99 WASHINGTON ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts RE EIVEQ3T1OF
Board of Building Regulations and Standards INSPECTIQ iAL 1�E$
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Det�yplish 1 IQ 3: 2 3
One-or Two-Family Dwelling [tUU�l7 MM
�^ This Section For Official Use Only
lT' Building Permit Number: Date p lied:
S �)
Building Official(Print Name) Signature Da
l SECTION 1:SITE INFORMATION
1 11 Property Address: 1.2 Assessors Map&Parcel Numbers
Zl�l 1J13[h_Shtn -fbn .St. � 3(
l.l a Is this an accepted street?yes >✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public fig Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
C1,rirles r*rte_Kien ScLn. MA bnw
Name(Print) City,State,ZIP
CI°I WCLS.V tv� 4. *31 cM-Sq4.19o5
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building lit Owner-Occupied 1( Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : 13aiiyoL rn re.tt oAA
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ $7Z.lr6 bO 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $
❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 33)5,UD 2. Other Fees: $ ��
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ I) �) ❑Paid in Full ❑Outstanding Balance Due:
r
006 &Vr�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
/� CS•6 f33'1S clI3ItL
3YI[in i' 111LAThF License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) 11
It Kehm6YC br.
No.and Street Type Description
-� U Unrestricted(Buildings up to 35,000 cu.ft.)
d Gr�U2rS . M N L�-tclz3 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofin Coverin
WS Window and Siding
(( SF Solid Fuel Burning Appliances
q'iQ-'[l+�- 3333 Y1VtantiZ �YQu.151Ch,LGYI._ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 1031n I t "1�Q 1 b
�Y1rG.)n S LY�n , (L-A Lea" HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
12 1—A..A4fr\ k6.C-0 w-
No.and Street Email address
baAL*-Vs. MA ctzi 2 3 �lrs ll4 3333
City/Town,State,ZIP Telephone
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 .......... L`i l No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' 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 in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) 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"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,Mass. 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /� �/� `.. -r.-- Q Please Print
Legibly Q
Name(Business/Organization/individual): r 111Urp1WS �I,a�1 6n, • �c�9 - a+ X•Am 4,
Address: "i2 Holten &.
City/State/ZipjDanay-S . MA wal Phone#: 9-1K• •1-14.31"14
Are on an employer?Check the appropriate box: Type of project(required):
I. 71 am an employer with_ 4. ❑ 1 am a general contractor and I 6. G New construction
employees(full and/or part time).' have hired the sub-contractors 7. ❑ Remodeling
2. 0 1 am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers' 9. 0 Building addition
[No workers'comp.insurance comp.insurance.$
required] 5.0 We are a corporation and its 10. 0 Electrical repairs or additions
3. ❑ I am a homeowner doing all work officers have exercised their 11. [If Plumbing repairs or additions
myself [No workers'comp. right of exemption perm MGL
insurance required] t c. 152,§ 1(4),and we have no 12. 0 Roof repairs
employees.[no workers' 13. 0 Other
comp.insurance required.]
-Any applicant that checks box#1 most also fill out the section below sbowing their workers'compensation policy information.
tHomeowners who submit this affidavit indicating they are doing as work and then hire outside contractors must submit a new affidavit indicating such.
#Contactors that check this box must attach an additional sheet showing the name of the sub contractors and state whether or not thou entities have employees. if
the sub-contractors have employees,they most provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below Is the policy and job site
information.
Insurance Company Name:(Al `ASQCtailtA EMPIC11US Ins Co
Policy#or Self-ins.Lic.#: WCC SDI OC9 201 =6 Expiration Date: 6 l 11016
Job Site Address: 91 tl65 irvvr_•,n cj *3[ City/state/Zip: c50-QAxy� - U A C)I"110
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 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
$250.00 a day against violator. Be advised that a copy of this statement maybe forwarded to the Office of Investigations of the
DIA for coverage verification.
I do herby certify under the pains and penalties of perjury that the information provided above is true and correct.
I/
Signature: � .//�.Ol/ Date J aZi7�
Print Name: &IlLn f NullrIcihu Phone #: L11%•1l4 - 3[•1 +
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 Heath 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact person: Phone#:
72 Holten Street Danvers,MA 01923
Telephone(978) 774-3333 * Fax(978) 774-8709
Home Improvement License 003611 * Mass.Builders License#073375
CONTRACT
This contract,dated below,for materials and/or labor to be supplied by Browns Kitchen&Bath Center
(Hereinafter,referred to as the connector),at the sole request and order of:
NAME: Charles Strickler PHONE:978-594-1905
DATE:April 29,2015
ADDRESS:99 Washington St.#31 Salem,MA 01970
(Hereinafter referred to as the owner or buyer)to be supplied/performed at premises set forth above,subject to all of the terms and
conditions set forth on both sides of the Agreement,as follows:
Brown's Kitchen and Bath Center is happy to furnish you with a quote on your Bathroom project.
