14 WINTER ST - BUILDING INSPECTION (5) 27473n;Rev1sedAhjr
TheCommonwealthofMassachusettsRECEIVEDq rBoard of Building Regulations and 9tp�ltl lI IONAL SERV/ Massachusetts State Building Code, 780 CMR Building Permit Application To Construct, Repair, R a%Rr-v8m*SIU
One-or Avo-Family Dwelling
This Section For Official Ilse On
Buildmg Permit Number. _ Date Applied:
Dui Mail Omcial(Print Nome). Signature Date
J SECTION 1:SITE INFORMATION'
I.I Pro erty Ad(Iress: 1.2 Assessors Map dt Parcel Numbers
14
i I.l a Is this an accepted street?yqs. no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dlmenslons:
Zuoing District P-nVosed Use. - - Lot Area(sq it) - Frontage(It) .. . .
l5 Bu1lJingSetbaek+(R)
-Front Yard.. _ .._- Side Y" _ - Rear YaW
gequirod Provided Required .:' Provided ..Required,.. Provided
1.6 Water Supply:(M.G.I,ci do,§54) 1.7 Flood Zoae Information, 1.8 Sewage Dhposa!System:
Zone: Outside Flood 2one7 Muniei O On site dis stem' 0
Public 0 Private 0. pN P sY
.. _.._ . Chedcif'es0
SECT[ONIrPROPE1ffY•OWIVERSHIP)'
2.1 Owneriof ecord:
`i✓1 I rdI Q¢h
(Print) City,Slate ZIP .
t /�3�9%09X5
No.and Sucet Telephone - Email Addnss
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)`
New Construction 0 Existing Building O Owner-Occupied 0 1 Repairs(s) O 1 Alteration(s) O Addition 0
Demolition O Accessory Bldg.0 . Nu. berofUnits I Other O specify:
Brief Description of Proposed tVork2: . Y ce . 4f k) YU r'r t7
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 0mcial Use Only
Labor and Materiah
I.Building S 1. Building Permit Fee:S Indicate how fee is determined:
0 Standard Cityfrown Application Fee
2.Electrical S
0 Total Pioject Cost'(Item 6)x multiplier x
3.Plumbing S P Qther Fees: S
14.Mcchanical (FIVAC) S List: A ,
5.Mechanical (Fire S Total All Fees:S
Suppression) Check
6.Total Project Cost: S OOO i d ❑Paid no Check
Full 0 O mount: Cash Amount:
Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction syperrisoraL•(ccnse(CSt),; o r1.7C?2T 6-fq- 7 t
Jd License Number Expiration Date
Name of L I Ider' Jj Liss CSL'rypc(see below)
. Type'. - .::.': Description .
No.and Sire t
� ! /)1���9� U Uruestricled OuilJia u -1o35Ob0cu.R.
R Restricted 1aQ2 Famil Dwellin
Cityfrown,S•te,ZIP M masorov
RC Roofin Coven
WS WtndowwtdSidin
SF I Solid Fuel Burning Appliances
I Insulation
Telephone
Email address D Demolition
5:�ggisteledHo a Improvement Contractor(HIC) /�Q y_�8 ,o
V P 111C Registration Number Expiration Date
111 mph• Namepr I}IC Rgglstrunt Name
_�� /'7�4111 flrY K,IJ
No pp�(rentl� mg- 0�568 �yjl„�50,�7j� Email address
City/Town, State ZIP Telephone
SECTION&NVORKERS'.COMPENSATION INSUWCE*!DAVIT(M:G,L c.ISZ g 2SC(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 Isivanee of the building permit
Signed Affidavit Attached? Yes........ No...........0
SECTION AUTHOItIZAT[ON TO BE COMPLETED.)VHEN',
OWNER'S AGENT OR CONTRACTOtL APPLIES PON BUILDING.PERf)IIT'
I,as Owner of the subject property,hereby authori �l I
19 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date f
SECTION 7b:OWNER'OR'AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information
contained in this application is true and Irate to the bes my knowledge and understanding.
S-) N lt (- e /6
Print Owner's or Authorized Agent's N (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 ytr(have access to the arbitration
program or guaranty fund under tiLG.L.c. IJ2A.Otherimportant information on the HIC-Program can be foTiml
www m:tss.eov'oca Information on the Construction Supervisor License can befound at wtuw.mass.uuvhlns .
