11 WINTER ISLAND RD - BUILDING INSPECTION (2) 1 �
� I
1 I'he C'omn"oil veaIth of Massachusetts
Board of Building Regulations and Standards CITY OF
MaSS11ChLISC1t5 State Building Code, 780 C•MR SALEM
`J L,'•, R�rlsrJ.ILv'till
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or 1•wn•Familt'Duelling
This Section For Ot)ic' Use Onl
Building Permit Number: Dat Applied::
' vu�
� BwlJmg ORicial(Print N;une) Siytaturc pate '-
SECTION I: SITE INFORMATION
1.1 Property A dress: 1.2 Assessors Map& Parcel Numbers
L la is this an accepted street?yes no Map Number Parcel Number
1.3 Zo Ill Information: IA Property Dimensions:
Zoning District I4oposed Use Lnl Area IN It) Fmnlage(Il)
1.5 Building Setbacks(R)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: — Outside Flood Zone?
Check if vs❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Regord: f'/a r r 1 1
Mane(Print) LIP
5�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
hiv M1
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and \laterials) Ofltcial Use Only
I. Building g I. Building Permit Fee: E Indicate how fee is determined:
'_. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier
i, Plunihing g 2. Other Fees: S
a. Mechanical Ili\':\(•) 5 List:
i +. .\lerhanical (Fire 5
Su p pression) Tut:d :\II Fees: S _ -
Total Project Cu.cC S /) Check No. ---('heck :\mount: - _----('ash Anioune
v 0 Paid in Full 13 Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
.e Lc,SQ }�'- Y►')� )22S C.Cif License Nunthcr Fcpljir�atinn Date
No. and Slrcet —Fp12Fb_ _Sf• --- _-- Lisf•C'SL 1)pe lice below)
PC
Dc�iption —
N,unc ul'C.SI. I)older
/,t_ O , a l I hvcslncicJ I UuJJm-s a to 35,01)0 cu. Il.)
_�A ) vests {// It Restriocd IK? Funtil Dwdlin
Cit_vi 11.11.Stine,LlP M Mason
RC' Roulin Coecrin
__. W'S Window and Sidin
SF Solid Fuel Burning Appliances
978 3 60 .. 5`f✓o J h 6lzea, YAh oo• I Isulation
I ele hone Finail address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Numhcr Fzpirnion Dule
1IIC C'ompan) Name or I IIC Registrant Name
No.;md Street Email address
City/Town.State,ZIP relc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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 Signature) Dute
SECTION 7b:OWNEW 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 and accurate to the best of my knowledge and understanding.
Print Owner's or:\uthurizcJ Agent's Name Ilikctnmic.Signalwel Date
NOTES:
I. ;In Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
not registered in the Hume Improvement Contractor(HIC) Program).will no have access to the arbitration
program or guaramy fund under%I.G.L.c. 142A.Other important information on the HIC Program can be found at
otsw wa,, „% i Information on the Construction Supervisor License can be found at yes Jp,
2. When substantial work is planned,pros ide the information below:
Total floor area isy. a.l ___-_1 including Garage, finished basement'attics,decks or porch)
Grois living area I sy. fl.l - . _ Habitable room count
\umber of fireplaces_ _ N'unlher of bedrooms
Numbentfbathrooms -� Numberofhalfhafhs _
I)peofheatings)stem -.- -- ---__ Number ofdecks, porches.
