TECHNOLOGY WAY - BUILDING INSPECTION (2) a The Commonwealth of Massachusetts CITY
Board of Hui Wing Regulations and Standards OF SALEM
Massachusetts State Building Code, 780 CMR, 7ib edition Revised JainiorP
t
Building Permit Application Tu Construct, Repair, Renovate Or Demolish a
!. =lIIIN
One-or Two-FumilP Dwelling
This Section For Official Use Only
Building Permit Num er: Date Applied:
11J Signature: ( � I
(`V\CnJ nuilding om s,ioned Inspector of ftildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Ma Number Parcel Number
I.la Is this an accepted street?yes_ no_ P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check it' es❑
SECTION 2: PROPERTY OWNERSHIP'
----------------------
I.1 Owner ofRe[�)Qrd: 14f�{ ��t(=G)2S(A tauC
S tB NL -- � , Address for Service:
Name,(Print)
Sign 1 Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteranon(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brt es ription of Proposed Wor =•
"liaee F ohlT ?I 02n elal'CT/a 6.e.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
I. Building Permit Fee:S Indicate how fee is determined:
I. Building S
❑Standard City/Town Application Fee
2. Electrical S O Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: Sas� /f
4. Mechanical (11VAC) S List:_:— J X r(�lld
5. Mechanical (Fire S" Total All Fees:S
Su ression
Check No. Check Amount: Cash Amount:_
6.Total Project Cost: S 6 ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
rAddms
Can traction Supervisor(CSL)
/�l.. ILicense Number lis imt' n Dute
cr� List C'SL 1'%pe(see below)
fs pe DescriptionFt
Il ( nreslrictcJ u to 35pU0 Cu. Ft.)
R Restricted 1&2 FamilyUwellin -
Signature ����^^.'r M Mason Onl
n? WZ 952� RC' RcsiJcntiul RoutingCovering
I WS Residemial Window and Siding
SF IResidential Solid Fuel Burning Appliance Installation
D 1 Residential Demolition
5.2 Regisjty Hf aIrtl�overWntContractor(HIC) /19q3G
1 I IC'Company at�r or 11(CII��iegis rrmtt Name m Registration Number
Addre �C '(
• Lion Dates
Signature 'reluphone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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...........O
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: NERt OR AUTHO ZED AGENT DECLARATION
I, Alntt S ,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-s �rFl21�e
Print N t
SignaturZroT Owner or Authorized Agent Date r
(Signed under the vains and penalties of r'u
NOTES:
I. An Owner who obtains a building permit to do his7her own work,or an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program),will Prol 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 790 CMR Regulations I 10.116 and I IO.RS, respectively.
? 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.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half7balhs
Type of heating system Number of decks/porches /
Type of cooling system Enclosed Open
3. "Total Project Square Footage-may he substituted For"Total Project Cost"
^,44 CITY OF SALEM
�r PUBLIC PROPRERTY
DEPARTMENT
,tw::K:IY:)KMl 1111
vl�Yt'x 11:Was1,1016 l ON Srs ELF- • Setest, MnSSACi It it I ca0197'-
TnL:978.715.9595 IS P.ts. 9711-740.9846
NVlorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
N ) )licant Information (/PI(� Please Print Le ihly
Namelau<incsyQr�anintin In//dlvlduull: l r'-rQr"Q
Address: 3� c 14.3K l Srae rr
tl-
City,slarc;/-ip: J�o,,Q � l/� 0 20 I'hunrrt: � �C� 5.�2Q��z� _
:kre you an employer? Check the appropriate box: 'Type of project(required):
I.❑ 1 wtt a employer with 4. ❑ I mn a general contractor and 1 6, ❑ new construction
nt to ces(full and/ur art-time).' have hired the sub-contractors
,_,,J� P Y P 7. El Remodeling
2.(�1 1 ;Im a sole proprietor or partner- listed on the attached sheet
ship and have no employees These sub-contractors have 8. ❑ Demoliriun
working tier me in any capacity. workers' comp. insurance. 9. ❑ Building addition
No workers'comp. insurance 5. ❑ We area corporation and its
required.] o
I 10.❑Electrical repairs or additions
tliccrs have exercised their
right of cxcn, tion per NIGL I LE] Plumbing repairs or additions
3.❑ I am a homeowner doing all work S P
myself. (No workers' comp. C. 152. j I(4),and we have no 12.❑ Ruuf repairs
insurance required.] r employees. LNo workers' 13.❑Other
comp. insurance required.]
•nip:grphcani that checks box ill must also till wa the vectiun klow showing their wurkeva'cumpensatiot policy inliumatitm.
'l lomeuwnen who udtmil this affidavit indicating they are doing all work and then him outside cuturncton must.uhmil a new al'r:IWvil indita ems.,ch.
