1 WEST TER - BUILDING INSPECTION �
���'o�
� �, The Commomvcalth of Massachusetts
tl� �{}4 y DoarJ of Building Regulations anJ Standards ��TY
,/� � � �a �� Massachusens State Building Code, 780 CMR, 7'h edition UF SALEM
�/v! '+�„� Revisrd Junnury,
I3uilding Permit Application To Construct,Repair, Renovate Or Demolish a l. 1008
One-or h o-Famrly Dwr!ling
This Se tion For Olticial Use Onl
Building Pertnit u er: Date Applied: i � l�
Signawre: � �'. ( � i ( ("�
f1uilJingCummissio r Ins " t fBuildings Date �
; SECTION I:SITE INFORMATION
1.1 Property Addrese: �I o i y'�o �,Z p�yeeean Map& Percel Numben
/ /,d�5'7 �b/1iP/fL£ fj,CEM M��
I.la Is this an accepted street?yes� ✓ n� Map Number Parcel Num6er I�
I.S Zoning Intormat�on: I.4 Property Dlmensions:
Zoning District ProposeJ Use Lot Area(sq Il) Fronmge(ft) I
1.5 Building Setbacks(ft) I
Front Yard Side Yards Rear Yard
Reyuired Provided RequireJ Provided Required Provided
1.6 Water Supply:(nt.G.L c.40,§54) 1.7 Flood Zone Informatlon: 1.8 Sewage Dbposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone7 Municipal O On site disposal system ❑ I
Check iPyesO ,
SECTION 2: PROPERTY OWNERSHIP�
2.1 Owner�of Record: ��' �f _ �B Gf�(�
/°,'�ti��r �/ �S'��.l�r/e� t /.eJ.v��-- ���v�c� �go�t
� e Print) �/� Address for Service:
����e�`�'!� �Z�7}G�` �a/2/
. gn turo 'Peiephone
SECT[ON 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction O Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessary Bldg.❑ Number of U�ts Other ❑ Specify:
Brief Description of Proposed Work':
/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
I�em Estimared Coscs: O(Ocisl Use Only
Labor and Ma[erials
I. [3uilding 5 L [3uilding Permit Fee:S Indicate how f'ee is determined:
�. Electrical S ❑Standard City/I'own Applicalion Fee
O Tolal Project Cost�Qtem 6)x multiplier x
3. Plumbing S 2. Other Fees: S
d. Mechanical (FIVAC) S Li51�
5. Mechanical (Fire S �
Su ressiun Total All Fees: S
6.Total Project Cost: S - Check Na_Check Amounr. �oun :_
4• Q� ❑Paid in Full ❑Outstanding Balance Due:
,
SECTION S: COIVSTRUCTION SERV ICES
5.1 Licensed Construction Supervisor(CSL)
Liccnse Numl�er lispiratiun Uute �
N�me uf CSL-I lulder List CSL I'S'pe Isee below� I'
��� Descri tion
.4dJress U UnresuicteA u lu 75,000 Ca Ft.
� ' R Restricred 1&2 Famil Uwellin
Signawrc � M Mason Onl
RC Residential Rootin Coverin
Telephone WS ResidentialWindowandSidin
SF ResiJential Sulid Fuel Bumin A liance Installatiun
D Residential Demolilion I
51 Regbtered Home lmprovemen[Contractor(HIC)
HIC Comp;uiy N:une or HIC Regisvant Name Registratiun Number
AJdress Cspiration Date
tiignuture Telephune
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance aftidavit must be completed and submined with this application. Failure to provide
this aftidavit will result in the denial of the Issuance of lhe building permit. �
Signed Affidavit Attached? Yes..........❑ No...........❑
SECTION 7a:OWNER AUTHORIZAT[ON TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
r
� , as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relaQtive ro work authorized by this building permit application.
/��O./��z.��f'���'�=�
�� atureofOwner Date
SECTION 7b:OWNER�OR AUTHOR[ZED AGENT DECLARATION
� ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
� /� O i�
nn ame �'�'�d�r�/is(�C`cde-�
y'gnature of Owner or Authorized Agent Date
Si ed under the ains and nalties of r'u
NOTES:
I. An Owne�who obtains a building permit to do his/her own work,or an owner who hires an unregistered cuntractor
(not regisrered in the Home Improvement ConUacror(HIC)Program),will nor have access ro the;ubitration
program or guaranty fund under M.G.L.c. IJ2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the infortnation below:
Total tloors area(Sq. Ft.) (including garage, finished basemenl/anics,decks or porch)
Gross living area(Sq. Ft.) Habitable room counl
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt%baths
Type uf heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Twal Project Syuare Footage"may be substituted f'or"Tutal Project Cost"
;•i :. ,
OF
PROPERTY
DEPARTIMENT
wfnt-1 By ORMAN L
VnrM 130 v ADWAc.TON S7M= • JJ i Mw> ACMLLS5M 01170
TM rs-715-9s" • F.kc 97t.740.9W
HOMEOWNER LICENSE EXEMPTION
Please Priest
Date I
Job Location
Home Owner Address
Home Owner Telephone — _ A rL
Present Mailing Address
The current exemption of "Homeowners" was extended to include owner -occupied
dwellings of two Unita or lea and to allow such homeowners to engage an individual for
hire who. does not possess a license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be, a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner" shall submit to the Building Official, on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERSSIGNATLRE
APPROVAL OF BUILDNG PiSPECTOR
See other side for state code
CITY OF SALEM
• PUBLIC PROPRERTY
,i
�• DEPARTMENT
I'.I:1 Mlfl' 111r 1;;I I
51'a kr r •x•11 I fl, S1.\.i 11 111 J 1 , • . I'1 .
