1 WOODSIDE ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 730 CMR, 7'"edition OF SALEM
,a J i Reviseel JumrarY
Building Permit Appl' fononruct, Repair, Reno ate Or Demolish a i. =008
One t ti iiv Dwelling
Th s,Se do or Official tXc Only
Building Permit Number: Z I ate plied:
Signature:
Building Commissioner/Inspe tkLoriffuI Date
SECTIO 1:SITE INFORMATION
I.IOPropert�y� fAddrgss: S{y�e� 1.2 Assessors Map& Parcel Numbers
h¢ W6E S i �-
Lla 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 fl) 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:
Zone: _ Outside Flood Zone?
Public❑ Private 11 Zone:
if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ofRCrd: 1 �e��.� r
H amr",u c n
N 'int) Address for Service:
Signature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': t -%V ..s c iwLs +-
D_� -�r�r-�c' clsxc. Ak;wt-i C;.t. 1.1c4+z e.\ernEc„l-c ;1w..s�:.. i ��avwtcM�C
SECTION 4: ESTIMATED CONSTRUCTION COSTS A/1
Item Estimated Costs: Official Use Only \
Labor and Materials
1. Building S it 3'1-19, 1. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $ �� Pri C
4. Mechanical (FIVAC) $ Lis[: )��
5. Mechanical (Fire S
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cast: S �� 3as ❑ Paid in Full ❑Outstanding Balance Due:
t ,
SECTION 5: CONSTRUCTION SERVICES
/ 5.1 Licensed Construction Supervisor(CSL)
K2nLC� Iv\ tw��10. License Number Expiration Date
Name of CSL-I folder
�� s List CSL Type(see below)
�. rA4S
Type/ e Ueseri tion
Wdr sx� Unr
� 11 estricted(up to 35,000 Cu.Ft.)
11 Restricted I&2 FamiIX Dwelling
i ignature f M Mason Onl
617 SSBI 411'1, RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) ).3 e744 ful
1[ C.� Pl..ga_iA
EIEC,C`ompany Name ur 7�F�.71IC Registrant Name
Registration Number
ri f r V Club iC`>,.J YJIL4 o It
Addr 'S
Expiration Date
naturu '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 .......... ❑ No...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I -�—"yC. , as Owner of the subject property hereby
authorize e� ht.tia gl r to act on my behalf,in all matters
relative to work authorized�b this building permit application.
Si j ature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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(HIC)Program), will toot have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.116 and I IO.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"may be substituted for"Total Project Cost"
CITY OF SALEM
T.
!r PUBLIC 13ROPRERTY
a
--� DEPARTMENT
.i tie::M:fY:lalAall
%I tit a I2C.WMytl.\d l ON S tx CkT• in t e.N,M.vw.vr,i n it I t s J I97.^
Ila.:776.713.9313 • 1:%x 976.740.1ss6
"IfYorkers' Compensation Insurunce Allidavit: Builders/Contractors/Eiectricians/Piumberf
flnnlicant letrurination Pleas Print Lee]bly
11,'
Vi11Te 11htenevyl)rgamratioNlnd'v�duull: Y�C.n Ytt..a.c P,,
n
Address: Fe-h lav 2 e+J
City'smici%ip: W,Nw»4lz, LAK 01882 llhoneiit GO "I t4 4•?14
1Are you an culployer:'Check the appropriate box: Type urproject(required):
1.01 and a cmpluyur wish 4 Q 1 :un a general contractor and 1
1 -11 luyccs(I'ull andlur part-time).' have hired the sub-cuniracturs 6. 0 New construction
2.Py I ;on a sole prnprietttr or partner. listed on rhe anachcd sheet. : 7, �Remodeling
I and have no wnpluyerei These sub-contractors have S. Demolition
working tier me in any capacity. workers'comp, insurance. g.-.Q-Duil4ling-addition
----- -----. -----------
— - I Ntywnrkcrs'cu�ep.-uisursnce --S.--- Wa are u crnporuinn unJ its
rcyuircJ.] otYecrs hove exen iseJ their 10.❑Electrical repairs or additions
3.0 1 mina homeowner dieing all work right of exemption per NIG' I I.Q Plumbing repairs or additinns
myself. (No workers'chip. C. 152,§1(4),and we have no 12.0 Rouyn puirs
insurance required.] t employees. INo workers'
comp. insurance required.] 13.❑Officer
-any.gilelmua ilia chucks ba$l mica also till out the sechu t below tlwwiny'hair wwkeri c,"'tpenuaiwt put icy inPorme lion.
'I lumauwtwn who Adtmil this affidavit indicating they aer doing all work and then him uuaida cunrneton mull sul"it an"affidavit indicutins etch.
•l'onlracnwv'heal chcvk this bot mine attaehed.m addititteul slices.hawing thea tanto or flit subwomraceao and thea wurk ml,cantle.leeiney inrormarion.