Carnentrv:We will demo tub alcove.We will demo bathroom floor
The shower walls will have waterproof backer-board with Owner supplied,Brown's installed tile
The shower floor will have a rubber membrane with Owner supplied,Brown's installed tile
The shower will have I(one)tubby
We will re-install existing vanity
The vanity will have a Granite top with undermount sink
Flooring: The floor will be prepared for Owner supplied and Brown's installed tile.
Plumhina: We will disconnect all necessary fixtures.
we will supply and install a Symmons shower valve Model#S4701(chrome)
We will re-install existing faucet
We will re-install existing toilet
All work to be connected to existing plumbing.Any modifications to accept draws or other items will be extra.If
any upgrades are needed a quote will be provided.
Shower Door:None at this time(Please note that shower doors take 24 weeks after template)
Heating:None
Ventilation: None
Electrical:None
*Tile quote is based on a straight installation.Intricate patterns or large file are higher in price for install.Marble like tile is a
higher price for install.
*At time ofjob all knobs,handles, TP holders,towel bars eta must be on site for installation.if nor on site during job
installation a servicpfee will be charged to return to job and install these items.
Nothing other than stated above is Included in this quote.No paint or paper.All sales tax is included All work is fully
insured Any debris created by Browns will be disposed of by Browns.Local permit fees not included
*Owner Supplied material is the sole responsibility of the owner.Any defects or problems will be billed at an hourly rate.
Door Style AGREED PRICE: $11,675.00
HandlelPulls
Floor 1/3 DEPOSIT:
Counter _—
BALANCE DUE:
This quote is good for(30)Thirty Days from date above. The owner represents and warrants that he is owner of aforesaid premises and
that he/she has read this agreement,set forth on both sides.
IT IS EXPRESSLY AGREED THAT NO STATEMENT,ARRANGEMENT OR UNDERSTANDING,ORAL OR WRITTEN,
EXRESSED OR TMPLIED NOT CONTAINED HEREIN WILL BE RECOGNIZED AND THIS CONTRACT CONSTITUTES THE
ENTIRE AGREEMENT.
It is further agreed that this contract is not subject to cancellation except by written consent of both parties.
SALESPERSO ACCEPTED:
ACCEPTED B X
X
(SUBJECT TO ALL CONDITIONS ON THE REVERSE SIDE)
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18" 63"
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81"
All dimensions_size designations Browns Kitchen Bath This is an original design and must Designed: 4/29/2015
given are subject to verification on 15 Elm St. not be released or copied unless Printed: 4/29/2015
job site and adjustment to fit job Danvers, MA. 01923 applicable fee has been paid or job
conditions. 978-774-3333 order placed.
1c i.le h - ba4li
rlPcion1I An i I wT- c,- 1-
May 22 15 08:52a p,2
Saietn Retsetiral LI.G
4 Real Estate Revitalization
1 141 'bssninntw St
i Salem.hl'.019 t;
g)Nvn 497f.)i79-B27k
Fas(9719)744-7558
dpiN011'ipalCmrll w�].000:
5/21. 201`t
Re: Construction at Town House Square Condominium, Salem
To whom it may concern:
I am writing as a Trustee of Town House Square Condominium to affirm that the Trlitees
are aware of the proposed work to be performed by Brown's Kitchen and Bath Center of
Danvers,on =U'niitt 31 at Town House Square.
Feel free fo call or email me if you have any questions or concerns.
i
Si here
David Pabich tee
ouse Square Condominium
Cc: Brian Schwarzkoph,Trustee
May 22 15 08:52a p.1
B.F.Murphy Plumbing& Heating,Inc. Browns Kitchen & Bath Center,Inc.
72 Holten Street 72 Holten Street
Danvers,MA 01923 Danvers,MA 01923
Showroom located at IS Elm Street
(978) 774-3174 Fax(978) 774-8709 (978) 774-3333
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To:t- ' <�k2m lr,lu"It ttT 11 112 t'7t� Fax# 1�Sk -3i-!G -`1�4L-
From: ` tw:'ns K.t4In . f'1411 'L'A Date: 122115
Job. S-4r1C i Y.Ifhlt1 2.
Pages including cover
Confirmation is required by far
Sign and Return
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