I
FI: '171-,'14•n3'/j • 1' Vg: '179 -?*"84h
Construction Debris Disposal Affidavit
(ruquired tour all demolition :utd renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGC c 40. S 54;
Building Permit At is issued with the condition that the debris resulting from
this work shall he disposed of in properly licensed waste Disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by.
Tnr'�`-�
Inane of hauler)
'I'Ite debris will be disposed of in :
(nalneolr actIty
I;Iddm% III I W I lityl
or
Ja1e
The Commonwealth of Massachusetts
Department of Public Safety
\la.,.sachuuetls St.ite Budding (-ude(780C\IR)',rventh Ea tit
City of Salem
Building Permit Application for any Building other than a I. or
(This Section For Official Use Only)
Building Permit Number: I Date Applied: I Building Impectur:
SECTION l: LOCATION (Please indicate Block 0 and Lot 4 for locations for which a street address is not available)
..\u. and Street City /To -n Zip Qnie Name of Building (if.applicable)
SECTION 2: PROPOSED WORK
If New Construction check here ❑ or check all that apply in the two rows below
Existing Building Repair Alteration ❑ Addition ❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
U
Are building plans and/ur construction documents bring supplied as part of this permit application? Yes ❑ No — —
is an Independent Structural Engineering Peer Review required? Yes ❑ No �r
Brief Description of Proposed Work:
3:
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Evaluation is enclosed (See 780 CMR 3402.0) ❑ -
Existing Use Group(s): �.j Proposed UseGroup(s): r
Existing Hazard Index 780 CMR 34: 1 Proposed Hazard Index 780 CMR 34:
_. SECTION 4: BUILDING HEIGHT AND AREA
No. of Fluors/Stories (include basement levels) & Area Per Floor (sq. ft.)
Total Area (sq. ft.) and Total Height (ft.)
SECTION 5: USE GROUP (Check as applicable)
A: Assembly A -10'A -2r O A-2nc ❑ A-3 ❑ A4 ❑ A-5 ❑ B: Business ❑ E: Educational ❑
F: Facto F-1 D F2 ❑ H: High Hazard H-1 ❑ H-2 ❑ H-3 ❑ H4 ❑ H-5 ❑
1: Institutional VI ❑ 1-2 ❑ 1-3 ❑ 14 ❑ 1 M: Mercantile ❑ R: Residential R-10 R-2 ❑ R-3 ❑ R4 ❑
S: Storage S -I ❑ S-2 0 1 U: Utility ❑ 1 Special Use ❑ and please describe below:
Special Use: •
SECTION 6: CONSTRUCTION TYPE (Check as a licable)
IA❑ 111 IIA❑ 1180 it (IIB❑ IV C3 1 VA VB❑
SECTION 7: SITE INFORMATION (refer to 780 CMR 111.0 for details on each item)
Water Sup—ply/:m
. Flood Zone Information: Sewage Disposal: • Trench Permit: Debris Removal:
Public tfY Check if outside Floud Zuni ❑ Indicate municipal A trench will not be Licen,ed Di.posl Site ❑
required D or trench or .pecily: to t L.T�Z/
I'ncate ❑ or mdcntifv Zone: ur on .rte,c,trm D .permit is enclosed ❑
Railroad right-of-way: Hazards to Air Navigation: xL� I li,t,•nc l �nnmi„lam Itv, m„ 1'r, ,�.,:
\ot Apphcobly ❑ I. <trurlurc wnhm aopurt upF+reach arra' Is their ru\ ew aunplcted.' .
"t 'm,cnt. to I(udd rnclovd ❑, lb, ❑ or N,, ❑ 1'r, Cl \o ❑
' 'SEC'TION 8: CONTENT OF CERTIFICATE OF OCCUPANCY
L',a•(�ruu),(d: _ ra peof C•un,lruchon: Occupant Load per Ilour: I
I Lv, the L+uddn,h iantam,in tiprinUer tiu.,k•m.': Special St, uhtion,v
20 �/
64h4w&11 ft -p
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Wdress of Propertv Owner %
Vo1 LLD�n.)'7 ��AnZ S ZNiL- 7 �Q21 U>
Name (Print) No. and Street Ci 1Y/ Town Lip
Prop •rly the net Contact Information:
Title Telephone No. (business) Telephone No. (cell) a -mad address
If applicable, the property owner hereby authorizes
Name - Street Address Cily/To%vn Stair Zip
to act on the pro pert% ,%vner*, behalf, in all matters relative to work authorized by this buildin • permit application.
