25 UPHAM ST - BUILDING INSPECTION (2) Lk L0S;tA FG-� T S 2-7 Z6Z
'rhe Commonwealth of i'iassachtlSettS CITY OF
� Board of Building Regulations and Standards 4 1y 11S LEM"! / Massachusetts State Building Code, 780 Cbllfil` K01 . P OvAh Mar 2011
t ;
Building Permit Application To Construct, Repair, Renovate Or Demolish a
OOne-or Tivo-Family Divelling
f� This Section For Official Use only
1`l Building Permit Number: Date.Applied: 1t
Si'..ature. Date a
Du11ding 0111cial(Print Name). Signature.
µ,
SECTION C:SITE INFORNIATION' C
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers r7l<
L I a Is this an acce ted street?yes_✓ no Map Number Parcel Number
�y
1.3 Zoning Information: I.d Property Dimensions: 01
w
Lot Area(sy It) F
Zoning District Proposed Use Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§5d) 1.7 Flood Zone Information: 1.8 Sewage DD�isposal System:
Zone: _ Outside Flood Zone? 'On site disposal system ❑
Publica" Private❑ Municipal 81
Checkif esftY
SECTION2: PROPERTYOWNERSHIP!'
2.1 wner or Record: as �Ph S F Ss w
�t/4 -
W�me(Print) City,State,ZIP
SS'(a rs-. M/} i �1? 0?H-(,,?7A S(otp(o(! Sw,^,T-So
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building e Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ LNgyt� r�pfyl itvyI Other ❑ Specify:
Brief Description of Proposed Work': (< r y1c, ter`^
SECTION J: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials)
I. Building $ 0 COJc tt1 I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ✓ OJT W ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing S d0—\W 2. Other Fees: S
d.Mccltmtical (FIVAC) $ List:
5.:Mechanical (Fire S 'total All Fees:S
Suppression)
Check No._Chick Amount: Cash Amount:_
6. Tots) Project Cush. S ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 ConstrueVon supervisor License(CSL) OGM, 0
Seo �'A0�J� License Number Expiration Date
Name of CSL Holder List CSL Type(see below) y
$-f Type, , 1;,. �.� � : - Description .
Nu.and Street'I - t�J � U Unrestricted Ouildin s to 35,000 cu. tl.
.1 A, �� ? 01 R Restricted l&2 F;unil Dwellin
City/Iown,State,ZIP M Maso
RC Roofin Coverin
_ WS WindowandSidin
/ /_ SF Solid Fuel Burning Appliances
Sdo-kl If CO�CA5 1 Insulation
'isle hone Email address Demolition
5.2 Registered Home I�m(,pr�ov,ement Contractor(HIC) �! ?S/ q_/7
5m� k t>'f`�`Fi^� I HIC Registration Number Expiration Date
fC omppy Na m pQ I(Cif R egin� Name, nG �pQ?"7CaS^ �[o7d5c!d-/C) C
wStrceP
' Email address
Gty/Town State ZIP Tele 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........... 0
SECTION 7a:OWNERAUTHORIZATION,TO BE.COMPLETED WHEN.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[,as Owner of the subject property,hereby authorize SCG Ct
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
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 f this application is true and accurate to the best of my knowledge and understanding.
� ( Sc� d�4✓ .�I l 1 40
Print Owner's or Authorized Agent's Name(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 eur have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
www etas,eov'oca Information on the Construction Supervisor License can be found at ww�lJns
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage,finished basementlattics,decks or porch)
Gross living area(sq. 11.) 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"
0 YOFSALEK MASSAQiG n
BLUanaaDEPAwsMr
IM WA==MSM jJWFLM
ZbZ 7�9995.
$DomBitiBYD L AAX 7d049M
lldAYCR 7lsoussS'1.P a
� IHrPIBiIICA�Y/a�L1D�iQG1H8�
Construction Debris Disposa/Affjdovit
(required Wall. demolition and renovatbn work]
in Manknoe with the sho edition of the stele 6u#&w Code, 780MM Sestlon 1115 Debra
and the Provl90M of MGL o0Q S 54, Built Permit sy is issued wRh the
condition that the debris resul ft from this work sha0 be disposed of in a properly ikereed "
waste depasit fadiity as defined by MGL c 111,S 15k
The debris will be transported by.-
(name of hauler)
The debris will be disposed of in:
L S
(name of fadlity) ,
11 f,, d 3o 7(27
(address of facil") ,
Signature of applicant
Date
\ The Commonwealth ofMassaehusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibly
Business/Organization Na lme: S,` O, COvxS�Jj� �'
Address: `l ��" Q(li \6 k Gc �
City/State/Zip: eCL� 1A G+ Phone#: (D O -7 V� U
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
e
r part-time).* f 6. ❑Restaurant/Bar/Eating Establishment
2.YQ I am a sole proprietor or partnership and have no 7. ❑Office and/or Sales(incl.real estate,auto,etc.)
employees working for me in any capacity.
