22 CLIFTON AVE - BUILDING INSPECTION � gq
The Commonwealth of Massachusetts
Department of Public Safety
Ev Massachusetts State Building Code(780 CMR)
p Building Permit Application for any Building other than a One-or Two-Family L$yellingi
To r y.
(� (This Section For Official Use Only)
Building Permit Number: D .-6ate Applied: I O -ol- Building Official: v 41
SECTION"1:LOCATION (Please indicate Block#and Lot#for locations for which a street address is not oNilablq
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No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
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Edition of MA State Code used_ If New Construction check here❑or check all that apply in the twoT't�vs below
Existing Building Repair❑ Alteration liar Addition ❑ Demolition (Please fill out and submit Appendix'1)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No 1r
Is an Independent Structural Engineering Peer Review required? Yes ❑ No M'
Brief Description of Proposed Work: Neo G O F 4't" I
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SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
1..
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories (include basement levels)&Area Per Floor (sq.ft.) SA o
Total Area (sq. ft.)and Total Height(ft.) 14-}9
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5 ❑ B: Business ❑ E: Educational ❑
F: Factor F-1. ❑ F2❑ 1 H: High Hazard FI-I ❑ H-2❑ H-3 ❑ H-4❑ 1-1-5 ❑
L Institutional I-1 ❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-4 ❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
[A 11 IB ❑ IIA 11 IIB ❑ IIIA ❑ IIIB ❑ IV VA 11 VB 11
SECTION 7:SITE INFORMATION (refer to 780CMR 111.0 for details on each item)
Trench Permit: Debris Removal
Water Supply: Flood Zone Information: Sewage Disposal: Trench
Licensed Disposal Site ❑
Public Check if outside Flood Zone� Indicate municipal LTJ e trench will not c P
P° required ❑or trench or specify:G
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: lvt,A Historic C,xnni_ssior,Rgviuw�=Pro,_t,s:
Not Applicable a/ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed ClYes ❑ - N- f`f' Yes ❑ No C3�
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Croup(s); Type of Construction: Occupant Load per Floor: -
Does the building contain an Sprinkler System?: Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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Name(Print) No.and Street City/Town E Zip
Property Owner Contact Information:
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Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable, the property owner hereby authorizes
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Nan'-ie Street Address City/Town State Zip
to act on the property owner's behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 0 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
WIWAM Gl¢ C-C VIVI ,_05-IDw4gravGrt4�vd-
Name(Re tstra�n�t ._- 'telephone No. e-mail a dr�ss Re�i�s t"ra�h'o�n�u"m�ber
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Street Address City/Town State Zip Discipline Ex r tion Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
.,Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11: WORKERS C0MPENSXCION INSLRANCF AITIDAVIT M.G.L.c.152.§ 25C(6))
A Workers'Compensation Insurance Affidavit from the NIA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs: (Labor
and Materials) Total Construction Cost(from Item 6)_$
"t. Building $ ' p
Building Permit Fee=Total Construction Cost x (Insert here
2. Electrical $ 3 0 appropriate municipal factor)_$
3. Plumbing $ p o
4. Ndechanical (FIVAC) $ Note:Minimum fee=$ (contact municipality)
5. Mechanical (Other) $
Enclose check payable to
6.Total Cost $ 2 0 0 (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering m name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
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�a >l>licado i is true and accurate ue best of my knowledge and understand ug.
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Please print and sign name 'title Telephone No. Date
Street Address City/Town State Zip A r�
QIP ti L nh �� O \ Ja l
Municipal Inspector to fill out this section upon application approval: a✓ � "��� ea .
Name Date
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Construction Debris Disposa/Affjdavit
(required forall demolition and.renovation worki
In aecorcimm with the"edition of tike state BuMnK Code, 7M CAOUL Section 111.5 Debd
and the proWdons of AAGL eW,S S4; Permit if
Buildhg is issued with the
condition that
the debris resu
from this
� work shad be disposed of in a properl y IToensed
waste deposit fadrrtyas defined by MGL c 111,S lWA.
The debris will be transported by:
G L av.{- 3
(name of hauler)
The debris will be disposed of in:
(name of fadiity)
(address of facility)
Signature of applicant
( 0 - 01 - 16
Date
The Commonwealth of Massachusetts
Department of Industrial Accidents
IV Congress Street,Suite 100
Boston,MA 02114-2017
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www mass.gov/dia
Workers' Compensation Insurance Affidavit:General Businesses.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information / Please Print Legibly
Business/Organization Name: L C z v a ee ',b .(`*y
Address: (�__p✓1 �>_n�. S'�
City/State/Zip: L y F} f S D 110 Phone#:
Are you an employer?Check the appropriate box: Business Type(required):
1.❑ I am a employer with employees(full and/ 5. ❑Retail
or part-time).* 6. ❑Restaurant/Bar/Eating Establishment
2.t{ I am a sole proprietor or partnership and have no ?. ❑Office and/or Sales(incl.real estate, auto,etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑Entertainment
their right of exemption per c. 152, §1(4),and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]*
4.❑ We are a non-profit organization,staffed by volunteers, 11.❑Health Care
with no employees. [No workers' comp.insurance req.] 12.0 Other
*Any applicant that checks box q1 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box NI.