SECTION I0: CONSTRUCTION CONTROL (Please fill out Appendix 2)
(If buildin • is less than 35,0011 cu. It. of enclosed s ace and/or 1101 under Construction Contrul then cherk here O and ski S"lio 1 10-1)
10.1 Registered Professional Responsible for Construction Control
Name (Registrant) ; Tri ,hone No. e-mail address Registration r, /. �,/, j
Street Address City/Town
10.2 General Contractor _
State Zip I Discipline Expiration Date
�-p tvcry 7c-r"•7�—�=1 cr•-7i
Company
r !o
Name of Person Res, risible f`q C�nstructiun �/_ ' ense No. and Type if Applicable
St_ regt A 'dressY? ,� .� — — City/Town State Zip
Telephone No. (business) Telephone No. (cell) e-mail address
SECTION 11: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152.4 2506))
A Workers' Compensation 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 O No O
SECTION 12: CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost (from Item 6) = S
1. Building $ Building Permit Fee = Total Construction Cost x — (Insert here
2. Electrical $ appropriate municipal factor) _ $
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee = $-4— (contact municipality)
5. Mechanical (Other) $ Enclose check payable to
6. Total Cost $ � Z-0 t) 1 (contact municipality) and write check number here
I SECTION 13: SIGNATURE OF BUILDING PERMIT APPLICANT I
By entering my name below, I hereby attest under the pains and penalties of perjury
ap//p(�icaWm is true{,annddaccu�rraateetto9the
'best of mY knowledge and understanding.
Pleaae print and sign name (n �—' Title
1lreel
Cit%/ Town
6
the information contained in this
�28 /� - (I7'rL
Telephone ..No. Dale
State � Zip
Municipal Inspector to fill out this section upon application approval: �— %
CITY OF SM -EM, NLISSACHUSETTS
3L DING DEPARTlLNT
120 WASHINGTON STUJIM, )• FLOOR
TEL (978)1+'19595
FAX (973)14498W
KJ>D3EA"Y DRISCOLL 7110AWST.FO[tti
1TAYolI
DltEcfatOf PL ecuPtOPEtTY/fll'QDINGCO\MSSIONFtl
Workers' Cornpensatlon Insurance Affidavit Builders/ContrscloNEleetrlelrnalPlumbers
•nor apPan/'ti 611001111 ha e-1 11111111 alta as WA 1110 Issues lekw atseip'air wMa' CWNPWNEs polky io&owio m
' I6wwnrwre who Nib" Ahs Ad" idkol"'hep an Jove all awk ars nes Me s wipe cIsmaeaws ssr Pause a raw aahkvie meiesiea rr►
T.wlresye,e lay chwa )five ora slue aeIstlre as sJiti,e,d V V dMlwi'te'11e es1Y dna wraawIsearle,e twe'hrle wa,aee' uwq. paltry ieaewIsYM&
l am eve rwpleyer that b p ovldis ww/ers' emep essave /mate pmfiar ealy/gsea aehrtr V do pNleP awd jet slat
;Inn/we►rnasnacrelmCompany Vome:( J�rvCe '7N R A r`t"^ ti
GANSENBERG CONSTRUCTION ON
21r Lincoln Rd. ML
Salem Ma 01970
978-335-4742
08
PROPOSAL SUBMITTED TO: ie 159161
NAME: S. W, y C hie 159161 WORK PERFORMED AT
Anne Olenio same
ADDRESS: 180 FortAve. DATE OF PLANS:
tba
PHONE: 978-686-2632
We hereby propose to furnish the materials and labor necessary for the completion of:
Remove roof shingles from entire roof. _ Install new
"plywood over boarding -
Cover with Ice &Water shield: Shingle with 30 year architect shingles (color of choice -
reoommend white) Use 8" aluminum drip on all edges. Clean grounds
All materials are guaranteed to be as specified, and the above work to be preformed in
accordance with the drawings or specifications for above work, and completed in a
substantial workmanlike manner for the sum of***** $6,200.00 ******
$ 2,200.00 deposit to order materials. $ 2,000.00 when work begins,
$2,000.00 upon completion
Respectfully submitted: _Alan Gansenbe
Note- this
Accepted ..,I,,,u
14 aays
ACCEPTANCE OF PROPOSAL
The above prices, specifications and conditions are satisfactory and are here
by
You are authorized to do the work as specified. Payment to be madecepted.
as outlined above.
Date Signature
CITY OF SALEM
PUBLIC PROPRERTY
� N
DEPARTMENT
I'.IU MI11' ON,'ll
I_C u'.+J IL\b.+!V 51NurT 5.111 \I, :1.\»\I III J I,•:I'/ -
141 `I t 744'1M15 1' tt: 978•740-I846
Construction Debris Disposal Affidavit
(rcyuired 11jr all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.3
Debris, and the provisions of MGL c 40. S 34;
Building Permit p is issued with the condition that the dcbris resulting front
this work shall he disposed of in a properly dccui-d waste disposal facility as defined by MGL c
111.5 130A.
The debris will be trun2poacd by.
11mmo of hauler)
'I'Ite debris will be disposed of in :
pl:une u/l�aci ay
(;lddrnN of 1'sallity)
lists