-Contrwua,,that check this box must attached-Sriadditional sixes+hawing the name of tlw subcontractors and their.vuken'comp.policy infonnntian.
l am can employer Unul is providfgq workers'cunrpenxnlion insurance fur ney employers. Behnv is the policy and Job.tile
iuJur,nurion.
Insurance Company Naine: _._... _.. _.._.__......-._.__.__—_
Policy 1i Sir Sclf-ins. Lice K: —___ sees..._ Expiration Date:
Job Site Address: C-ilylStateizip:
Attach It copy of the workers'compensation policy declaration page(showing;the policy ntuuber and expiration date).
Failure to sucurn coverage as required under Section 25A uf.MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1.500.00 and/or one-year imprisonment, as well ascivil penalties in the Turin of a STOP WORK ORDER and a fine
of up m 5250.00 it day against the violator. Re advised that a copy of this statement may be 1'urwarded to the Office of
hit'rsngauons ul'thc DIA Ibr insurance coverage varilicatiun.
l dw hereby certify wider r pr )is and penoltics U erju that the injunnullon provided above is true and correct.
]).tic, /174r-/. -12- 20
lI, e 9`7�S S32 9-<-2/
D[liclul use only. Do mat Ivrite in this area.to be completed by city or town official 1
i
City car l'own: _- Pcrnnit/License
Issuing Authority (circle one):
I. Iloard of][catch E. Bulletin,; Dcpartinewt .1. Cilyr foam Clerk 4. Llectrieal Inspector 5. Plumbing luspector
6. Other .__.
Coutacll'crWil: __ .- Phoned:
Information and Instructions
Massachusetts General Laws chapter 1 J2 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute, an employee is defined as"...every person in the service of another under any contract of hire,
etprass or implied, oral or written."
An employer is defined as"an individual, partnership,association,corporation or other legal entity, or any two or more
of the loretwing engaged in a joint emerpri;e, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,paimership,association or otter legal entity,employing employees. However the
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 employs persons to do maintenance, construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
\tGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally, NIGL chapter 152, a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomwnce of public work until acceptable evidence ofcompliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractors) name(s), address(es)and phone number(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 complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennidlicense 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
town)."A copy of the affidavit that has been officially stamped or marked 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 nmst be filled 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.it dog license or permit to burn leaves ctc.)said person is NOT required to complete this affidavit.
I he of ice of Investigations would like to thank you in advance for your cooperation and shuuld you have any questions,
please do not hesitate to give us a call.
The Department's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
office of Investigations
600 Washington Street
Boston, MA 02111
Tel. tit 617-727-4900 ext 406 or 1-877-MASSAFE
Fax k 617-727-7749
Revised 5-26-05
www.mass.gov/tile
CITY OF S.U.&M, NL-kSSACHUSETTS
BUUMLNG DEPARTMENT
130 W-AsmLNGTON STRErm, 3iO FLOOR
` I-EL (978) 745-9595
FAX(978) 740-9846
K!J®ERIEY DRISCOLL
.MAYOR THomm ST.PIERRa
DIRECTOR OF PUBLIC PROPERTY/BCIIDLYG COMMIMONER
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-ofMGL-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:
(name of hauler)
The debris will be disposed of in
(name of fa•ility)
09a 0 Z
P (address of facility)
�G aX 3�8
signature of permit applicant
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bate
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TECHNOLOGY WAY 680-11
his# 4 , k 1ss93N�,,,�r, li?s COMMONWEALTH OF MASSACHUSETTS
Map 07ain i;I', ., i r :,§si'`.
Block `1 as CITY OF SALEM
Lot rJE . 0087 =1i 1J
.,
Category: Foundation Only '
Permit# _,.y.. . . , ; BUILDING PERMIT
Proj eft# 7S 2011 001166E :-.'i
Est. Cost: i $149,000 00,,
Fee Charged:` # $1,639.00 ;
Balance Due: $ 00 PERMISSION IS HEREBY GRANTED TO:
Const. Cl ' F!t` "" _ Contractor: License: Expires
Use Group:-aj7t� .-,, `; i a 9tlt = Peter Varone CONSTRUCTIO SUPERVISOR-97667
Lot S1ze(sq.'ft)
Owner: OSB CAPITAL/WARREN SHORE
Zoning .
Units Gained: , __
y Applicant: Peter Varone
",� , ' �I "I.1; s+�
Units Lost: '' N AT: TECHNOLOGY WAY
Dig Safe#:,
ISSUED ON. 29-Mar-2011 AMENDED ON. EXPIRES ON: 29-Aug-2011
TO PERFORM THE FOLLOWING WORK:
FOUNDATION& SLAB ONLY jbh
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbine Building
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# Smoke:
Water: Alarm:
Assessor Treasury:
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING REC-2011-001293 - 29-Mar-11 1074 $1,639.00
GeoTMSO 2011 Des Lauriers Municipal Solutions,Inc.