[No workers' comp.insurance required] $• ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152,§1(4),and we have 10.0 Manufacturing
no employees. [No workers' comp. insurance required]* 11.❑ Health Care
4.❑ We are a non-profit organization,staffed by volunteers, o
with no employees. [No workers' comp. insurance regl 12.[;14ther C O1,1 S f r✓K-156--,
-Any applicant that checks box#1 most also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box#1.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: SCO{}1 C(q ,p til S c.wlze__t eR
Insurer's Address:
City/State/Zip: /�q
Policy#or Self-ins.Lic.#_ Expiration Date: � _?` / 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$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$250.00 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.
I do hereby certify, rider the p 'ns and p Wallies of perjury that the information provided as ove 's true and correct.
Signature: Date: 1�/ I//L
Phone#:
Official use only. Do not write in this area, to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.inms.gov/dia
Information and Instructions
Massachusetts General Laws chapter 152 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,
express 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 foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other 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."
MGL 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,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply your insurance company's name,address and phone number along with a certificate 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 be 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 fill in the permit/license number which will be used as a reference number.In addition,an applicant that
must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary). 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
must 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.a dog license or permit to bum leaves etc.)said person is NOT required to complete this
affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
www.mass.gov/dia
Forth Revised 02-23-15
RM
F,
®R fi,
W
ON FU�
Ifi
-41
"fit
Doi-
iafiPwit
if-M
F
pa I;
W, INN,
--g
5 1W
bw , , g,
14.0.,Q -19 F R
M51 1 . MIT
M-F
if f,
.F
T-21,
goo
if
;WU
fil
q
-66
ki
ME
JOES,
g
AM
UZ I z
Z
F."
ami
NO R
"M m
l 0 --%L
ffF
K W
k-fi, P
I-
O
afi
'37f
If-
x-
jrii,Z
30"! t
- i., W-571,i
437X-5 R.Iii
411 15- 1
W,
X
fio--
2am" M- ME
FiNr
,4f
,, .�*, A��,t-iiii I I,
fill
jz
i,171�
!Lig j
......... ........
fiifg-
4 121-11 12
OZIM
iiif
-14t I
:41 RON
IN 1
x� Jfkj lffag Q, n—'r WL �- -ifim,
=4tfi`4 I 17+E7�1N' Fil
IFE p
mig
M.L1
ME W,
. ..........
n�Zu
Page 1 of 1
Card 1 of 1
[Location 25 UPHAM STREET P—roperly,Account Number Parcel ID Old Parcel Parcel ID 62—
Current Propeq Mailing Address
Owner ROTOLOSTEVEN M City SALEM
ROTOLO SHEILAGH M State MA
Address 25 UPHAM STREET Zip 01970
Zoning R2
Current Property Sales Information
Sale Date 3/1/2002 Legal Reference 18400-538
Sale Price 210,000 Grantor Seller ONORATO ANTHONY V,
Current Prope2 Assessment
Card 1 Value
Year 2016 Building Value 146,300
Xtra Features Value 0
Land Area 0.038 acres Land Value 101,700
Total Value 248,000
Narrative Description
his property contains 0.038 acres of land mainly classified as One Family with a(n)Old Style style
uilding,,built about 1850, having Wood Shingle exterior and Asphalt Shgl roof cover,with 1 unit(s),5
C I rooms 2 total bedrooms 1 total baths ,0 total half baths 0 total 314 baths .
Legal Description
Click Property Images to Enlarge
a rcL
WL
YrL
n
i 11
(n I
� � 9R H
BYl
(mQ1
(
p ]
http://salem.patriotproperties.com/summary-bottom.asp 11/3/2016
3�
, a Whib[N
-- t� n Iliq_ IJP�elce�6in
I a
I ry�;iG`� a7 11,71�,''' TTTa.rlbr
I ���_.= I I I a Brialrya
JnPiN
�J� II _ 0 5 '.I "11 y ay�irrwlwm
6' flu = (�� tdn 11 'I �� GAL- day 17 7.- ,ral.reanaw
Loeb.
