65 WEATHERLY DR - BUILDING INSPECTION ao
132 G� 2-CD Co
The Commonwealth of Massachusetts
a Board of Building Regulations and Standard SPECTIONEALE ERVI FM
Massachusetts State Building Code, 780 CM
Revised Mar 2017
Building Permit Application To Construct,Repair,Renovate li
One-or Two-Family Dwelling ��Qq 21 This Section For Official Use Only
J Building Permit Number: Date Applie :
Building Official(Print Name) Signature Date
1
1 ^ SECTION l: SITE INFORMATION
1.1 Ptc,Fs= A 1.2 As_ ,s- s it n +_ z
Lla Is this an accepted street?yes no Map Number ParcelNumber
1 t 1: __ '.t }:..aJn: : 1.P .+X.".y -. 'Ls:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
I.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Publi Zone: _ Outside Flood Zone? Municipal X On site disposal system ❑
C,�� Private❑ Check if yes❑ P po y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record•
k vITY2 rso� � + _ ol,4 -Dl%60
Name(Print) City,State,ZIP
(P17- 65'0 - F y f(&
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building I wner-Occupied I Repairs(s) ❑ 1 Alteration(s) ❑ .Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other Specify: K,
Brief Description of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ f Z�o , 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard Cityffown Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 0"0 2. Other Fees: $
4. Mechanical (HVAC) $ e List:
5.Mechanical (Fire $
Total All Fees: $
Suppression)
_
vd Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �Zr ❑Paid in Full ❑ Outstanding Balance Due:
MA 1 -M to o
Mntt-CV 611
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 1 p)-7 qO 12-S-
1 J- U 456,[C S License Number Expiration Date
Dame of CSL Holder U List CSL Type(see below)
5 P Sf .
No.and Street Type Description
�- M6 f r - ow, U Unrestricted2 Family
(Buildings u el inR cu.ft.)
R Restricted 1&2 Famil Dwellin
Cityfrown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
L SF Solid Fuel Burning Appliances
97���� y/�/ 4,wayl-sey I Insulation
Telephone Ismail address `� D Demolition
5.2 Registered Home Improvement Contractor(IHC) 1,57—fro
S z'ryow A<;"- � HIC Registration Number Expiration Date
HIC Company Namc or HIC 2sgi;L `.aT_ J
QINO✓�Sai/QS ep
No.and Street Email address
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 .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
to act on my behalf, in ail matters relative to work authorized by this building permit application.
1�11
Print Owner's Name(Electronic Signature)
Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entciing❑iy iname bel0:v,i i:erct,•y uiiu"st tmd'.',:'the pa0s aIld pcFtalii S pf pcijU y thHt ali of tie iitiJ.mlla i%n
contained in this application is true and accurate to the best of my knowledge and understanding.
,,59eKelrrfW�v- /yf r��cc5 — S $ /S
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/oc Information on the Construction Supervisor License can be found at www.mass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch)
Gross livinag area(sq.ft.) -- Habitable room count
of fireplace, Nil— dlooms
Number of bathrooms Number of half/baths
'Type of hFzting system Nurt ber of decks/porches
Type F ,...r:,.,, EnCie _�'
3 "Total Project Square Footage"may be substinited for"Total Project Cost" �
CITY OF &U.&M. 2NvIakSSACHUSETTS
• BuHMING DEPART%MNT
120 WASHINGTON STREET,r FLOOR
TEL (978)745-9595
FAx(979)740-9846
KI BERLEY DRISCOLL
MAYOR TkomAs ST.PmERRE
DIRECTOR OF PUBLIC PROPERTY/111:11MUSIG COMMSIONER
Workers' Compensation Insurance Affidavit: Buildens/Contractors/Electricians/Plumben
Applicant Information_ — �/ Please Print Legibly
Name(Busirwstiorganization/Individu-a1a N��l): //�'Q� """ /'"/ U/ae'S
Address: S�r'vu._ S T City/State/Zip: 1 "/20 2Y ' A/'�' 0191/
� Phone#: 97k 3/�/—///9'/
Are you to employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
,,.i employees(full and/or part-time).* have hired the sub-contractors
2_QN
am a sole proprietor or partner- listed on the attached sheet.: 7•%piodeling
ship and have no employees These sub-contractors have 8. Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.El am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12. Roof repairs
insurance required.]t employees.[No workers' 13.�Otha Alt l t��/ �% S
comp.insurance required.] �G
Any applicant that checks bar so must also fill out the section home showing their wakes'compensation policy information.
'I lomcmenen who submit this affidwB indicating they am doing all work and that hire outride commence,most wbmh a new andm it imikaning eueh
:Cwuraaon that check this has must anadW an additional shot showing are name of the sob•cootru m and their we*='carp.policy information.
Ian an employer that 4 providing workers'eompensadon insurance for my employees. Below Is the pol/cy and Job site
information,
Insurance Company dame:_ —,we— A" Lt� .
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 6S /*/ear/] 191-' City/State/Zip: � r 07 1?70
Attach a copy of the workers'compensation policy declaration page(slowing 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 a fine
of up to 5250.00 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 terrify under the pains and penalties of perjury that the information provided abovve Is rue and correct
i m tre: Date: �!9�?�/ S
Phone,7:
OJJlcfal use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/I.Icense#
Issuing Authority(circle one):
1.Board of Ilerlth L Building Department 3.Cityrrown Cleric 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Perron Phone#'
• 8. m
CITY OF S.U.& . N-WSACHUSETTS
BL'ILDNG DEPART%&NT
120 WASHLYGTON STREET,r FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KINfBERLEY DRISCOLL
MAYORTriObtAS ST.PrFxR&
DIRECTOR OF PUBLIC PROPERTY/BLILDNG COMMSSIONER
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 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 MGL c
111, S 150A.
The debris will be transported by:
T7 KgwL.- 440c 'V
(name of hauler) JJ
The debris will be disposed of in :
(name of facility)
Pit 6!j:!� . k4- m lq 6o
(address of facility)
signature of permit applicant
s A /7.0 1.5
date
andy�r.e�:
Marcia Kirkpatrick
• From: Cyndy Anselmo <cyndy@ecpllc.net>
Sent: Friday, May 29, 2015 12:09 PM
To: Marcia Kirkpatrick
Subject: 65 Weatherly Drive, Salem
Hi Marcia
The Weatherly Drive Condominium Trust has given approval to Deniece Grace, the owner of 65 Weatherly Drive, to do
remodeling of the interior of her unit, and her contractor hs supplied the appropriate insurance paperwork to the Trust.
Thank you.
cyndy
Cyndy Anselmo
East Coast Properties, LLC
Real Estate and Property Management
400 Highland Avenue Suite 11
Salem, MA 01970
P: 978-741-2003
F: 978-745-9684
cyndv(�ecpllc.net
1