18 CHASE ST - BUILDING PERMIT APP �3l-a
9
The Commonwealth of Massach:ovate
tts
Board of Building Regulations and dardsZDemolish
To
wn of
�� Massachusetis State Building Code, 780 C , T"ediBuilding Dept
Building Permit Application To Construct, Repair, O
One- or Tiro-Fmndi,Duelli
This Section For Official Unly
Building Permit pilumber Date Applied:
Signature:
Building Commissidite6l Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 P roy Addr1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes_ no Map Number Parcel Number -
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Dlstnct Proposed Use Lot Area(sq fl) Frontage(fl)
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. 40,154) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP' 1
2.1 Own r'of Record• - G 4
j f � ;Dgr ,ssY
Name(Print) A dress for Service:
/r7 S-- 7'fS—_ 27 -L-/
S; Telephone
Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
E
CEC3
❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) O Alteration(s) ❑ Addition ❑olAccessory Bldg. 13Number of Units_ Other ❑ Specify:
Brief scn�ion ooff,Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building S 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing 5 2. Other Fees: S
4. .Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
-7 Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S ,y ,3 eo x. �. ❑ Paid in Full ❑Outstanding Balance Due:
o
"di ,heti
57g- !M 7 .(0
r
SECTION 5: CONSTRUCTION SERVICES
5.1 LLiicensedConstructio Supervisor(CSL) 5— 7
• L `.�: License Number s tauo Date
N,gmcf CS Helder List CSL Type(see below)
�, G- _oma
o /3F a
Address � RDResidential
Descri non
Q�` ricted u to 35,000 Cu. Ft.)
ted 1&2 FamilyDwelling
Sig e
Onlntial Roofin CovermTelephone ntial Window and Sidin/ dtial Solid Fuel Bumin A liance Installation
7 / "� Lial Demolition
5.2 Reg ered Hiarne int rovemen Contract r(HIC) !/
HIC
pany Na or HIC Re strati N e C Registration Number
7o . i
Address �l
1_ oP8„3 Exp anon Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 Alrtdavit Attached? Yes.......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. , 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.
i G s o
Si nature of Owner
Date/ �—
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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.
/bY-G fiiA L /� Sp Q ,A /e � Q
P
7�� L/&=*X—
SSiignature of Owner or Authorized Agent Date/
(Signed under the pains and penalties of peru
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 no 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 IO.R6 and I IO.RS, respectively.
2. When substantial work is planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenUattics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
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"
R
`t CITY OF S.1I.&%I, .LkSSACHi;SETTS
BUILDLNG DEPARTMENT
\ I20 WASHINGTON STREET, 3m FLOOR
TEL (9711) 745-9595
FAX(978) 740.9W
(Us,(BFRTEY DRISCOLL
MAYOR THODIAS ST.PIERRS
DIRECTOR OF PUBLIC PROPERTY/at:MDLNG Cow liSSIO-iER
Workers' Compensation Insurance Affidavit: Duilders/Contractors/Electricians/Plumbers
APrllicant Information CPlease Print Legibly
NatTle (Busim�s.OrganizatiorolndividtW): /La S e_ `i'4
Address: if` U S5 -e
City/State/Zip: 4�, ,SS r k A Phone H: /STB- T 77— 61J.3
Are you an employer?Cheek the appropriate box: Type of project(required):
1.❑ I aa employer with 4. ❑ I am a general contractor and 1
nployees(full and/or part-time).* have hired the su a contnemrs 6. ❑New construction
2. I am a sole proprietor or partner- listed on the attached sheet :
7• C1 Remodeling
ship and have no employees Then sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its l0. Electrical repairs required.] officers have exercised their ❑ pairs or additions
3.111 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,Q 1(4),and we have no 12.0 Roof repairs
insurance required.] t employees. [No workers' 13.0 Other
comp. insurance required.1
•Any applicant that chaks bot sl must also rill out the stento below showing their workers'compensation policy information.
'1 Laneuwnrers who submit this afildavil indicating they are doing all work and than hire outside earmsa rs most submit a new affidavit irdiaing such.
:(",,nnacton that cheek this lac must 311whOd an aldn"tal Arst showing'be name of dw sub•comractotf and their work= wmp.policy inro maum.
I urs an employer that Is providing workers'comp this/nsarartce for my employees. Below fir(lie jWfcy and fob site
information. f�
Insurance Company Name: � d
Policy a or Sclf--its. Lie. #:-7/ 1 �Op/� C 62"o Expiration Date:.3�'.y
lob Sire Address: / C —4(� City/StatetZip: 0 �7,9�p
.teach a copy of the workers'compensation policy declaration page(showing the polity number and expiration date). i
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a finis
of up to 5250.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of
In%esttgatiuns of the DIA for insurance coverage verification.
/do hereby cern under the pains and penalties airperjury that the information provided above is true and correeL masesssUll
�;i_nalure: � 2- J<, Date:
Phone A:
Dfciul use only. Do not write in this area, to be completed by city or town affici ij
City or ruwn: __ Permir/f•Iccme p
i Issuing Authority (circle one):
L Board of Ilealth 2, BuildinL Department 3.City/ruwn Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
i
CuntactPerson: - __ _ __. ___ Phaaeli•
1
,1
v
CITY OF SALEM
A PUBLIC PROPRERTY
DEPAR'T'MENT
'd 1:: \1 ,,i ll•a,.•":1:3IIr � 1.\I� �I. \L\•,V
III- '1-$-4;.7yh I \C 'i'9-'4:'641.
Construction Debris Disposal Affidavit
(icyuired lilr all demolition and renovation work)
In accordance wt the sixth edition of the State Building Code, 780 C'MR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resultingu from
this work shall he disposed of in a pruperly licensed waste disposal I'acility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
I he dcs we
bri ill bdisposed ofin
1
(name of facility)
(address of lanli(vl
S101amlc of I :nett .1111)11cam
d
date
\1
,x
Lie./Reg./Ins.
Proposal
SEARLES CARPENTRY
Leroy Searles
53 Centre St.
Danvers, MA 01923-1419
978 777-8032
Proposal Submitted Date: 6/2/09
Name: Rite Darisse Address: 18 Chase St.Salem Ma 01970
Phone: 978 745 2721
Job Name: Job Location: Phone:
Specifications & Estimates:
1) Build new deck with two sets of steps
2) Build frame using 2"x8"pressers treaded lumber 2"x8"are 16"on center.
3) Dig approximately 2 holes 12"x4' deeps and fill with cement.
4) Install new 2"x8"against house and fasten with '/2"by 5" lag bolts.
5) Build two steps.
6) Install new touge and groove fir on deck and steps. 3� 3 O G. v+--
7) Install new post and handrail using fir lumber. / O ° 01--�
8) Install new lattice around bottom of deck using pressure treaded lumber
9) Removal of all debris. -3
/� U
10)Removal off old deck approximately 5'x 12'
TOTAL MATERIAL &LABOR
DUMP$3,300.00
We PROPOSE hereby to furnish material, labor—complete in accordance with above specifications,for the sum of
Three thousand three hundred dollars,[S 3,300.001 payment to be made as follows;one half to start,and'/.at half-
way point,and '/.(balance)upon completion. (Any alterations involving extra costs must be in writing,including
extra charges.)
Le Searles or Agent
ACCEPTANCE OF PROPOSAL;The above prices,specifications and conditions are satisfactory and are hereby
accepted. You are authorized to do the work as specified. Payment will be made as outlined above.
Sighatare Signature