4 ADAMS ST - BUILDING INSPECTION ion
�JJ a FheCtn„�alth of Massachusetts
Board of 13uilding Regulations and Standards CITY
d OF SALEMMassachusetts State Building Code, 730 C'MR, 7i°edition Krvi,red JruuarrV
Building Permit Application To Construct, Repair, Renovate Or Demolish a
On or Tu•o-Fumily Dwelling
/This Section For Official Use Only
Building Permit Number: ate Applied:
Signature:
Building Commissioned Inspecto 1' i dings Date
SEC ON 1:SITE INFORMATION
1.1 Pro erty ddress: 1.2 Assessors Map& Parcel Numbers
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 Il) Frontage(fl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provtdcd Required Provided
1.6 Water pply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage D osal System:
Zone: _ Outside Flood Zone?
Public Private 13CheckifyesO Municipal Onsite disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2. Owne/C1t/p/f Record �[
Name. ' t) AJdress for Service:
Signature .telephone
SECTION 3: DESCRIPT!PN OF PROPOSED WORK=(check all that apply)
New Construction❑ 1 Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) P1 Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: 11
Brief escrip ' n of Proposed Work': _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Ilam Estimated Costs: Official Use Only
(Labor and Materials
I. Building S ZSR , I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City, sown Application Fee
2. Electrical $ . - ,
❑Total Project Cosf (Item 6)x multiplier x
3. Plumbing $ '7. 200. 2. Other Fees: S
4. Mechanical (IIVAC) S 002, List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
.�f Check No._Check Amount: Cash Amount:_
6.Total Project Cost: $ /�/ 2-c:>O 0 Paid in Full 0 Outstanding Balance Due:
r ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 2Z�6 7
License Number/ I:. piru on Uate
Nan t .CSI.- older
_ List CSL-type(see below)
a 1"v4
Tr Description
:\JJns 11 Unrestricted(tip 10 35,000 Cu.Ft.)
_ It Restricted l&2 FamilyDwcllin
Signature p M ,Mason Only
5&- &��'7�p RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 RI!�tedHoWgAn rovementContractor(HIC)
i
IIIc Compan Name r 1110 •gist t ame /Registration Number
Espi tion Date
Si g;akirr Y Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
Workers Compensation Insurance affidavit must be c mpI ted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes .......... Nu...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE 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. .
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
M?wI, ,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
beha
�
Print Name
Signatureof 0%-vner oPAvffiWzcd Agent Uat
(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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the FIIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, 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.) Flabitable 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
`, PUBLIC PROPRERTY
DEPARTMENT
INII.;N:i y axlws-t l
12�-WA\HINci l ot:S I XELT • SAth.M,MAN!SACIu it j is0197.
1*e.1;'178-.745.9595 • ICsx.`178.7#^•7846
Workers' Compensation Insurance :affidavit: Builders/Contractors/Electricians/Plumbers
y ylicant Information Please Print Letzibiv
�Ii1171C l0ucuwssiOr;;anvatiaoVlndtvid�ul):
Address: r:;L7
City,Srarci%ip Phone 0:
/
Are uan employer?Check the appropriate box: 'Typo or project(required):
4. Q I ran a general contractor and 1
I. I ant a employer with �� 6. w construction
entployccs(full antUurgart-tints).• have hired the sub-contractors
_.❑ I ,un a sols proprietor or partner-
listed on rhe anachcd sheet. �• Retnodeline
ship and have no cinpluyccs These subcontractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. Building addition
I No workers'comp. insurance 5. 0 We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.0 1 ran a homeowner doing all work right of exemption per MCL I LQ Plumbing repairs or additions
myself.(Ko workers'comp, c. 152,§1(4),and we have no 12.0 Roufrepairs
insurance required.] r cmployces. ]Ko workers' 13.0 Other
comp. insurance required.]
•nay.�,phanul Ihut chucks box#1 must also fill nut rhe v:chon Ixluw showing their workui cumpenuaiuo policy inlium:,tiun.
'
Homeowners who mbinil this afndavit indicating they are doing all work and then him outside cunractor,must.ubmii a new affidavit indicating.oath.
4'oatrwnns that chuck this box attar anochcd an additional shael+hawing the name of the sub.aontraciors and their wurken'comp.policy infurmanun.
t ran an cuy)loyer drat Lr providing Ivorkers'coinpencrUinn insurance for goy earployees. Belary is the pulicy and job.site
iajorniarion-
insurance Company Name ---- .
