8 WEST TER - BUILDING INSPECTION (2) ✓{ ! 13— I LF—I Za �
a� The Commonwealth of Massachusetts
�r Board of Building Regulations and Stand Z,EWE? VICES CITY OF
i +V SER SALEM
Massachusetts State Building Cod ��(��(��QH�
�`J1'G Revised Mar 20(l
Building Permit Application 'ro Construct, Repair, Renovate Or penipli,3 Q
One-or Two-b-andly Dtvellin SEQ
This Section For Official Use Only
Building Permit Number: Date Ap lied:
01 ( I iAsk .1 WIO(Ic_4 /aa—e ;7
13uildingOtlicial(PrintNam r se) h ignature
SECTION 1:sIT INFORNU TION
1.1 Property Address: 1.2 Assessors Map&r Parcel Numbers
S 0 e A I 'Er,2r2s4cg _
I.la Is this an accepted street?yes no Map Number Puccl Number
1.3 Zoning lnformation: IA Property Dimensions:
Zoning District Proposed Use Lot Area(Sq 11) Fronluge(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
Lfi Water Supply:(bLG.I,c.,lo,§5,1) 1.7 Flood Zone Information: 1.3 Sewage Disposal System.---
Public
❑ Private❑ Zone: _ Outside Flood Zone!Check ifyes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owned of Record:
T (�tti��_ �04P b-,
None(Print)_ City.Slatc,ZIP
le9rs� 1 ERRs4e,` g78 7rFy� 27z6
No.and Strect Telephone Vomit Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building bra O, !pairs(s) Rk Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Spceily:
Brier Description of Proposed Mr ok' -- —
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item IslimaNd Costs: Official Use Only
Labor and ;blateri;ds)
1. Building $ 1. Building Permit Fec:S Indicate how fee is determined:
2. Electrical g ❑Standard City/Fawn Application Fee
❑"Total Project Cost'(Item G)x multiplier _ x
:3. Plumbing S 7, ptltcr Fces: S —
d. Mechanical (HVAC) .S List:_
5. ;Mechanical (Fire
Suppression) 'fetal All Fecs: S _
('heck No. ____Check r\mount: _ _C;tsh r\nuwnl:
G. 'total Project Cost .S ❑ Paid in hall ❑Outstanding B;d:uue DLIe: - ----
del J 97b'- z/6 - 7 7 9 s CDo�VA)
t
SECTION5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) -
License Number Expiration Date
Name of CSL Molder r+
C' - List CSL'I'ype(see below)
x
No.and Street MRR,
Description
cted Buildin s u to 35,000 cu. ftJ
ed ISt2 Famil Dwellin
City/I'owq State,%IP Mason
Coverin
andSiel Burning Appliances
f Insulation
Tele)hone Email address D Demolition
5.2 Registered Home Improvement Contractor(if IC)
HIC Registration Numher E.xpir;nion Date
I III Company Name or IIIC: Registrant Naum
No,and Slrcot —
Email address
City/Town,State, ZIP '1'ele.hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(b1.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this aRidavit 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 PEILMIT
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 Sigm)nve) Out.
SECTION 7b:OWN ERt 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 a ''ation is true and accurate to the best of my knowledge and understanding.
