1 WINTER ISLAND RD - BUILDING INSPECTION (4) $210 Ch. 1 ov 8
1 The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
@` E Massachusetts State Building Code, 780 CMR
g ISP O�WWaSFRVI CES
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling b
This Section For Offici se Only r, ', :.
Building Permit Number: Date pplied:
Building Official(Print Name) Signature Date
SECTION 1: SITE INFORMATION
1.1 Property Address: �J 1.2 Assessors Map&Parcel Numbers
j ry;Qk, �s/canv� !-J (/y /7
1.1 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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1}wn4 olrRec rd: / di
Name(Print) City,State,ZIP
1sstgr2� gJ ?-rd--7N1-7S-YJ i�Qlon/99L�ufy ,cm„r
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Additions'
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Br=—�gptioWZ:
b 0 e ;
fOx2o O,Z;fA a
SECTION 4:ESTIMATED CONSTCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ p10 0DO 000 1. Building Permit Fee:$ Indicate how fee is determined:
'
❑ Standard City/Town Application Fee
2.Electrical $ 1,
LlTotal Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ -
Suppression) Total All Fees:$..
�p � Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �°N68 p Paid in Full ❑ Outstanding Balance Due:
J't Ja0
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CC_ 07 ��/R 6y v�
C ® /2 icLicense Number Expiration Date
Name of CSL Holder . I
omeeS Gm rte+ List CSL Type(see below) l/
r
No.and Street r� Type Description
� t 1 '1„e� y rn d L #. /_/ U Unrestricted(Buildingsu to 35,000 cu.ft.
oL✓/ 7 R Restricted 1&2 FamilyDwelling
City/I'owq Slate,ZIP M Mason
ry
Cll4er InR 15623 RC Roofing Covering
WS Window and Siding
�6 ,/ / SF Solid Fuel Burning Appliances
G
97o fqo 41b /l {, MI $jy ,co I Insulation
�TNWyU65lw�/10 �72/a/d COh t�t
Telephone Email ad ess D Demolition
5.2 Registered Home Improvement Contractor (HIC)
1730?6g 1:7,5,2
HIC Colppany Name or,,P�lC Rep�ctrant Name HIC Registration Number Expiration ate
I111YlE� NiD 11�',schrn �g�vnr,�
No.V-3Street Ta ty'. R A �t 7���170-Fi130 Lmail address
Ci o/Town,State,ZIP L( 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 .......... D No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
\, OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
J� 1,as Owner of the subject property,hereby authorize Anrnrye 4&
/ to act on my behalf,in all matters relative to work authorized by this building permit application.
F. Lvk � - -5-1
le,
Owner�ame(EcrcmSisaure)
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 ta the best of my knowledge and understanding. ,
Iom -1 Vaccu 6wo-1 5 P- 19
Print Owner's or Authorized Agent's Name(EleAronic 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dIs-
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"
✓he foanwnaw�nea/az a6✓v[rzovacnuavua License or registration valid for inJividul use only
Office of Consumer Affairs& Business Regulation g y
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration ,173269 Type: Office of Consumer Affairs and Business Regulation
1.. Expiration 9/20/2014 DBA - 10 Park Plaza-Suite 5170
Boston,MA 02116
4HAX ER PRO CONSTRUCTION
THOMAS HAMM
23 TATUM ROAD �� 3-cr 3 o
SHREWSBURY, Undersecretary Not valid without signature
- ��lassachusetts.-Department of Pullic-Safety' '
Board ofBuddmg Re6ulations,and Standards,-=.
Construction Supeni.sar '
License: CS-092219
THOMAS AHAMM
259 Deers Horn R6ad aUtz?Lancaster MA 01523 '
Exp ration>'w
Commissioner 04/27/2015`:,
_r
-- . r CA _7
- - - - -� _--
— — a T
— — T J, -
- -L _
Ll
I —
_
,. CITY OF Si1L.t.i'Il� LY IaNSSAC1ZUSE TTS
i} J 1t BLILDLNG, DEP.IRTNIE`:T
120 W-UHLNGTON STREET, 3'D FLOOR
TEL (978) 745-9595
F.kx(978) 7-10-9845
Kt�tBERi.EY DRISCOLL
NLAYoa Dios LAS ST.PMRRB
DIRECTOR of PusLIC PROP ERTY/HLILDLNG CO\O(I55tOV EA
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 l l 1.5
Debris, mid die provisions of MGL c 40, S 54;
Building Permit k 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 tNIGL c
I It, S I50A.