I'1Ile Of0001i'14i1i1eln _ _ _ I'nclosed
1, "foul Project Square Footage'•m;q be:uhstituted tort"fatal Project Cost"
4
l
CITY OF S,u-E.«, Akss,kcjjuSET1'S
8L'tLDLNG DEP.IRT1tE\T
120 W tsilLNGTON STAFgT, jo F-tOOI
TtEL (978) 745-9595
KI3®ER1EY DRMOLL F,Vt(978) 740-984d
AL1YOR 7kO.tW SLFtFtta
DIRECTOfa OP Pl'BUC"OPERTY/8( MONG CO\L\llsslOhiE,
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 I I I.S
Debris, and the provisions of MOL c 40, S 54;
Building Permit N
this work shall be is issued with the condition that the dcbris resulting from
I If. S ISOA. disposed of in a properly licensed waste disposal facility as defincd by M(;L c
The debris will be transported by:
In una of hauler)
The debris will be disposed of in
(name or facdiry)
Iildress of fa.di�y)
+'Mninue ofpermrt ipplu+nt
� 'life
• t]
CITY OF SALEM
' ;1/ PUBLIC 1'RUPRERTY
=~ DEPARTMENT
ou.n'I Y'rnl4.•11
\l IL ye
I!:T,%IIfj I.lox ilikkI• a i.All•M,M.hA.u.ln V I n JI'rl�
Workers' Compenjailore Insurunca 'if""" : Uullden/ContractursiCie triclanwPlumben
1 � Illcun In nnndUo
V,IITIC
c I ' I I Le 'hi
I Iluvl�uryl)r;lanvnillAV lnJorlduull: J
11.ItIrusv: / 149-0_ p 7
Cilyr.5tarcr%ip• SglP�vi Krn�: QI�� °,
I hone ik 7 �� 7ra (—g000
.1ry A ou an exglloysr:'C heck the approyriuu bud;
:ufl a umplu)ur with d. Q 1+un a yunurol Contractor and 1000 " .
nrpro)eel(required):
Linyself.
uyues(full Jnd/ur part•tinlr).• hawhiroJthe auh-uuntraewrsNew cunsuuetiuna solo prnpriun]r or partnuh listed on rile aaachcd rhuet t Relnaldin�
nJ have no mnpluyuus These subcanlnerars have
nY thr me m anycapJclly. uvrkcre'comp, , Damoliriunurkurs'sump, insurance i Q We are a calponstion and itsOudding addiliund j .01cers have elan irad theirlacrrical repairs or additions hulrlcula+er Juin�all work iyhr of e.temptionpar Ic lumbinr n pairs ur addiliary.(�'o oarkera'cumP• c. 132, }I( ,and wr hnve no
cu rcyuited.) r mpluyces. INo wnrkeq' uufrepuird
C.
insuranwreyuind.j tbercoo rl mlrr JInlaW IMvt, I+luw rk 1»ly,lanitl IAif efllJfvh inuturin 1 a IIa11set. w iur►
'f..nAnwlun IAM heI'J Alit this 401d vil in fd•le 6'hoon,i l doing al.ru,tow III him wneide euxru,"hi
.IMI Jluwin AW n]xlf of the lub%m wr w%im s n•O'•InJsvir inJlalalrllet vAsL
rarpxe and Il fM Ia Wkoln'msp.Isrttey Inl6rreelua
ixjur/urn un arnployrr/huf lr prvvlJlne rrtrrArrs'rumperrn//ox GAfurnrrar/or rxy rrxpluprra Bdxlr/s rhr pit/Isy arse//u1.,;f.
xrufGrA j
Inauranuc company Nmne: C®h
/YrG . .1n4w•�A/J(�
"111icy d Of Sodr-ins. Lic.h: -
�—'- Expiruhun O,na.
lob Silo, Alfdrer.'t: —�—
.NfacA n nryy orthe Irorkort'eumpvmallon pulley deulerallun pupa(showlnp rhetpoliey number and eeplratlun data),
f]Jure I Assure cuwruye as required uudcr imunt,n 2!/1 ul'SIGL e. 112 eau lead to rile flnposition of criminal penalties ore
rills ly/nl it WiJ y idailunahe vt Bnpri.Annlaunt, Js bell JA cirri Iwnall,"in the titan ofa STOP WORK UROER anJ a fine
ni up rn i!in )Q n Jay Ilainu Ihd nal,lnv. Ile ddvl.ra•d Ihm a copy uftilts]lutemvm may bit IurwJrJuJ to the UlOElcv mil'
hn.]u�Ju' In ut'thu UIr1 :or nlaurlCce:urcra;u Iculia]lam.
/du ha•rrAy r,/ri/(o rurJav Jrr plrinr IarJ prnu/lire ujper/nry that rhr ie urrxrNow/ prvriJe/ubure is rear hind correct
'dig,
' r1//ltiu!Arse err/y, /)v erne Irriq in/hie Jn•u, lit Ar[uury/vied D
y city ur lolrx,r//lriuL
f ire yr I'nlrn: _
P\nnir/Lltrma 1
Irruinp .lulhnrily (tirrlo nuul;
I Ill .u'JIf IIr.J111 !. Ilnddln� Ile y.tr rutcnl 1, l ill.'f Dint C'1¢rk !. l'latviad lit,Icclur i,
I
6. Ulhrr I Plumbing Inrycctor
�I 1', u Acl I'Irwn:
i
information and Cnstructions
V.u;.lchu.etts General Laws ch,ytec l i2 lrywres all 9vCry `+is to+on in the scry Je ui anotheren.t leer lily :nlnct of 6)( these lhire.
s.