Policy N or Sclf-ins. Lic.N: T— VC Expiration Date: 2 //
Job Site Address: �d�n.�.� CitytSlateizip: .
Attach a copy of elle workers' compensation policy declaration page(showing the policy number•and expiration date).
Failure to secure coverage as required under Section 25A of`IOL c. 152 can lead to the imposition of criminal penalties of a
fine up (,)S 1.500.00 andiur one-year imprisonment,as wc11 as civil penalties in the form of a STOP WORK ORDER and a fine
of up to)250.00 a Jay against the violator. He advised that a copy of this slateinenf may be 1'urwarded to the Office of
Inrrsogaunns of the DIA :or imuru:cc coverage tcrilic.ulun.
/du hereby nrtijy car r rho r pont tics u(perjury that the infurinatlon provided above is true and correct.
lit C: _ /
[[6.
icial use wdy. no not write in this area,to be cuntpleted by city or tonus official t
I
y or Town: Pcnnit/License g_ _ _
uing.\ulhorily(circle enc): I
l°ard of licalth 2. Building Dcpartineul 3.Cityi I onu Clerk J. Llectriad Inspector 5• Plumbing Inspector
Other _ .__.
Contact Pcnun: ._ Thune 7:
Information and Instructions
,,\Iassachusens General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this matute,an employee is defined as"...every person in the service of another under any contract of hire,
cypress or implied,ural or written."
An employer s defined as"an individual, partnership,association,corporation or other legal entity,or any two or more
or the tore_gumg engaged in a Joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of ;or individual,piumership,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 maintcnunce,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, Z25C(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, :blGL chapter 152, 4. 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 compliunce with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary, supply sub-contractor(s) name(s),addresses)and phone numbers)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 docs 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 resumed 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.cure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must Submit multiple penniu'licetse 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 Jog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I he i)tlice tar Investigations would like to thank you in advance fur your cooperation and should you have any questions,
please du nut hesitate to give us a call.
The Department's address, telephone and fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of InvesNgadons
600 Washington Street
Boston, MA 02111
Tel. k 617-727-4900 ext 406 or 1-877-MASSAFE
Fax k 617-727-7749
www.mass.gov/dia
CITY OF S.ULE.NI, l�L-kSSACHUSETTS
BCILDLNG DEPARTMENT
110 WASHLNGTON STRM. Yo Rom
TEL (978)74S-9595
PAX(978) 740-9846
KIJt$ERLEY DRISCOLL
MAYOR T HO.ws ST.PIEM
DIRECTOR OF PUBLIC PROPERTY/11CIID62NIG CONLQIMIONER
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 1 11.5
Debris,and the provisions of MGL c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
I1/a2rla�s.J�� �.ct�,
(name of hauler)
The debris will be disposed of in
(na a of facility)
(address of facility)
signor perms appli ant
/U
datC
Icbnvl(J.x
- Jan 14 2011 10: 46nM HP LASERJET FRXPETERSTROU 19767179044 page 1
Peter Strout
General Contracting
29 Intervale Rd.
Salem, MA
978-804-0018
1/14/10
Mr.Thomas St.Pierre
Building Commissioner
Salem, MA
120 Washington St.
Salem, MA
Re;4 Adams St.
Tom,
This letter is to follow up on a conversation we had relative to the occupancy of
the property and the use of the lower level space. I am sending you a plan
indicating the use of each area. The Pelletiers have told me they intend to retire
there and in no way want to have an apartment in the lower level they just
want extra living space.
Sincere) ,
Peter trout
Jan 14 2011 10: 46AM HP LASERJET FA%PETERSTROU 19787179044 page 2
12ENoVAT CoA! vJo(�k
4
SW ' 5-0112"
bu y-c1
LAUrod71tK 4
M 124" L
leLn4Y �Ho�'
Jk
2a r
# q ADAuns s-rQEAtl-
1�•�"LLFI"1�2
Jan 14 2011 10: 46AM HP LASERJET FAXPETERSTROU 19787179044 page 1
Peter Strout
General Contracting
29 Intervale Rd.
Salem, MA
978-804-0018
1/14/20
Mr. Thomas St.Pierre
Building Commissioner
Salem, MA
iZ0 Washington St.
Salem, MA
Re;4 Adams St.
Tom,
This letter is to follow up on a conversation we had relative to the occupancy of
the property and the use of the lower level space. I am sending you a plan
indicating the use of each area. The Pelletiers have told me they intend to retire
there and in no way want to have an apartment in the lower level they just
want extra living space.
Sin
cerei ,
Peter trout