10-1 WEATHERLY DR - BUILDING INSPECTION A
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The Commonwealth of Massachusetts
Department of Public Safety
➢V Massachusetts State Building Code(780 CNIR)
Building Permit Application for any Building other than a One-or Two-Family Dw ling
_(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
(�J SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a s avaQ2ble)
n is-/ w 6ovow C'44(6m (5�-Mo rii
No.and Street ity/Town Zip Code Name of Building(if tpliril-aLn
dM
SECTION 2 PROPOSED WORK
Edition of MA State Code used If New Construction check here❑or check all that apply in th l yo,to low
Existing Building❑ Repair❑ 1 Alteration ❑ Addition❑ Demolition Cl (Please fill out illd sUbo. AppMIN I)
Change of Use ❑ ChangeofOccupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑e No
Is an Independent Structural Engineering Peer Review required? Yes ❑ Nor ❑
Brief Description of Fred Work: TE'e-woVA?� 10 bSrr C BAA-Ty,
,9L6ar�rR/n,L TLf2Txritr�G LFS aVb��Fr� • Tr
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Flours/Stories(include basement levels)&Area Per Floor(sq. ft.)
Total Area(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as ap licabte)
A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F: Facto F-I ❑ F2❑ 1 It: High Hazard H-1❑ H-2❑ H-3 ❑ H--I❑ H-5❑
I: Institutional I-1❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable)
IA ❑ IB ❑ IIA ❑ IIB ❑ IIIA ❑ IIIB ❑ I IV ❑ I VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if Outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site❑
required❑or trench or specify:
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: hazards to Air Navigation: V 41 li t n ��,•" i r i,
Not Applicable Cl Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ 1 Yes❑ No Cl
SECTION 6:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Croup(s):_ Type of Construction:. Occupant Load per Floor:
Does the building contain.m Sprinkler SystOm?: __ Special Stipulations:_
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SECTION 9t PROPERTY OWNER r\UT}IORIZA'fION ''
Name and Address of Property Owner
7AT/L1L//9- �/�6A/A/bC /(/-/ G✓ F?r t1 DK ��1LLlK. C�j7U i
c
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
'KIT/OC/.p OCyrvlvw
'title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
OC.rIA-A/trc orepsr/cx at-( J/o(, , µ14 Olq76
'Name .T Street Address City/Town State Zip
to act on tlie, roper roperty owner'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.R.of enclosed space and/or not under Construction Control then check here 0 and jkip Section 10.1
10.1 Registered Professional Responsible for Construction Control
N ne(Regi tram) ' Telephone Nu. e-mail address Registration Number
� N/ rs'� 141,1- o1sgs
Street Address '" City/Town State Zip Discipline Expiration Date
10.2 General Contractor
�(�CISIG�I 7L'ca+ck-,?e-Z-i r� �,rT. ZL L
Company Name
,t1v�.� Diu �a37?3
Name of Person Respojr ible for Construction License No. and Type if Applicable
3o �cwa/( JT iL( 'NF /uA Vs
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION II:WORKERS'COAII'ENSAI ION INSURANCE AFFIDAVII' Nf.G.L.c.152.§25C 6
A Workers'Connpensation 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 a--
Item and Materials) 'total Construction Cost(from Item 6)_$ ?/¢4G
l Building $ ..3 GGG Building Permit Fee=Total Construction Cost x_(Insert here
2. Electrical $ /a(J'G appropriate municipal factor)_$
3. Plumbing $ / G6
.1. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5. Niechanicil Other S Enclose check payable to
6.Total Cost S 7/2OG (contact numicipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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 ccurate to the best of my knowledge and understanding.