I'nnu,tll W 111l* t4luld.m emplures is dctineJ as" ry P' .
:.press ur,mpbcJ. oral nr svrnten ,
arinenhip.Jaa0e1'JIWa.coryorauun ur other Icyal cnnry.of
lily
lu s.r Iwo r f bean
\n ,.,nplupar is JetineJ zs"an individual. p to m .mpleyees. HOwcvcr the
I the l,,regomg engaged in a joint enlluemephtp rusoclay°a or Other legal :net empJ ya ceJ`e ill temp
eceever ur upant of this
uusle+of.ill individual, p
Hans to three
mainununce,cumtruction Of repuir work on such Jwalliny huuss
owner of a dwelling hoses having not more than Ihrn ,Po;because of sutmgnt@ and ch employmento residds lbe deemed cu be in emPluye."
,Iwclhoy house of,nother who Curti.Ymttth�ereto shall
or,,n the;rounds ur building aPD
\IGL chapter I S1, r)23C(6)also states that"everY slate ar local licensing
ayeaey shag withheld Ill Issuance or
crate a business or to construct build
h Ih�lnsurane�Ila he avers`Irequlr+dr
renawal of a license ur partials to uy of its political subdivisions shall
Applicant who has not prndu ced accept ableer'Neuher tha ommonwCJld1 nor MY
\dJilionally, sIGL chapter 1 S_, i-
nter into any ;entraet t'tsr the P+rtorg e!ul PUl"ged o theuconlr3ct `JlutholrityviJ+nee ul'cumyliwlcs w ith the lnwrone
requiremcne of this chapter have been P'
Applicants 1 to our situation Will,if
checkirl the boxes that apply Y
es sad Phone number(l)along with their cartihcate(+)of
plc;iws I;II out the w°rken' compensation atlldavit completely,by with no employtrss uthar than the
necessary.supply sub-contraclor(s)nume(e),uddresA )
workers' compensation ilaurance. tract LLC or LLP does have
Insw-Jnee, Limited Liability Cmttpanics(LLC)or Limited Liability ParuletsNps(LL
memhan ur puAnrrs, an not required to carry of submitted to the Dcitutment of Industrial
enlployeae,u policy is requited. Ile advised that this affidavit slay dsvit s of
illpla nls for contlmlatiun of instsrari Covaroga, Also be sun to sip sad Jute the u1'sted, n the sstltl+v(t should
11CaUan rot the pannit a license i+beina requasted,ton o Workers'
be rcnlmed w the city or town that
have aany qu+stloos regarding the law or if you,in reyuued
Industrial,\eciddnte. Should ysot a:the miniver listed below, Self-insured eompaaiee should enter their
compensation Polley,gleam Call the Dapurtm
self-insurance license number on the a orciptillile line.
City or'Cowa Offlel+U
rho De «ment has provided a apuee'h.t,u test m
arlL
Plca,c he sure that the affidavit is complete ;Ind printed legibly. l>' beam
Of rho aitiJrvit for you w sill out in the evem the Otfia of investigations has to contact you regarding DP
I'I:ase be sure to rill in the p+rsnitllicense nwnbur which will be used ss a reference nwnb+t In addition,an applicant
that must submit mulliyie yenniu'liceww applications in any given year, need only submit ono.loc io t provided (City nt
Policy information tit necessary)and under"lob Site AJdres`J or mathe pkedlbys lte euy araowni tray locations o (the
city or
town).",\Copy ut the uflldavit That has been officially rump
,PPlicanI as proof that a valid affidavit is on rile for ILture Petmie ut licenses. A new atusines must m Riled nut sae
y ear. W'hera a home owner or citizen is obtaining a license or Permit not related to any business or commareial venture
day Ilcallse nr Permit w burn leaves ate.)said Persoo is NOT required to complete this affida ithas+ m uesuens,
I hC t)I04 tit lim mlp emit wouid it" to thank you ell ,dVetncc tut your 000p+ra111111 alld siluuld y Y 4
locate du nul 11411(21a to yrve us
fhc U.P,uuncnt's ,dJress, t¢Iephun+ ,Th CoM;anw"Ith of Muwchusetu
Department of Industrial Accidents
Onlea of Iavallgadons
600 Washington Street
90311001 MA 02111
617-727-4900 text 406 of 1.877•MASSAFE
Fax M 617.727.77.39
"d < ,, ,5 lvww.mass.8ov/dia
1
gONulr� CITY OF SALEM, MASSACHUSETTS -
,�' PUBLIC PROPERTY DEPARTMENT
120 WASHINGTON STREET. 3RD FLOOR
9 1 SALEM, MASSACHUSETTS O 1970
TELEPHONE: 978-745-9595 �.