/mw all¢)"player rear it providing workers'cunrprnmtlon inrur"nee for my emplayeer. Below Is the policy and Job.cite
iujur"neadom
Insurance Company Vmne:
Policy letter Self-ins. Lic.it: ._. . .._ Expiration Date:
Job Sita Address: Citylstateizip:
Attach it cupy of the workers'compcnsatlun pulley declaration page(showing the policy nuntbvr and expiration date).
Failure to sccury coverage as required under Section 25A ul'NIGL c. 152 can lead to the imposition of criminal penalties of a
tine uP to S1.500.01f)and/or une-year imprisonment,as well as civil penalties in the t'onn of a STOP WORK ORDER and a rine
of up In i250.00 a day aguinbt the.violahu. lie advised then a copy of this stulemmn may be lurwardcd lie the 0111ce uC
III% gauum ul'[1,c DIA for msurar.ce cnvcragc t,:fiticaltun.
i da hereby rertiify mailer lite int olld pem�t'perjnry Thur rhe injurrnulion provided ubuva it true uad corrvr•p
—77 gin:a:w�ro:
041w obc)ev, arm
"ever m.dy. Dd not nrits,in this urelt, to be raatpieted by city or torvn ajJiviuL i
i
City of I'nwn: - Pcrinitll.lcvnsc d
Issuing.\ulhmrily(circle one):
I. ILtarJ of IlvaUh 2. Ihtildim) 1
I vpartmcut I. (:illi fowu Clerk 4. Electrical Iocp"tor 5, Metalling lutpector I
L. (it _
l'�nuacl 1'v nuul - . . Phone l:
Information and Instructions
\I:hsi.+CllasCUi all elllployefs to provide workers' compensation tor their employees-
(,ienCfal Laws chapter 132 1'C4W[Cs
I'ursu uu "...every Pelson in the service of another under any contort of hire,
to this btatute,in emplured is defined as
:%prcis Or implied. oral or written."
An empluyrr Is detin¢n!as"an individual,prMenhip,association.corporation or tither legal entity,or any two or more
it the lo[CgJtag engaged in a joint enterprise, and Ilicludtng the legal representatives of a deceased employer,or the
1cccivcr or tfublee of .u+individual, m
patership,association or other legal cnnty,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
,Iweiling Iwuic of another who employ"persons to shall aintnot enance of such constremploymcm be deemed ttion of repair work on ube in clmpluyeri6
Or On the grounds or building appurtenant
�IGL chapter 152, §25C(6)also slates that"every state or local licensing agency shall withhold the Issuance or
renewal of a license ur permit to operate a business or to construct buildings la the commonwealth for any
+ppllennt wino has not produced acceptable evidence of compliance with the insurance coverage required:'
>dditionally, hIGL chapter l5'_, 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract c for the performance of public work until acceptable evidence ofcumpliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
- Phase fill cut-thaworkers_compensation affidavit completely,by checking the boxes that apply to your situation and, if
ss(ey)and phona nu
necessary, supply sub-contractor(s)nrmc(s),rdtlrember(a)along-with-theiccerttficateL)
oth
insurance. Limited Liability Companies(LLQ o Limitedtb
ilitY
LLP
with n
employees
mr
aitmisurance(If an)
oroLLP does haveer than the
embers or partners,are not required to carrycompensation
emplmith oyees,u policy is require
d. Be advised that this affidavit may be submitted to the Department of Industrial
its for confirmation of insurance coverage. Also be sure to sign and duce the affidavit. The affidavit should
be rett,mcd to tine city or town that the upplicad notsrpermit or the low license if bic are rrcyuued to obtnequested, not e+tu workers' of
Industriul Accidents. Should you have any yregarding
t the number listed below. Self-insured companies should enter their
compensation policy,please call the Depurunent a
self-insurance license number on the appropriate line.
Clry or'fown Ofnclals
vit is complete and printed legibly. The Department has provided u space at the bottom
Please be sure that the affida
Of the affidavit for you to till out in tie 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
ons in any given year,need only submit one affidavit indicating current
that Intuit submit multiple pennit'liem+se applicati
policy information t if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town).,*A copy of the uftiduvit that has been officially stamped or marked by the city or town Inay be provided to the
applicunt as proof that a valid affidavit is on rile for future permits or licenses. A new affidavit must be filled out each
year. \'v herea home owner or citizen is obtaining a license or permit not related to any business or commercial venture
1 i.c. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I ho 0I of Invesrigatiuns would like to thunk you in adv;mcc fur your cooperation and shuuld you have any yuebtions,
pleabe du not hesitate to give us'call'
The uep;uuncnt's address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
'Cel. # 617-727-4900 ext 406 or 1-877-MASSAFE
Fax #617-727-7749
Itt•.tied www.mass.gov/dia
- �� ,�lasctrhusrtts - Department of Public Safeh
Board of Building Regulations ;1nd Standards
Construction Supervisor License
License: cs 80550
.KENNETH C MINASIAN }
22 EARLES ROW
WILMINGTON, MA
01887
7
(lnnndssimlr Expiration: 8/22/2013
_ _ Tr#: 19398
!J9 Oi Fice of Consumer Affairs aid Business Regulation
10 Park Plaza t 'suite 5170
Boston, MassachLetts 02'116
Home.Improvement C.onraFtor Registration
Registration: 139414
Type: Individual
- Gtz�l= Expiration: 7/14/2011 Tr# 296869
KEN MINASIAN' ,I =a - -- ----
KENNETH MIN. SIAN
115 VERMONT 'T. --
METHUEN, MA '1844
Update Address and return card. Mark reason for change.