(� TA bumroramv-xe lae+
.iF rry �✓ IPA �`. _i 1 . fib'e
= III -Sxsme
O ' rllf A IPi.:: 9:MISA
11i
simian
c"aao fl
4+ p 271,{.
v
i I kf i, 7 5
a s o
a P
+ � I
4 Fy JI5
a
i r t 1J'I 1��,J5 Fk II 2 9a
I d'; a 19 ` ' it t'I
a g,
/ 7
I
q /� I
T� ' ,II III Yr ' (]o
u a� d 1�kah a a w4 �. 'i i II a e
��',!I�rl Iliaapl rd I 2 e ! .Aye R d a
dJl jy� J;41 6�1 Vl Y 1 1.9��
[NeW[hsnmau Nears - O
prsXmaWKmseaaNlerq "�' 41�ilbu wu' I1'r"
NOP
Obrldntl0.rams[etly.Tw IW'�N fiFi' __
eeenemumnuuamaerena 4- 9"J �1.e, 17�
rt[pNMlraw M[msm , _ o-. 5 I
nEsrMNe.4tleedM4ls. n p:_
0 80 1eo it Printed on 11AW016 at 12:51 PM
x ptar+rr
e
aww
w
i
MIX
t
#25a
r
a
F b '
r
�= AD
,fir
+ xa<.a.a . ,� r�rrrt,PlF " z �.
r
+�
y.
LN
^u
r 14
� 3h � �
r
14
�fr'' � A. yRF• xw -36%,... r, 'P `'" , t �If�l r1 -4�!if r' 10
/ #
k
46
IF
5 1
f M F
t
f
Y
Y
4 yTI�y�
V}
/�a a T
!�! Massachusetts -Department of Public Safety
�f Board of Building Regulations and Standards
Construction Supervisor Arlqk
License: CS4)64210
SCOTT T DAUTIOL
7 APPALOOSA.WE I@P
Pelham NH 03078
.72.. Expiration
f Commissioner - 01106=17
�-\ Office of Consumer Affairs&Business Regulatio6'
OME at on: EMENT CONTRACTOR
egistratwn 1j8575
DBA
Expiration 4/3[2017_ TYPe:
t —
SCOTT DAUTEUIL DEVELOP r
SCOTT DAUTEUIL
7 APPALOOSA AVE --
PELHAM,NH 03076 "^— =
Undersecretary
i .t -
a
r
.. $� t`• ��.. � W�fiYcl , �' Yi��YY�iiY+i�i k� �#
r
• �� �� � '' � yl�r ' 1 X ' 1 � � ��~µ It F.
pp �-
4 r [ } I
-
TIMM
i � �..,�_
,�
I µ
1
w.w
.a.
FF �
Y
9
r
3
r oa
a ,,,w
,per
T T
� r
. r
� � W
x � �
x S-e
T � �
�„��:�.
,�,��.4,
� l�i� - '=
�i' k ~
� 9
�,
w
4��NM(�*i .i
���� n b
���C.. w�
''' {..Sa
�1.6 d t.: �s i(3 1 1
� ,f� rt-_
,�,�R � ;. '�s'
,�' � � _ � �
� ri
t. M1 5 � • ' � �� is
f � � � � d. .
� k v
..
i� r. � ,,' �
��i �
i '} S - f
s� ¢ ..
�,,� �,
, •
,;.' ' �t%
�f,
' r,.
-- .,.,
� � � .'
�L
�� �
s
� , � � �
N
��
"�. i�::.
�' � { ..�
'�, �
ti
f
I � �
1 __
6
_A!... ..
N
i-f.
��
ti
ati
�'
�:
w Y
nt5° ' � �•- r Mrs ';
i�rx R 4�5�
•w
r
a.
T I'
1 •, r
4
�" z ;k ��d qx• , �z�� �, x
rr
4CF
t ! • J 4
J Jrl I
J 1
f >
ly°�
ypx
y..
IN
•,r - f
ola
yti
n
i y 0IQ. y
It
"d
Ikrw✓A
a
• � - �,`., [= �;.. to
l �
I b-K •sm zl Y fib.
a 4
�e2 `
IANP
W:1
5
ice. I� 1
■ �t
. , �. ;,
r
A� {"
Iv �fi yA
a '+
t
)f
d
� N
r
s
I .
i I
?w 4 + 1
� 1
h`.
,