5 TEDESCO POND PLACE - BUILDING INSPECTION The Commonwealth of Massachusetts
'• I - Department of Public Safety
\la6salhll?elt9 State Building Code(:80 CA1R)Seventh Edition
City of Salem _
Building Permit A lication'for any Building other than a I- or 2-Family Dwellin
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Inspector:
�� SECTION I: LOCATION (Please indicate Block# and Lot# for locations for which a street address is not available)
Ox/O l.A z
No.and Street Cih /Town Zip Code :Name of Building (if applicable)
SECTION 2:PROPOSED WORK
If New Construction check here❑or check all that apply in the two rows below
Existing Building ❑ Repair❑ Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
ChangeufUse ❑ Changeu(Occupar ❑ Other ❑ Specify:
Are Building plans and/ur cunstnmction documents being supplied as part of this permit application? Yes No ❑
Is an Independent Structural Engineering Peer Review required? Yes ❑ Nr�
Brief Description of Proposed Work: WITC-11 iV R;E7"4
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) ❑
Existing Use Group(s): Proposed Use Group(s): p
Existing Hazard Index 780 CMR 34: Proposed Hazard Index 780 CMR 34:
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&AreaSPerloor E(sqft.)Et H— E [H
Total Area (sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2r ❑ A-2nc❑ A-3 ❑ A-4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ 1 H: Hi Eh Hazard H-1 ❑. H-2 ❑ H-3 ❑ H-4 ❑ H-5❑
1: Institutional 1-1 ❑ 1-2❑ 1-3❑ 1-4❑ M: Mercantile❑ - R: Residential R-10 R-2 ❑ R-3❑ R-4 ❑
S: Storage SI ❑ S-2 ❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE (Check as applicable)
IA ❑ IB ❑ IIA ❑ 11B0 IIIA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outaide I9ood Zone ❑ Indicate municipal ❑ � trench will nut br Lia•nsed Disposal Site ❑
I'm ate 0 or induntik Znne: oron site s%,tem ❑ required ❑or trench m*.pecifm:
permit is enclosed ❑ _
Railroad right-af-way: Hazards to Air Navigation: Tll �
rsI:\ I II,t,m, t mmi>�i,m Itr+ir+, f'nn,
\n1 :\I+phial+ e ❑ .Sl niclroe�cilhin airport appruadm h their rem icy+ c,nnplcled,
, r l-„mcnt Io SuJd enclosed Yes ❑ nrNu ❑❑ Y ❑ Nn ❑
SECTION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
IiJilinn ,d Code: _ L.e Groupta: Im pc of Cumtniclion: Occupont Load per Flour.
1)oe.1 the Budding cnnt,lln in Sprinkler Sc.lem': Special Stipulations
SECTION 9: PROPERTY OWNER AUTHORIZATION '
Name and Address of Property Owner
Name(Print) No.and Street Cit),/Toll/r, Zip
Property Owner Contact Information:__
Title GTelephone cNo. (business) Telephone No. (cell) e-mail address
If pplicablr, the pr 1perty nyner hereby authorizes
Name Street Address City/Town Stale Zip
to act on the proper"*o%�ner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If building is less than 35,000 Cu. ft.of enclosed space and/or not under Construction Control then check here❑and skip Section 10.1)
10.1 Registered Professional Responsible for Construction Control
Name(Registrant) Telephone.No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
E
aop nY Na me: s �' $ 9 7 3 Sm
Name of Person Responsible for Construction License No. and Type if Applicable
?, /s2, :,� c�T✓�t37� SiFI.t � _ Jan D/ a
trS eet Address -�97 -ae 1237DCity/Town State Zip
Telephone No. (business) Telephone No. (cell) - e-mail address
SECTION 11: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152. 2506))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor Xx
Item and Materials) Total Construction Cost(from Item 61. Buildin $g Z�� Building Permit Fee=Total Constructio2. Electrical $ ( Q�G appropriate municipal factor3. Plumbing $
�. Mechanical (HVA $ Note:Minimum fee=$ (c
5. Mechanical ther) Enclose check payable to
0
6. Total Cos Q le (contact municipality)and write check number hrre
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and Lenalties of perjury that all of the information contained in this
application is true and accurate to the best of my knowlec e undemanding. 1 ��
111 • a• print and -i};n name Title Telephone No. I lle
..� / done,
d cj�0/D
tiUeel Address Citc�Tuwn State Zip.
Municipal Inspector to fill out this section upon application approval:
Name Date
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All dimensions size designations This is an original design and must Designed: 7/1 0/2 009 1i
given are subject to verification on not be released or copied unless Printed: 7/10/2009
job site and adjustment to fit job ` applicable fee has been paid orjob
conditions. order placed.