The debris will be transported by:
r
(namauflteuler)
Thee ttlebris will be disposed of in :
(name of racdity) f f —
--- Coy Sok �d J�,, v 1. yj
(Iddres.c or ritcility)
l/
signature of permit,ppfican[
�12-711y
CITY OF S:`d.EM, lL-iisSACHUSET B
• !!x t BUDDING DEPARTNIE.NT
120 WASHINGTON STREET, 3w FLOOR
TEL (978) 735.9595
F.ar(978) 730-9846
KimBERLEY DRISCOLL
INL'AYOR T Homs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LUISSIONER
Woricers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legibly
NalnC (Business.Organiraliom'Imlividual): A
Address: r2 ti -khlnn r
City/State/Zip: 56" Istj MA 015-YS— Phone K: 97,Y'q?O^(,60
Are you un employer!Check the appropriate box: Type of project(requlred):
1.❑ I am a employer with 4• ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the subcontractors
2.❑ I ant a sole proprietor or partner. listed on the attached sheet. t 7• ❑Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity, workers'comp. insurance. y. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation mid its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LCI 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.❑ Other
cutup. insurance required.)
•Any applicant slut checks box et must also fill out the rutin,,below showing their wosken'cumpensmion pulicy tio;)Mutiun.
'I Ltmmwnets who sahmit this stndnvirindicating theyarc doing all work mid then hire outside contmetm moat sohmit anew afEdavit indicating suck
$'mnrwtors Out chuck this bus mtisl aaachn!un:Wditiuwl shut showing the mmite of the subtemnctun and their wnrken'comp.Policy information.
fans an eurpluyer rhar fs providinK workers'cumpmtsatlun insurance for my employees. Uelwv is die polley and fob site
lujanuation p /` r
Insurance Company Name: I f-QdeI2/5 _L.fOot?(�-(n (a (/(�I�, co tST Nfwef I Cd
Policy O or Self-iter. Lic. N: v L3'lO IJ -2)qz f - 13 Expiration Date: 4, 16 2r)!t/
lob Site Address: I wiJc r �S�Or� r% City/Stat,/Zip: 01970
Attach a copy of the ivorieers'compensation policy declaration page(showing the policy number and expiration date).
1-ailum to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
line up to 51,500.00 untVor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S250.e10 a day against the violator. Ile advised that a copy of this statement may be fornvardcd to(he office of
Imcstigaiions of the DIA for Insurance coverage verification.
l du hereby certify r die ain nd penalties of perjury that the inforatudwr provided above i.r sue and correct.
S ,•n I rc' 5/27
(/p�, / Unte:
Phone 1: /c�-7?Yv V/3d
OJjie'iul use wily. Do not write in rine area,to be completed by city or tomo n/Jlcfa2
Ciro nr Tuwn:
Issuing Authurily (circle one): -- -_—__ --
L Hoard of Ileahh 2. Building Deltartmvut 3.Cityfrnwu Clerk 4. Electrical luspectur S. Plontbing Impector
6. Other
Contact Person:____.. .. _ ______ Phone 9:
Pro
Homeowner I ninni-maiiinj
,In
L
mI
sl,n� zlp("J,
LD)
—-vc�fv" LL
Ali
Y-V-&4,
..........I
tlkerniw in 1111111
...........
J ZO
die h!
Re4lot ed 11,om.ij,-")be folie,ing hinkling Peini,�,ioe'llilla"
inlil"Ill hesecured b,the,,nnraclo,is The hot...T...le",all,nt. .........
betillitro-A to 111111,5 eirco., it!-
IT, oil III,
(owners Who sec"DrC their own permits will he
minded from the Guaranty Fond provisions of kale"he"Crinlon'ol`�l if'kgln CTIMMCICLI Wilk
NICI chripter 142A.) "it)
_�/Z.____Dave when enutmcled work will he SIIhl;kmrh:TPyc,mpk,,cd,
Total Contractr-11-11 zFil—.1.111
File C.onmoo, to Pahl...the ..Ili.luohh
glothe foll.in
jIons;lllIingc........fnOt in C,l,ml 1/3 offlu,moll M"PaIr Price 111, the Cost of,p"kil"ll"I"",'wriche'llir lfeeieved
I- or up'n cilintild...IT IT!