2. When substantial work is planned,provide the information below:
'rotas floor area(sq. R.) N (including garage, finished basement/attics,decks or porch)
Gross living urea(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt)baths
Type of heating system Number of decks/patches
'rypeufcoolingsystem Enclosed Open
j. 'Total Project Square Footage"may be substituted fur"Total Project Cost'
CITY OF SALSA MASSAC HLISEM
BtmDm DEPAFmffm
120 WARmJGz NS7REET,3RDFLooR
7kL(978)745.9595.
PAX(978)740.9846
%7M8ERLEYDRISQ'�IZ
MAYOR TrMUgs STAIEW
DntEcrest crPuBucPxcffmYAuaDm azamsroim
Construction Debris Disposa/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 coo, S 54; Building Permit g 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:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Si nature of applicant
Date
The Commonwealth of Massachusetts
Department oflndustrial Accidents
I Congress Street, Suite 100
Boston,MA 02114-2017
www mass.gov/dia
]Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/Orggaar iza_ti_on/Ind'v dual); t
Address: /'fin/� � � R IO
City/State/Zip:_ �� O19� Phone#:
Are you an employer. Check the appropriate box:
Type of project(required):
am a employer with em to ees full and/or a -P Y ( p n time). 7. New constructi❑ on
2.❑I am a sole proprietor or partnership and have no employees working for me in g, Remodeling
an capacity. o workers'-com . ❑ g
Y P ty 1N insurance required.]P 9 ]
3.❑I am a homeowner doing all work myself[No workers'comp.insurance required.]f 9. ❑Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on mproperty. I will 10 ❑Building addition
Y
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the subcontractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.: 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
"Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer.that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. G Q
Insurance Company Name: ti&
Policy#or Self-ins.Lic.#: -2 O) Cj Expiration P Date:o— 2,_ /6
/ Ex
Job Site Address: / C/ /V City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify nd the pains and Ides ofperjury that the information provided above is true
and correct.
Signature _ Date-
Phone 4: -2 9?j��lS� 3 6f
Official use only. Do not write in this area,to be completed by city or town officiaL
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. +�
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written"
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if "
necessary,supply sub-contractor(s)name(s), address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)"A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
®S Massachusetts Department of Pu61,ic Safety
} Board of Building Regulations and Standards
License: CSSL-099979
Construction Supervisor Specialty
tiM'I Tl
JOHN H CARROLL`
27 HAMILTON RdrAW -
PEABODY MA 01960'
Expiration:
I Commissioner O811412017
71
C-/4'CciommwrwieaCCfr a�Cy.` aaaac%uoe'tGJ-
v m q
� ":Offiee of Consumer Atiaire&Business Regulation ti
MEIMRROVEMENTCQMTRACTOR!" •
i :gistratfon: 8TypeY-
xpirahon: 8 � DBA`
1" -G S HOME
827 HAMILTON RD ,�• - i� Y4 1 }
Yr•�PEABODY,MA 0196D.•"� --z�
Undersecretary"`
Commonwealth of Massachusetts
Citv of Salem
a
Y sqa e 120 W ashington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy
Permit No. B-16-27
FEE PAID: $154.00 PERFAIT TO BUILD
DATE ISSUED: 1/13/2016
This certifies that YOUNGWORTH KIM L
has permission to erect, alter, or demolish a building 14 WINTER STREET Map/Lot: 350088-0
r, La
as follows: Windows INSTALL TWENTY (20) REPLACEMENT,WINDOWS '
e
�- _ ujk
,NyEic� Ei EavSres � r
Contractor Name: JOHN CARROLL ; , » .w"•. „A'x,
DBA: US HOME IMPROVEMENT x' }
Contractor License No: CS106653
t t .Ic 1/13/2016
Building Official' "f""^"' Date
,. is e`
This permit shall be deemed abandoned and invalid unlesss the w v ork authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request.r"-,,- k� l� ' 'u IpK
,,
s..... ,�
All work authorized by this permit shall conform to the approved application and the approved construction documents�for which this permit has been granted.
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open,for public inspection for the entire duration of the
work until the completion of the same. e , , ', a {
I
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
y ..91i ,a " 3 , IY$
H IC #: 13076$ "Persons contracting with unregistered contractors do not have access to the guaranty fund"(as set forth in MGL c.142A).
Aged;s� 9s,n ro
i Restrictions: '� -`'`a � �
s
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.