Address Renewal Employment n Lost Card
CAI O SOW W04-G101216
j i 5 14 erlr t-0� �i tZ Nltll�t
Custom Renovations by Ram Contractors Estimate
22 Earles Row
Wilmington. MA 01887 6/2/2011 1 104 2Es 04 s
/20
BILL TO SHIP TO
Martha Ryan
1 Woodside Ave
Salem, MA 01970
IlJt p,+7 zlu-kv.e r �%7� f��r11�1(
plw 6--45 — rvn kA-C'
p)AS a-y 3?�S
fA° INS ,tLlA6�5 �(1:Nt t` �1 M S� !—7,��
OJT
ITEM DESCRIPTION QTY RATE AMOUNT
Basement Remodel basement to include: 1 9,350.00
Attaining municipal permit including paying fee
Any remainig demolition nessesary for the
framing of walls in floor plan sketch
Note:existing ceiling to remain then receive 1W
board over
Frame all walls shown in sketch and as discussed
during walkthrough
Install blue board over all new framing and apply
plaster veneer skim coat
All carpentry for the finished area and bathroom 0.00
only including: (2)interior hinged duos, (1)
exterior hinged door, (1)bifokl door, and
baseboaZ needed
Instal owner supplied file d grout in bathroom 0.00
over ex ng concre a oor labor and setting
material included
Page 1
Custom Renovations by Ram Contractors Estimate
22 Earles Row
DATE ESTIMATE#
Wilmington. MA 01887
6/2/2011 104
BILL TO .SHIP TO
Martha Ryan
1 Woodside Ave
Salem, MA 01970
- ITEM DESCRIPTION CITY , RATE AMOUNT
Notes: Exterior rated door to be therm tru 0.00
smooth factory primed basic style owner to
Supp knob
Interred units to be hod core, prirrled,
split jamb,owner to Supp nobs
Bi-fold size to be determin nd will match or
compliment other doors
Baseboard to be primed 5 1/4"speed base
All waste generated from this job will be removed
from property and properly diposed of by RamCo
Imprtant notes: Under this estimate RamCo does 0.00
not assume any reponsibility,to coordinated:
oversee or hold any responsibility for any other
trades who work on the job. It is assumed that the
owner is hiring each trade individually and she will
be present for there work,to make decisions and
coordinate
.This estimate does not cover work in the back
area proposed closet space work in this area is
considered an extra
Carpeting is not covered in this estimate, price 0.00
available upon request
Insulation Insulate all newly built exterior walls and bathroom 1 875.00
for sound barrier
Page 2
f
Custom Renovations by Ram Contractors Estimate
22 Earles Row
Wilmington MA 01887 DATE ESTIMATE#
6/2/2011 104
BILL TO SHIP TO
Martha Ryan
1 Woodside Ave
Salem, MA 01970
ITEM DESCRIPTION QTY RATE AMOUNT
Paint Paint all new work including walls, ceiling,doors 1 1,975.00
and trim
Note:owner to supply all finish paints
RamCoreccomend Ben Moore Regal Matte finish
or better. RamCo will supply all prep materials
and_primer--- --------
Flooring~ Install carpeting to cover aproximatele`jr3ci0 SF 1 0.00
and (1) run of stairs with landing
i
e rR
r2f01Z:" Total
'r3z5. �J
�'`
Page 3
CITY OF S. I.E.` , AxSSACHUSETL'S
• BUMDLNG DEPARTMENT
120 WASHLNGTON STREET, Y°FLOOR
T-EL (978) 745.959S
PAX(978) 740-9846
KIJBERIEY DRISCOLL
T
MAYOR tto.+us ST.PtBRRB
DIRECTOR OF PLBLIC PROPERTY/BUMMNIG 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 t 11.5
Debris,and the provisions of MGL c 40, S 54;
Building Permit All 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 MGL c
I 11, S 150A.
Thedebriswill be transported by:
(name of hauler)
The debris will be disposed of in
r
(name of facility)
(address of facility)
signature of permit applicant
af3J d�
(late
a,n,„ira,R