�w.gpo� FAx: 978-740-9846
KIMBERLEY DRISCOLL.MAYOR , 1 ( ^\ P64)
Section 116.0
DEMOLITION OF STRUCTURES
Structures over fifty(50) years old must have approval of the
Salem Historic Society
UTILITY DISCONNECTIONS REQUIRED
Authorized Agent Date of Disconnection
xWater 2
(see attached requirements) / V
Electrical ( r J2/�2
:2
Fire
Health
Vl• cblt r
Sewer
Salem Historic Commission
Dig Safe Number O e
Pest Control:
***DOCUMENTATION OF ALL THE ABOVE MUST BE ATTACHED BEFORE
PERMIT CAN BE ISSUED***
Fee for Demolition $5.00 application fee plus $2.00 per 100 square ft gross area,
Minimum $25.00
` City of Salem, Massachusetts
Fire Department
mNa 48 Lafayette Street
David'W Cody Saeem, Massachusetts 01970-3695 Fire Prevention
Chief Tel. 978-744-1235 Bureau
978-744-6990 FaX 978-745-4646 978-745-7777
dcody@sa(emcom
Demolition
• Before a structure can be demolished, the Salem Fire Department shall conduct a
preliminary demolition inspection, to ascertain any conditions which may require
a fire watch* or other preventative measures to be taken before, during, or after
the demolition process. Minimum of two weeks notice required to schedule
appointment
• A permit to demolish or remove a structure shall not be issued until the
preliminary inspection has been conducted and a report of requirements necessary
to prevent life safety hazards has been obtained by the applicant.
• The inspection report shall include but not limited to: cutting and welding permit,
fire watch, on site storage of materials, underground storage tank compliance....
• Proof of utility disconnects.
• The requirements outlined in the report shall become a part of the restrictions of
the demolition permit issued by the Building Inspector.
*Fire watch patrol Salem Code of Ordinances Sec. 20-124
October 5, 2010
CITY OF SALEM
j( f b SALEM,MASSACHUSETTS
�, s — ENGINEERING DEPARTMENT
r? ��P 120 WASHINGTON STREET, 4TH FLOOR
a g Lr SALEM, MA 01970
Phone: (978) 745-9595 x5673
Kimberley Driscoll Fax: (978) 745-0349
Mayor
DAVID H. KNOWLTON, P.E.
CITY ENGINEER
January 30, 2009
Water, Sewer and Drainage Requirements
Regarding the Demolition of Structures within the City of Salem
In accordance with the provisions of the General Laws of the Commonwealth of Massachusetts
and the Salem Water and Sewer Department, the following regulations governing the demolition
of structures within the City of Salem shall be followed.
This regulation is made in the interest of protecting the city's water, sewer, drainage and public
way infrastructure at each connection located within the City of Salem, as well as to prevent
conditions which may cause danger to public safety, result in water loss, or damage to city or
private property due to water or sewer loss or back-ups, or cause pollution of the city's storm water
receiving waters.
I. Prior to demolition of structure, a licensed plumber shall ascertain where all water, sewer
and drainage lines are located entering and leaving said structure. The plumber shall make
a determination of existing or prior use of each line, including, but not limited to domestic,
commercial or industrial use; irrigation; fire suppression; sewer, storm drain or septic
system; roof drain; or sump pump. After all lines have been located, the plumber shall
make a formal written report with plans of all lines found to the City Engineer.