41708242.kit ,� Legend Drew'ing#: 1
PROPOSAL-
Joe Linn f �W 4 PROPOSAL NO
Independent Contractor r
90 Margin Street SHEET NO.
Salem, Massachusetts 01970 DATE
Tel: (978) 741-4758 /• r ,} — U
PROPOSAL SUBMITTED TO: Fax: 978 741-19M WORK TO BE PERFORMED AT:
NAME/j , / ,•`"-� ADDRESS
�j'7.. r /a
ADDREj,.-,-
S r ai—
r"' DATE OF PLANS
PHONE NO. ,,.,., ARCHITECT
We hereby propose to furnish the materials and perform the labor necessary for the completion of G4 7C�� i ��O%� -
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All material is guaranteed to be as specified, and the above work to be performed in accordance with the drawings and specifi-
cations submitted for above work and completed in a substantial workmanlike manner for the sum of Dollars ($ _-f6; v� )
with ayme is le made as follows.
i5 O'A`14 /i,"s
.3 Respectfully submitted _
Any alteration or deviation from above specifications Involving extra costs ? I
will be executed only upon written order, and will become an extra charge +.- {
Perover and above the estimate. All agreements contingent upon strikes, ac-
cidents.or delays beyond our control. ! 1
1 Note—This proposal may be withdrawn
by us if not accepted within - days.
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the viork
as specified. Payments will be made as outlined above.
Signature _
Date- Signature
ate'. NO3818-e0 PROPOSAL
CITY OF Salt -a•-NI, ,L-ksS.kcHUSET B
BL'ILDNG DEPART%MNT
120 WASHNGTON STREET, )'a,FtOOR
TE1_ (978) 74S-959S
FA.x(978) 740698M
KI, Rt EY DRISCOLl
MAYOR Il{ohtAi ST.Pfflllts
DIRECTOR OF PL SLIC PROPERTY/BU MDNG CO>L%IISSIO%'ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
-%nallcant In(nrmatlon Please Print Legibly
Name (Business.Organsratiomindivcdual): ��✓ `����
Address: '0 �'" "A)
�^ elp'O -7 17/ 3 7a
City/StatriZip: �/ &ft'l Phone M:
,%re you an employer!Cheek the appropriate box: Type or project(required):
1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
�,( employe"(full and/or part-time).* have hired the subcontractors
2.IEI. I am a sole proprie lot or partner- listed on the attached sheet: 7. XRemodelins
6 ship and have no employees These sub-contractors have a. ❑ Demolition
Workingfor me in an ca aci workers'comp.insurance
y p ty• 9. ❑ Building addition
[No workers'comp. insurance S. ❑ we are a corporation and its
required.] officers have exercised their 10.0 Etocirical repairs or additions
3.❑ 1 am a homeowner Join`all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152.41(4),and we have no 12.❑Roof repairs
insurance required.] t employe". (No workaW
13.❑Other
comp. insurance required.)
Any applicant that chocks but rl MUM aW fin ua the s lica below shoring their warktas'corrtpansatGar policy information.
' I I.wswuvtttas who su anit this affidavit indicating atcy are thing all work and then hits auaitk coanocbas~avhinit s new affidavit indicating awk
:r11 tan ahM deck this ba must anachd an additional rhst+howing an cmma of the ar►•eonvston was tMlr wohws'corny,policy infomatim.
/as an employer that Is providing,workers'rompeasadon lnsaronee for my employees: Below/s the pefley on/Jab All
it formaliam
Insurance Company Name:
Policy N or Self-ins. Lic.N: Expiration Date:
' Job Site Address: City/StatrJZip:
,attack a copy of the workers'compensation policy declaration pap(showing the polkry number and expiration dab).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
nine up to S 1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of s STOP WORK ORDER and a fins
Of up to$250.00 a day against the violator. Ik advi.*W that a copy of this slalcmcnl maybe rorwarded to the Office of
Invcsugatiuru ar the DIA for insurance coverage verification.
/do hereby semi) under tha pans id pel h as of per/uty that the in/brmadon provided ubovel'is ewe and correeg.
Pour
Olrhial oar only, no not write in this area, to he:untioleted by city or town"I leial �
City or ruwn: __ Pcrmit/l.lccnseN__
Lsuing.%uthunly (circle one):
I. Ruird of llealth 2. Rudding Deparlment 3. Citytrown Clerk 4. Electrical lnspccto► 5. Plumbing Inspector
6. ther
C:mlact Person: _ ._ _. Phone N: --... . ....... ...._...-
" CITY OF SALEM
.y
PUBLIC PROPRERTY
q ,r � DEPARTMENT
:1tyC P�%
120 W.\ii HNG'IONS'I BUT •SA PV, Nl ASSU I II 'I I i N J")
f[I:978-'45-)595 ♦ 1'sx:978-7409846
Construction Debris Disposal Affidavit
(required fur 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 M __ 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 faci ity)
(address of facility)
signa'rwf permit applicant
r
date
P/4 .
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,..�-rvma Rau" u ati sad CTOR t'1
��d of Soilding .
MEN7 CONTRA_-- �11
ViOME IMPROVE _ t _
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tlon 141739 Tr# 263016Re9tstra 412.010 ExPlraupO l�dlvidual `
1TYPe E•;A
,t
JOE LINN i .•j
JOSEPH LINO pdmin straar.
90 MARGIN STREET: `
� SALEM.WAA 01970
.- r ��ia iiomm-wou o�✓l',aaoac/ti�ae(ts' �Board of of Building Regulations and Standards
•. °"' Construction Supervisor License. fit
License: CS 87350 �.
Expiration` 1111/2010 Tr# 14803 §
s
Restriction 00'i` '
t ;
� JOSEPH0 LINN " 41
90 MARGIN ST
SALEM,MA 01970 Commissioner ,-