Print Owner's or A orired i\genCs Nu .Itttttnmic Signature) D'ite
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(FIIC) Program), will not have access to the arbitration
program or guaranty fund under�bLG.L. c. 1 d2A.Other important information on the HIC Program can be found at
w ww.nnass.11ov/oca Information on the Constriction Supervisor License can be found at www.mass.vov/dps
2. When substantial work is planned, provide the information below:
Total Boor area(sq. 11 _(including garage, finished basenxenb'altics,decks or porch)
Gross living area(sq. ftJ _ I Iabilable room count
Number of fireplaces.-----------_--- Nunxher of'bedrooms
Numbcrofbafhroonxs Numberofhalf%baths ---------------
I*ype of heating.system Number ofdecks/porches
-Type ofcooling system---_ ---_-------_ Enclosed --Open
Tolal Project Square Footage"may be substituted for"Total Project Cost"
,a
RECEIVED
INSPECTIONAL SERVICES
SEP -5 A 3� 29
QTY OF SALEM, MASSAQIUSETTS
t L frs BUILDINGDEPARTMEN
y: y 120 WASHINGTON STREET,3ED FLOOR
�? r
\�Nbsa TEL. (978) 745-9595
FAX(978) 740-9846
KINEBERLEY DRISCOLL
MAYOR THOMAs STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONEVE SSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date \
Job Location /
L A- Dc zv
� a'E�7- ��/�i2a2-E E�'-�
Home Owner Address — Lc.) &eW 16A e4C e—
Present Mailing Address Y- IJ ts-' C£
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) 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 understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
0o' Commonwealth of Massachusetts
� �33
City of Salem
y sFi '<s 120 Washington St,3rd Floor Salem,MA o1970(978)745-9595 x5841
Nr.n�
Return card to Building Division for Certificate of Occupancy
Permit No. B-14-1291 Ill
FEE PAID: $280.00 P E RM I T T 0 Bit A L 01"Joh'
SATE ISSUED: 8/7/2014
This certifies that WHOLLEY WILLIAM J WHOLLEY DONNA L
has permission to erect, alter, or demolish a building _,8,WEST,TERRACE -�. _ Map/Lot: 330738-0
as follows: Repair REPAIRING WATER DAMAGE CAUSED BY A'BROKEN'2ND FLOOR BATH WATER
PIPE. COMPLETE BATH REPAIR; LIVING ROOM &`CELLAR REPAIR WALLS, CEILINGS &
FLOORS. .
Contractor Name:
DBA:
E t L3 f
Contractor License No:
�
ht A
8/7/2014
jai
Building Official Date
I .0%P,
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 (
s W.—
Fi; llr a ;It
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 any building and structures shall be in compliance with the local zoning by-lawsand 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. J M t v '„ Y
6i"4t„
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire,Offiaals are provided on this permit.
r r a. _ a ,`t „
H IC $/: Persons contracting with unregistered contractors do not have access to the guaranty fund"(asset forth in MGL c.142A).
W ,
Restrictions: '( "
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
M
• TTb- CK19 -7?
a\ The Commonwealth of Massachusetts RECEIVED
1 Board of Building Regulations and Stand r
Massachusetts State Building Code,�80 EC110NAL SER ICE TY OFSALEM
Revi d Mar 2011
Building Permit Application To Construct,Repair,RenovttDrT�rrlpllJsh
One-or Two-Family Dwelling 44
This Section For Official Use Only
Building Permit Number: Date plied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1e�F per`ty Addr ss: 7 1.2 Assessors Map&Parcel Numbers
I.1 a Is this an acceptedstreet?yes_'no Map Number Parcel Number
1.3 21Zoning 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❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Re rd:
tA/;& /s1Mnnf. �N _& p/ 970
Name(Print) --� City,State,ZIP -
k (Ab Al <��, 97h'-210- 7?IC
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Cl Specify:
Bri Des ription of Proposed Woo ': � '
�.(
SECTION 4,ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
1.Building $3O/C 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $
❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ ,�"� 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
1,, Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ❑Paid in Full ❑Outstanding Balance Due:
S�N� � t-b• 0- g ��
SECTION 5: CONSTRUCTION SERVICES ,
5.1 Construction Supervisor License(CSL) Zy 0�
cl
License Number Exfirati tDate
Name of CSL Holder
�O 1n t List CSL Type(see below)
No.an S et Type Description
O/ �d U Unrestricted Bn11dIn s u to 15, .0 cu.ft.
