ft
1 Glazing Area maybe either Rough Opening or Unit dimensions.
2 Based on NFRC listing. Applies either to every unit,or to area-weighted average of all units.
3 R-30 ceiling insulation may be used in place of R-37 if the insulation achieves the full R-value over the entire ceiling area
(i.e: not compressed over exterior walls,and including any access openings.)
❑ "SUNROOM"addition(greater than 40% glazing-to-wall and ceiling gross area)
Attach "Consumer Information Form"from 780 CMR Appendix B.
Official's Name: Official's Signature:
Application Approved ❑ Denied ❑ Date of Approval/Denial:
Reason(s)for Denial: (provide additional details as needed on back side)
CrrY OF SALEM
' PUBLIC PROPERTY
DEPARTMENT
�•�• �3ov►.uow,ors+mr.s.u>i�tw<uoa�,sOtertt
I7v:lMUSa t.Pete 17L7464"
Constimetiotit Debris Disposal At'ltdavit
(required ihr an demoiidon and mm4a ias wort)
in aexordmoe with the ninth @Mom albs Sant BuUd 6q Coder 711600 sa dos 111.11
pebrit,and dw p mviaiom o(IM o 406 s A
SuRding pamb M is tasted with dw aoodidon that dw ddhsis rauldes Root
tlrit wont shaq bt disposad otin s peoperT)I tlastaed wssist dtsposs�l Aditt�►>•ddned by MOB.o
i u,s ua►.
The dells wiii be transported byt
(aaor dlswlsrl
The debris will be disposed of in:
(name d theitit»
(aJdnaa of hei>it»
U sirnaaue d ' �pPliaat
dum
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
tcntaEatat oarscott
MAYOR 120WASW=ONSr "0 sALEu.MwaAaMser[s 01970
TEta 97$-745-9S93 a FAM 9M740.9$46
Workers' Compensation Insurance Affidavit: Bniiders/Contnetorsmectridans/Phunben
Applicant Informadon Please prime Legibly
Name i "dual): i
Address: 5 7 ��.i 1Y/�( 5-/-
City/State/Zip: Ae-ti 6jj Phone# c! �' 3 s" /
An you n employer?Cheek the appropriate born Type of project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 ❑employees(Aug and/or part-time).• have hired the a6 connaaon 6 New
construction
2.� I am a auk proprietor or partner. lisped on the attached sheet t 7. ❑Remodeling
ship and be"no employees These stub conuectore have a. ❑Demolition
working for me in any capacity. workers'comp,insurance. 9 Building
(No workers'comp,insurance 5. 11.We are a corporation and its 10 ❑Electrical
required) officers have exercised chair ❑ repairs or addaiams
3.❑ I am a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions
Myself (No works='comp. c. 152,jl(4A and we have no 12.❑Rootrepai=
nsturance required.]t employees[No workers' 13.❑Other
comp.Wmmu a requirod I
�AJW WVH900 tW chedw bm e1 am atop w am Me reetlw below ehoaAee ubatr wodt�a
Homeowsm fit o m*"Wsdadwk uhay m ddae as wwdc sad uhr hip agrYda aietss��it whr
reaeuaaton do do*Ws hoot moat ruehd as aeditiami.haet�s*A mma of dw mb400awt=and tbahr wotkaa'Gump htewmads&.
!an an employer that B providing,workers'coarpeesudem Wurawcalor my 981Rkyees Below is the podry and Job rke inforesadion
Insurance Company Name:
Policy#or Self-ins.Lic #;
Expiration Date:
Job site Address City/StatdZip:
Attack a copy of the workers'eompeu adom policy declaration page(showing the policy number and aspiration date).
