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9 WARREN ST - BUILDING INSPECTION (2) ! EIVEO 'rile Commonwealth of�I,ssachusett4NSPECTI CITY OF Board of Building Regulations and Standards S��LEM �j Massachusetts State Building Code, 780 CNI14 Ma 1 a A ev�.,ell.11ur?Ol Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: DateA PFlied: 3 0 I Building 011icial(Print Name). Signature Da e SECTION 1:SITE INFORMATION` 1.1 Property Address: 1.2 Assessors Map Br Parcel Numbers Map Number Parcel Number I.la Is this an accepted street, yes_ no I 1.3 Zoning Information: 1.4 Property Dimensions: > Lot Area(sy ft) Frontage(It) \ Zoning District Proposed Use 1.5 BuildingSetbacks(ft) Front Yard Side Yams 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? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if ye3O SECTION2: PROPERTY OWNERSHIP!` 2.1 Owner'of Record: �prq #.)CCz-�as>(5aaa)ts �teZIP `v(�t 0197a �h17 ne(Print) City,State,ZlP P.I3t!�2�En1,sT Hot-8(o�-73Y� No. mid Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Altemtion(s) ❑ 1 Addition Cl Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work2: /U I kr'rAfC` �o?AU1EL�tOF !/r/S`r'n'I.G Q•r�4S/�f� aol� H/ l 14) U .,�ni,,,,.r Dili iwlsrAt4- let, • ak4�ge.sUiu-� (� �' cL f I SECTION a: ESTIMATED CONSTRUCTION COSTS Estimated Casts: Official Use Only Item Labur and Materials) I. Building $ D I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee '-, Electrical S ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing S 2. Other Fees: S t.Mechanical (hIVAC) S List: 5. ;\Ixhanical (F1fe S "rutal All Fees:S Suppression) ' Check Nu._Check Amount: Cash:\nunuu:_ 6.Total Project Cost: .S 000. ❑Paid in Full ❑Outstanding Balance Due: O �, Y{,Q A �t VV%49 0 f 7` n 3C I/.NOISEG'PION 5: CONSTRucrfON SERVICES 5.1 C nstruc.tion Supervisor License(CSL) ��.,� fn� ��}�"WAO 711�ric Pin Licens Ymnber Esp ratio Doe Nunes of CSL Holder nt/ List CSL'fype(see below) 7VL 44yio— — Type Description No. ;md Street /�' U Unrestricted(Buildings u to 35,000 eu. 11.) aaon7 m aq&&' R Restricted 1&2 Family Dwelling Cityfl,own,Stan ,ZIP M Masonry Rooting Cowrin Window and Siding /ram SF Solid Fuel Burning Appliances /�j•s31.�6�i% rnsulation 'Nle hone Email address D Demolition 5.2 Registered ered Home Improvement Contractor( C e „ llu IT (aKkololl� HIC (2 Registruuon umber Exf irutifin Date f IIC Cum . y Name or fIIC Registrar one loS-p�r No. an4lStreet Email address de- 6- ,W4 oigd� Cit /Town,StateZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.151§ 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:0WNER AUTHORIZATION TO BE COMPLETED WHEN. OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PE"IIT I,as Owner of the subject property,hereby authorize 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, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accurate to the best of my knowledge and understanding. EA1 m14G� ,d-,C /& Print Owner's or Authorized Agent's Name(Electronic Signature) ate 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(IIIC) Program), will not have access to the arbitration program or guaranty fund under M.G.L.c. 1 d2A.Other important information on the HIC Program can be found at wwvv.mass.cov-'oc:t Information on the Construction Supervisor License can be found at wsvw.wass.eov'dps When substantial work is planned,provide the information below: Total floor nrea(sq. 11.) (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 I'ypeof Cooling sysmnn Enclosed Open_ 1. •folal Project Square Footage"may be;nbstituted liar"futal Project Cost' �yvf CITY V F SiU2,N j� LY�a��JSi 1C�11/rJ L' 1 1 J BUILONG DEPART.NtErT •.\�i ,� 120 W:tsHLVGTON $'CRF&T, 1°BOOR TEL (978) 745-9595 F.ux(978) 740.984S IU1iHE1tLEY DRISCOLL N LAYOR Tt-1OaLA$ST.PIEUZ DIRECTOR OF PUBLIC PROPEPTY/8UILDLNG CON p1I55[ONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5 Debris, and the provisions of NIGL 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 tNIGL c l 11, S 150A. The debris will be transported by: y (name ufhauler) The debris will be disposed Orin (narne of facility) _Jjlf�j�uJc .� - Oddress of facility) ignaturcufper i "011cant dale opm-M, CITY OF �LENI, �� SS.ICHL'SETTBUILDING DEPIRTN-NT 120 %)VASHLNGTON STREET, 3t�FLOOR TEL (978) 745-9595 F.kx(978) 740-98-16 KI- .