2. Once the plumber's report has been reviewed and approved by the City Engineer, a
Registered Professional Civil Engineer (hereinafter referred to as "the Engineer") shall
make a determination of the point of origin or discharge on each city main, for each line
identified in the plumbers report. The Engineer shall also ascertain the location, use, and
point of origin or discharge of any other lines on the property that may or may not be
affected by the demolition or connected to the structure. The Engineer shall provide the
City Engineer, for review and approval, a stamped plan of the property and adjacent City
utilities, indicating the results of his investigations.
3. A request to the Department of Public Services, for assistance in shutting down any water
main, prior to cutting and capping it, shall be made only after the City Engineer has
approved the written reports and plans described above.
Water, Sewer and Drainage Requirements Regarding the Demolition of Structures January 30, 2009
Page 2
4. Prior to demolition of the structure and immediately following item #3 above, a City of
Salem licensed drain layer shall cut and cap the water, sewer and drainage lines at the city
main and arrange for an inspection by the Department of Public Services prior to backfill.
Backfill, compaction, temporary and permanent paving will follow to current city
standards.
5. In the event that the lines will be used immediately after demolition for construction
purposes, a set of plans and/or drawings, stamped by a Registered Professional Engineer,
describing the lines to be used during construction, must be provided to the City Engineer
for review and approval, prior to obtaining a building demolition permit. Any other lines
identified shall be abandoned as described herein.
6. A demolition permit shall not be issued until the items above have been completed and the
Department of Public Services has conducted an inspection and signed off on the water and
sewer portion of the Building Department prerequisite Utility Disconnections Required
Form.
A proved by:
avid H. Knowlton, P.E.
City Engineer
\\Salemdc0l\WaterAdmin\dknowiton\My Documents\miscellaneous\demo regulations water,sewer and drainage 1-30-09.doc
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0 CMR: STATE BUILDING CODE COIRA155ION
760
SECTION 115.0 CONDITIONS OF PERMIT i
-#, �.�
115.1 compliance with cede: The Dermit shall be a license to N!
ork an
proceed ,d shall not
N� c the ancd~or set aside any of the provisions be. construed as uofothis
to.violate, stipulated by modification or legally
code, except as specifically ,
granted variation in accordance with Section 126.0. 1
115.2 Compliance with permit: All work shall conform to the I I
and stamped or endorsed applicationed amendments thereto. permit I +
has been issued and any PP
y A lot or site shaLL not be changed,
115.3 Change in site P �0, area from I ;
: increased or diminished
In Section 133.6,tunless a revised �
affidavit of
: .:+:•� site plan,
showing such changes accompanied by the necessary d•
owner or applicant shall have been filed and ape
;.: ..
street opening,
E:ccep Ion, A revised site Plan wiA not ba required if the
�.;r yt• range is caused by reason of an official
/•yw• street widening or other public improvement. i t
t K
+.`�,14 SECTION 116.0 DEWLITION OF STAUCTt7AES
116.1 Service connections: Before a building or all! notify
can
be demolished or removed, the owner or agent shall notes
Or stru`c-
utoties having service connections within the building
or structWO
troy, such as; water. electric, gas, sewer and other c
time A Pit to demolish or remove aired f om the utilities, i
r•,.• shall not be issued until a release is obtained from
_ sand aurt
tating that their respective service connections have been ra-
�. ant equipment. such as; meter and regulators
.+ moved or sealed and Plugged in a safe manner-
or structure has been
cration has not been
116.2 'Lot regulation: when a building
ti"�•.±s
l , demolished or removed rid vaunt lot shallbe filled with non-
projected or apDed• the with adlacent d
' �anie fill. graded and clairttainad In confomttthe accumulation
des. Tbs lot sh" be maintained free from con visions
which
of rubbbh and all other unsafe or haserdcus fans shall be
endanger the Ufa or health of the public: proms
male to prevent the accmaW&thm of water or damage to any
`.; foundations on the premise or the adjoining ng prcpar and the
I a necessary retaining walls and fenw shall be erected in accord- '
ancs`with the provisions of Article 13. ,
r SECTION 117.0 MOVED STRUCTURESmoved
a,
� t:f � 117.1 General: Buildings an with theres
provisonslof this ode. !I
the jurisdiction shall comply
tr. il
9/L80