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal fine up to$1,500.00 and/or one-yea imprisonment,as well as civil penalties
ofa
of up to$250.00 a day against the violator. Be advised that a copy of taxiesthis in Chet ormmay be STOP WORK to the ORDER
of
a fine
Investigations of the DIA for insurance coverage verification
/do hereby certl//��ander she d pefiahier ojper/wry that the ifijornadew provided above is awn and correct
Signature• i/ z Da• y �,
Phone# 7�
O,dlcld wss'only, 00 fiat write IN this area,to be completed by city of toww ojJfcial
City or Town: Permit/Liceme#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.C10frown Clerk 4. Electrical Inspector S.Plumbing Inspector 6.Other
Contact Person: Phone#
Information and Instructions r
Massachusetts General Laws chapter 152«quirea all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employes is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
"an individual.patmersNp,association'Corporation or other legal entity.or or the
ny two Or in=
An sarPloyo►is defined d i and including the legal representatives of s deceased employer,
of the foregoing engaged in a joiro enterprise. entity,emploYing employ"' However the
receiver a trustee of an individual.partnership,association er wheree tesidsa theKin.or the occupant of the
owner of a dwelling boom having not mere than three apartments d who o Mid or t- - worn an such dwelling house
dwelling house of another who employs persons m ob maintemnC0.construction
of such�PloYment be deemed to be an employer."
or on the grounds or building thereto shall rot because
that"every state or local nestadag agsaey shah withhold the Uss�or
MGL chapter 152. a or p)mlO states or to costtcaet buildings in the rnmmosweaith for aq
resuwal of a tleessa or perPeit to operate l bevisess req
who bas not produced aeeeptablo svfdcW of compiles"with the fn y oat«coverage
coons s
aPP�� 1S states Neither the commonwealth tar any po•
A"rinmany,MOL chapter 2,12SQ7) O work until acceptable evidence of complamee with the insurance
enter into any contract for the perf°rme°CO of public
the contracting authority"
requirements of this chapter have been presented
Applleants
affidavit Completely,by cheekmg the boxy that apply m'Your situation and.it
Please fin out the wodcera'compensation a ss)and phone number(:)along with their eertificsa(a)of
necessary.supply sub 4oems)nab°)' with no emploYeea other than the
Limited Liability, (LLt 7 or Limited Liability n himranc4L if an(LLP)�or LLP does have
we not required to carry workers Compensation tnaPttance•
members tit p Be advised that this affidavit maybe submitted to the Department of Industrial
employee+a Policy is reoptired Abe be ant to sign and date the a9Wavif. The affidavit should
Accidents for confirmation of insurance covtuaga or license is being regoeate4 not the of
be named to the city or town that the application for the permit m obtain a workers'
itiduatrisl ACCWM . Should you have any
questions regarding the how er if you as required
compensation Policy.plow Can the Department at the
number listed below. self-insured companies should ether their
self-inauance license°umber on the
City or Tows Otlleiab
complete and printed legibly. The Department has Provided a space at the bottom
Please be sore that the affidavit is comp ons has to contact you regarding the applicant.
of the affidavit for you to fill out in the event the Offua of Investigations
Please be sure to fin in the permitllicense number which will be used ss a reference number. In addition,an applicant
Plat moat submit multiple petmiNlicense 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
marked by the city or town may be provided to the
town)."A copy of the affidavit that has bean officially stamped or mits or licenses. A now afbdrvir um"be filled out each
applicant ss proof that a valid affidavit is on file for flrturo Perper
year.Where a home owner ar citizen is obtaining a license err P 0°t related to any business err commercial venmra
(i.e. a dog license or Permit
to bum leaves etc.)said person is NOT required to Complete this atiidsviR
wowld like to thank you in advance for your cooperation and should you have any questions,
The Office of investigations
please do not hesitate to give us a call.
The Department's address.telephone and fax number.
The Commonvrealth of Massachusetts
MWtwm of Dial Accidents
091a of tavesd9Wons
600 was>tinom Street
Boston,MA 02111
Tel. #617-7274900 W 406 or 1-877-MASSAFE
Fax Al 617-727-7749
Revised 5-26-05 wwwa awgov/dia