. ...... ..9 Pit.....
hallor"I IT,
11c.ro-. Iranill
11 1
N Frotylit"dpro,
"C'no","Lomn to""'
,it I'll,I,--"""ed lu the In"
Whirr" -'erro"t
`
minded
Crom t '(;-'r
mc, C hatilattir 142'k
LiPill Cej"plc!iCj, Iftl,e,,"Trac! tLx f'hid.delluMing fall pn'}...........it Contract is""Picica m,ok
HIT,Nis......O"'MCMU"I I......
III&Wd I's,;,," I
"W"Emnt'on
"I 11o,,illi,
WITS mko.j,.
'I-I,,11(-) aeproc dc,".P I......... larL orgmq M,
"et TO
"N'l;M�v ler 11i"LlIll Tom,I(b)th,'01i.,i ,,,i ,f,
I,,ll"Llial 011311111 in rmFl,r,,I
"heclol"
h,x
gardlessofih ,int. ,Earn im
M-1.11LEA; el ein"re"t-1 il"Ifill�gleel To be s-leh, In,all P""en"To
flil
ClAnnind AccciAlore-Upon itirl:ar.this document ......�`o"UCII"1oICtirndcrjaW, UIIJl'S5othco.sc noted within this dtW.....ent,the
connalA,spoil not n"PIN Ihvl any lieu or olliers-Tintv onere,,I h3S been phCC(j on The thj,n,,
her""'iph'il this min.10. ReviewIhc 1611 .....a c:,onob,and notices
170.1 he pr..laed into sieving The rnmran.I;,k,nine To need ,,111,11%,an'temand it lIzi,
r I I I lf�orreljong is "Cle,'
�10Ke
I.he law requirusnrn5t
snhconlrvcturx In 6e reasiercd with the
liron ,,,Prinn'llithotir Cn"PaClor
lJORIC 1111prowincrif Contractor Rc,i,onihn PrONCIVent co"alict.'s and
ictommun"1:IV Vrifiag to The Director,[10 Park uston,MA 021,
t ar by calling(17-S7 i-ft7R7 or RRS-IF3-371 i.
• )"Ill'The COMILlor have insurance? Ask lint('o,jW)Cjo,for 111 9 insurance company ill
".C.Ment. foomilion So That ml C."I Clink.coverage,ou ask to
Guide in tiro}Inmc,mpmvcntvot Y,)I,,lights and rics ...iInkn,,, Rtl,,,I the lonn,I t hon Maljon on the j,je flki,inno anit g,,e coll).o_k,Consam"
Contractor
11111,19VICTUME if it Ila,he,,,signed at, ocher
provided yo, lot,R.The
han the rnmnch;r'c
cm In loan nil ml,rt 6s imr mom orila nr 1.11:11, 1ail pos;mk.IW rcluean,,Ill or lo,chzlo,
'-fri, 63 in - `I
I'll Into;�`e L I, cd nin,,I,of'Can, not laf% Tn loid orthi `F1111.
cNittioli forn,for an C:,Pla'Buort or N
7-- ------
--- ------------
-t
IT"It",I;SIgont"o,
kill,
Assessor's Mop 44
Lot 15
PROPOSED —
EXPANSION 6
5,x 7'
Assessor's Map 44 Area =
Lot 16 /01, 3,900 S.F.f
Story
PROPOSED Wood
ADDITION Dwelling
of
CO
h. < Assessor's Map 44
\ Lot 18
n &�
PROPOSED
`\ DECK x
S/ J
61
O
•;. 4?A�hA ��
i
� PERE,�iZQt+R �
l'
PLOT PLAN OF LAND
SALEM, A/A.
Zoning District: R-1 PREPARED FOR:
Deed Reference: Book 26237, Page 561 FOTINI MANOLAKOS
Assessor's Map 44, Lot 17jD o fi WINTER ISLAND ROAD
Proposed Lot Coverage
o SCALE:1"=20' DATE: NOVEMBER I5, 2011
Njote This plen vras prepared from a tape survey DAVID P. TERENLONI, P.L.S.
and is intended for building inspector purposes only.
4U 01960
Offsets shown on or scaled from this plan are 4 ALLF,N ROAD, PF,AIdDDY,
orproximate only and should not he used to determine
property !1nes. P11--107