Please print anTLI sign name r Title Telephone No Date
Street Address City/Town State Zip
Alunicipal Inspector to fill out this section upon application approval:
Name Date
T
CITY OF SzU EM, N1i1SS:1CHUSETTS
BuILDNG DEPARTMENT -
tr 120 WASHNGTON STREET, 3r°FLOOR
TEL (978) 745-9595
F.ur(978) 740-9846
KI.\[BERt FY DRISCOLL
i.v1AYOR THo&w ST.PIERRL;
DIRECTOR OF PUBLIC PROPERTY/auiLDIVG CO\LNIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information _ Please Print Legibly
Morelliusit ss Orgmtitatian'Individuai): tslChl / GtJtZ/rt�L L� CGI✓fT Z
Address: 3CJ
Cily/State/Zip: lfE '� AI N G147 C Phone C 31- -7>>5-
Are yn n employer?Check the appropriate box: 'Type of project(required):
1.01 am a employer with 3 4• C] I am a general contractor and 1 6. ❑New construction
etttployeea(Poll and/or pan-time).• have hired the sub-contractors
2.(] I am a sole proprietor or Banner- listed on the attached sheet t ?• ❑Remodeling
ship and have no employees - These sub-contractors have S. C]Demolition
working for me in any capacity. %vorkers'comp. insurance. 9• Building addition
]No workers'comp. insurance 5. [] We are a corporation and its
required,] officers have exercised their
IO.C]Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.C] Plumbing repairs or additions
myself. (No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. (IvtG workers' 13.❑Other
camp.insurance required.)
•Anv applicWt our chswks bus Of must also fill out IhC 1ccliun Wow Showing their warkrli cumpensadon polity inrumatton.
'I Inmeuwrw"who submit this anhinvis indicating they am doing all work and then hire outride contractors mat suhmil a new aMdavit indicating such
t'nnmetun that clivrk this box mat attached an additional about showing the nwne of the subwentnrton and their workers'comp.poitry infermatien.
f our can etitpluyer ilia!is providing workers'c•unipensailon htsurunce for my employees Deluw is lhs pulley attd jab site
inforaratian.
Insurance Company Name:--_
Policy it or Seif-itts. Lie.H: Expiration Dale:
fob Site Address: City/Stan/Zip:
,Vlach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of,%IGL e. 152 an lead to the imposition ofcriminal penalties of a
line up to S1.500.00 und/ar one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline.
of up to s230.Oo a day against file violator. De advised that a copy of this statement may be furworded to the ODice of
In veil iguliunc ul'lhe MA for insurance coverage verification.
/du hereby cerrify rut ¢ulseF/puGWy(adyd+tchler of perjury that the h Junnudors provided ubuvve is true and correct.
Phone '!'
official use unly. Du nor ovrite in lhiv area,to be cvnrplelerd by city at lown o/Jieiul
City nr Tuwn: _ .. Permiul.lcensc
Issuing Aut horily(circle vile):
I. board of Ilrahh 2. Building Departulent .{.('ityffuwu Clerk 4. Electrical Inspector 5.'Plnnnbing Inspector
6. Other
Contact Tenon: Phone ;r: I
QTY OF S ALEM, MASSACHUSEM
{` r BurLmNG DEPARTMENT
_ 120 WASHINGTON STREET,3AD FLOOR
TEL(978)745-9595
KAMERLEYDRISC)oLL FAX(978)740-9846
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING OOIvMSSIOMR
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 of MGL c40, S 54; Building Permit# is with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
�lZ�i Sic
(name of hauler)
The debris will be disposed of in:
--/-rU/✓ o
(name of facility)
k/GG�r -7�
(address of facility)
Signature of applicant
�- - /s
Date
4, Commonwealth of Massachusetts
yr 3r ,b
City of Salem lug
1 ;r_ 120 Washington St,3rd Roor Satem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Permit No. B-14-1905
FEE PAID: $165.00 PERMIT TO BUBILD
DATE ISSUED: 12/16/2014
This certifies that OCONNOR PATRICIA
has permission to erect, alter, or demolish a building 10 U10 1 WEATHERLY DRIVE Map/Lot: 210235-801
as follows: Renovation NEW KITCHEN CABINETS, FLOORING'&°NEW,RECESSED LIGHTING & UPDATE
ELECTRICAL I� ri s ` � ' I � 9r
4 i.:I !d t y Ti _ � y
Contractor Name: Precision Remodeling, Adam Dlxey maw
tq
DBA: tip F gpKti
Contractor License No: 103733 _ dot z
1 211 6/2 0 1 4
r
Building Official " Date
xR
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six-months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request '* i Iw"
_io
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
All construction,alterations and changes of use of anybuilding and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. _
s �
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
€
HIC #: 168276 Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A).
b
Restrictions: , Mq
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.