R Restricted 1&2 Famil Dwellin
City/Town,State,ZIP M Maso -
RC Roofm Coverin
WS Window and Sldin
SF Solid Fuel Burning Appliances
Insulation
Tele hone Email address D Demolition
5.2 Re istered H ,e Im rov�em t Contracto HI /
:TE _ ��'l�C pan a or C Reg trant e HIC Registration Number Expir ion Date
y
No.and e
O/ --p 9V Email address
i /Town,State, IP 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 Issuanc f 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
1,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 accurate a est of my knowledge and understanding.
Pr� r A Ag t s NaMe(L11ectronic Si ature) Dat�
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
wi"vinass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dns
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"
CITY OF Sid.EM, NL' SSACHUSETTS
; t
Mp� Bt:tlDt.lcDEPARr>tE.�ir
120 WASHLNGTON STREET, 3"O FLOOR
TEL (978) 745-9595
Rja(978) 740-98.16
KI.\lBERLEY DRISCOLL
"VLIYOR TtloatAS ST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BCILDr\G CMI]MISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plu'mbers
A a rtietnt Information Please Print I (bl
Name 1HuxinassnnOrganiration,'Individu:J):
Address: d") c_Q�zot Al
City/StStc/Zip:. /i� Phone If:_.9w-
Arc u can employer'!Check the appropriate box: F
project(required):
I. 1 am a employer with 4. (] i arrt a general contractor and Iw construction
employees(full and/or part-time).• have hired the sub-contractors
2.❑ lama sole proprietor or partner- listed on the attached sheet. I modeling
ship and have no employees These sub-contractors have molition
working Im me in any capacity. workers'comp. insurance. ildiug addition
(No workers'comp. insurance 5. ❑ We are a corporation cold its
required.) officers have exercised their ctrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(,No workers'sump. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) f employees. (No workers' 13,❑ Other
comp. insurance required.]
•Any upplinatt nut checks but a 1 mwt also rill caul caw aactiun k:low showing their workers'cumpnsaliun policy i,unm+atlon.
'I h+muuwwn who+ul+mit this alndavil indicating ihcy art doing all work and Ihcn hire outside conlractan most sohmif a new aflldavil indicating such.
$nmmutun that chak this bux mot aaacho l can addiflunal shml showing the na ne of that subaumncton and iholt workers'comp.policy information.
!unr can enrpluyer Drat lr proviJGrK Ivorkrrs'cumpmrsaJun Gt.rurusee for my earpluyers. Oeloly lr the po!!cy and fob site
Insurance Company Name: p p
Policy it or Sclf-ios. Lie, 0: //Z^ o Oelt 22C3-4 Enpiration Datt:Olob Site Address: � Vy� �� City/State/Zi
Attach a copy of the outliers'compensation policy declaration page(showing the pulley number and expiration date).
Euiluru to secure coverage as required under Section 25A ofblGL c. 152 can lead to the imposition oferiminal penalties of a
tine up to 51,500.00 and/or one-year imprisanricnt,as well as civil penalties in the forth of a STOP WORK ORDER and aline
of up to 525 AO a day against the violator. Ile advised that a copy of this.statement may be forwarded to the Office of
hn•estigatiuns ul'lhc DIA for insurance coverage verification. -
!de.hereby ernif rrJer t ' r nd penultles of perjury that the information provided ubuve A,true and correct.
Phone 4,
Qf iciu!use only. Do not rvrire in this area,ro be cuurpleted by city ur torus ujjlViut
City nr l•uwn: _ Permit/l.lcenie 4 i
Issuing Authority(circle one): —_ -- --- ----
I. Board of Ilcahh 2. Ikrildlnq ntpa rime nl 1.City/fawn Clerk J. E,Ice trio al Iaspccfor 5. Pin cat biog Inspec rur
6. Other __. . ..
Cunlact lemon: _ Phone 1:
CITY OF SALEM, MASSAC HUSETTS
}1 BUILDING DEPARTMENT
3\ s 120 WASEINGTON STREET,31D FLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR TY-IOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 issued 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:
- T
(name of hauler)
The debris
will be disposed of in:
(name of facility) A
(add ess of facility)
Signature of applicant
Date
li