TUBES, WHERE NEEDED.
PLEASE MAKE PAYABLE TO DENNIS CLARKE
V& PROPOSE HEREBY TO FURNISH MATERIAL AND
LABOR COMPLETE IN ACCORDANCE WITH ABOVE
SPECIFICATION FOR THE SUM $18800.00WITH $9440.00
DOWN $4000.00WHEN DECKING INSTALLED $4000.00
WHEN LATTICE INSTALLED $ 1360.00 WHEN WORK HAS
BEEN COMPLETED.
ACCEPTANCE OF PROPOSAL THE ABOVE PRICES
SPECIFICATIONS AND CONDITION ARE SATISFACTORY
AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO
DO THE AS SPECIFIED ,PAYMENTS BE MADE AS OUTLINED
ABO
SIGNATUVE --- -----SIGNATURE------------------
T . YOU FOR YOUR BUISNESS
CLARKE BROTHERS
36 PULASKI STREET PEABODY MASS
PHONE- 978-532-9521 CELL-781-838-1415
SAMUEL BROWN 414 JEFFERSON AVE SALEM
MASS 01970
1] REMOVE FRONT PORCH - RAILINGS -POST -
DECKING- AND FRAME AND SURPORT ROOF ,
AND REMOVE RAILING ON TOP OF PORCH ROOF.
2] BUILD NEW FRAME WITH 2X8 P.T FLOOR JOIST
EVERY 16" ON CENTER- RIM JOIST BOLTED TO
SILL OF HOUSE .
3] INSTALL NEW 5/4X 6 COMPOSIT DECKING
SCREWED TO FLOOR JOIST .
41 INSTALL NEW ROUND POST WITH NEW P.T
RAILINGS, RAILINGS WILL BE 2X4 TOP AND
BOTTOM WITH 2X2 SPINDLES EVERY 5" ON
CENTER .
5] BUILD NEW STAIRS WITH 2X12 STRINGERS ,
DECKING SAME AS ON FLOOR ON DECK USED
FOR STAIRS TREADS, RISERS AND TRIM WILL BE
WHITE AZEK TRIM BOARDS '
6] INSTALL NEW WHITE VINYL LATTICE WORK TO
CLOSE IN AROUND DECK AND STAIRS.
7] PORCH WILL BE SET ON FOOTINGS 4' BELOW
GROUND WITH CONCRET POURED INTO FORM
CLARKE BROTHERS
36 PULASKI STREET PEABODY MASS
PHONE- 978-532-9521 CELL-781-838-1415
SAMUEL BROWN 414 JEFFERSON AVE SALEM
MASS 01970
1] REMOVE FRONT PORCH - RAILINGS -POST -
DECKING- AND FRAME AND SURPORT ROOF ,
AND REMOVE RAILING ON TOP OF PORCH ROOF.
2] BUILD NEW FRAME WITH 2X8 P.T FLOOR JOIST
EVERY 16" ON CENTER- RIM JOIST BOLTED TO
SILL OF HOUSE .
31 INSTALL NEW 5AX 6 COMPOSIT DECKING
SCREWED TO FLOOR JOIST .
4] INSTALL NEW ROUND POST WITH NEW P.T
RAILINGS, RAILINGS WILL BE 2X4 TOP AND
BOTTOM WITH 2X2 SPINDLES EVERY 5" ON
CENTER .
5] BUILD NEW STAIRS WITH 2X12 STRINGERS ,
DECKING SAME AS ON FLOOR ON DECK USED
FOR STAIRS TREADS, RISERS AND TRIM WILL BE
WHITE AZEK TRIM BOARDS '
6] INSTALL NEW WHITE VINYL LATTICE WORK TO
CLOSE IN AROUND DECK AND STAIRS.
7] PORCH WILL BE SET ON FOOTINGS 4' BELOW
GROUND WITH CONCRET POURED INTO FORM
TUBES, WHERE NEEDED.
PLEASE MAKE PAYABLE TO DENNIS CLARKE
WE PROPOSE HEREBY TO FURNISH MATERIAL AND
LABOR COMPLETE IN ACCORDANCE WITH ABOVE
SPECIFICATION FOR THE SUM $18800.00WITH $9440.00
DOWN $4000.00WHEN DECKING INSTALLED $4000.00
WHEN LATTICE INSTALLED $ 1360.00 WHEN WORK HAS
BEEN COMPLETED.
ACCEPTANCE OW PROPOSAL THE ABOVE PRICES
SPECIFICATIONS AND CONDITION ARE SATISFACTORY
AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO
DO THE WJ99,,K AS SPECIFIED , PAYMENTS BE MADE AS OUTLINED
� ABOVE _ � ��w`='
SIGNATUR SIGNATUR4��
THANK YOU FOR YOUR BUISNESS