%IBEALEY DRISCOLL. THoms ST.PiERKE NVLLYOR DIAECL'GR OF PUBLIC PROPERTY/BUILDING CO\N[SSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Leeibiy NalnC 113usinuss Or/Sanizatiom'Individual): lAONtk rj(`f. COWCILAUI-MS Address: 1,pJ CJdLrJ`k Sc City/State/Zip: pe&aOMA Q Phone it: 9�_el -5 -I(7$q Are ru an employer?Check the appropriate box: - Type of project(required): I. I am a employer with_' 4• ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors _.❑ I atn a sole proprietor or partner• listed on the attached sheet,t 7. Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition [No worker'' comp. insurance 5. ❑ We are a corporation mid its required.l officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. (No workers'cutup. c. 152, 91(4),and we have no 12.❑ Roof repairs - insurance required.)t employees. [No workers' 13.❑ Other camp.insurance required.] •Any applicant dust cheeks but 11 must alsu fill out the section bclowshowing their woAco compensation policy in6hrtnatiun: 'I1,, a tt¢ra who>uhmit this arfdavit indicating thry am doing all work and then hire outside contractors must submit a new affidavit indicating such. $' mmctun that check this box man anachcd an additiunal sheet showing the mmne of the subeomracton and their workers'comp.pal icy information. I ant on employer that is providing workers'cronrpeusatlon hesuranceJor my employees. Bala Is the policy turd fob site infuriation. n Insurance Company Nmne:_L 6tgr` Qt/nL fWs• CD Policy n or self-iffy. Lic.n: (a/(',�- 3//1 S- 333Sa/�U L� Expiration Date: Ic Job Site Address: sr Ofg7,0 t 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 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to 5250.00 a day against the violator. lie advised that a copy of this statement may be furwarded to the OI'lice of Investigutioas of the DIA for insurance coverage verification. Ida hereby certify turder to pains and penaltiess of perfury that the iufurruaton provided above is true and currecL Si T' 1 1 c' Data Phone 1: Ofliciat use only. no rat write in this area,tube completed by city ur town officiaL Citynr'1'usvn: _._._.. . .__ Pcrmit/l.lccnseg _______ issuing Authority(circle one): I. Board of health 2. Building Department 3.C'ityffawn Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Otiher . ._-.— Contact Person: _. _.— Phone ti: Salem Historical Commission 120 WASHINGTON STREET,SALEM,MASSACHUSETTS 01970 (978)619-5685 FAX(978)740-0404 CERTIFICATE OF NON-APPLICABILITY It is hereby certified that the Salem Historical Commission has determined that the proposed: ❑ Construction ❑ Moving ❑ Reconstruction ❑ Alteration ❑ Demolition ❑ Painting ❑ Signage IE Other Work as described below does not involve an exterior architectural feature or involves a feature covered by the exemptions or limitations set forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic Districts Ordinance. District: McIntire Address of Property: o Warren 'Street Name of Record Owner: Erin Young& Josh Jarvis Description of Work Proposed: Replace damaged roof with black, 3-tab shingles. Non-applicability due to the work being in-kind replacement. Dated: March 12, 2014 SALEM HISTORICAL COMMISSION By05t,�tu\� The homeowner has the option not to commence the work(unless it relates to resolving an outstanding violation). All work commenced must be completed within one year from this date unless otherwise indicated. THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of _- Buildings (or any other necessary permits or approvals)prior to commencing work. 7�Q! Massachusetts-Department of Public Safety �. -Board of Building Regulations and Standards Cumtrudion Supeni+ur License: CS-087977 t r-rs ERIC W PALM` 3 HILTON S F c SALEM MA-,01970 - Expiration Commissioner 041Y3/2014 OfBse o�cons�u°m' Uoese HOME IMPROVEMENT CONTRACTOR Registra0on: r,:142089 Type: - Expiration 3f12C,t014 Ltd Liability Corpor { * _ { A TIC WEATHERIZA�'I�F- k: ERIC PALM -x 61R JEFFERSON SALEM,MA 01970 Underaetik ry_ II t s �YT/ze �Cnirrri<oxruaa�(f o{C�ijrtrr�j�r/ercrel?j j s OfSce of Consumer Affairs&Busiu ss Regulation_ r ©ME IMPROVEMENT CONTRACTOR leglstratlon 118301 k + T e: a� ' xplratlon ' 3/19/20:15 ' '�D B YP. ' DBA DSCPAINTING ANUCONSTRUCTION a DOUGLAS 50F.ULLERST a. EVERETT MA 02149+mot' , ,�, „Undersecretary - 3 a f Y l Massachusetts -Department of Public Safety t� p� Board Of Building Regulations and Standards Construction Supen'isor License CS.087797 DOUGLAS S AREVALO * - 50 Fuller. EVERETT MA 162149� �+^ Commissioner 0 29/2 15 ' 10/29/2015