I am an employer that is providing workers'compensation insurancefor my employee& Below is the policy information.
Insurance Company Name: tD1-4I R G 1 L-1 0 t 1.1 S k6tG N c. ,
Insurer's Address:
City/State/Zip: I�
Policy#or Self-ins.Lie.#� LA V et)or,O(D b 3 ri A t 6 Expiration Date: (0 7
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
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$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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby cerci ,under the pains and penalties ofperjury that the information provided above is true and correct.
Sijnatme: Date: f 0
Phone#:
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.Cityrrown Clerk 4.Licensing Board 5.Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia
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 your insurance company's name,address and phone number along with a certificate of insurance.
Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members
or partners,are not required to cant'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). 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 burn 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
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
Fonn Revised 02-23-15
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT`
120 WASF fNGTONSTREET,3"OFLOOR
TEL. (978)745-9595
KIMBERLEYDRISOpLL FAX(978)740-9846
MAYOR THOMAS ST-PIERRE
DIRECTOR OF PUBLICPROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT.
Date 10 -01 - 1 (,
Job Location—la C ( I t { 0\2 tlt V e > 0. I ear A1j_P S 0 L 9 l–Q
Home Owner Address !�fi M ', I }0 H }- 1 v h h M 14 C Q 0150?
Present Mailing Address 13- C I S Y f 0'n Ase Ca l e f-, m lW o t j1-
The
1The current exemption of"Homeowners"was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner"shall submit to the Building Official,on a form acceptable
to the Building Official,that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned"homeowner"certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE °-4'
APPROVAL OF BUILDING INSPECTOR
MORTGAGE INSPECTION
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SALEM, MASS.
REID LAND SURVEYORS
365 CHATHAM ST., LYNN, MASS.
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N/F No. "422
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N/F 9600±S.1� . I CERTIFY THAT THE DWELLING IS LOCATED
BEOTE AS SHOWN AND CONFORMED TO THE ZONING
SET BACK REQUIREMENTS OF THE CITY OF
SALEM WHEN CONSTRUCTED, OR IS
EXEMPT FROM VIOLATION ENFORCEMENT
UNDER M.G.L. TITLE VII CH. 40A SEC._ 7.
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WOOD NOTE. FENCES, WALL. SHRUBS,
A,A DRIVEWAYS. ETC. DO NOT NEC—
ESSARILY
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ESSA ILY REPRESENT PROPERTY
LINES1
APPROX. LOCATION
STON & CONC. WALL N/F
BANVILLE
2 CAR
N/F BRICK
AMBRDZAVITCH �,�� GARAGE
N/F
ROGERS
N, HEREBY, CERTIFY TO THE BEST OF MY KNOWLEDGE
THAT THE PREMISES SHOWN ON THIS PLAN ARE NOT LOCAT— NOTE: THIS PLAN WAS PREPARED FROM A
c ED WITHIN A SPECIAL FLOOD HAZARD AREA AS DELINEATED TAPE SURVEY AND IS INTENDED FOR
ON THE MAP OF ESSEX COUNTY PREPARED BY THE MORTGAGE PURPOSES ONLY. OFFSETS SHOO
18 FEDERAL EMERGENCY MANAGEMENT AGENCY OR IYS ON OR SCALED FROM THIS PLAN, ARE
j SUCCESSORS DATED 7/16/2014, MAP #280D8c04
PANEL NUMBER 419 OF 600, HONE X . % 19G. APPROXIMATE ONLY AND SHOULD NOT BE I FURTHER CERTIFY THAT THIS INSPECTION WAS PER—
USED TO DETERMINE PROPERTY LINES.
FORMED IN ACCORDANCE WITH TME •TECHNICAL STAND- SCALE: 1" - 30' DATE: SEPT. 22, 2016
ARDS FOR MORTGAGE LOAN INSPECTIONS' AS. ADOPTED
a BY THE MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS BOOK: 34729 PAGE: 212 CERT.#
AND CIVIL ENGINEERS.
e THIS CERTIFICATION DOES NOT INCLUDE SHRUBS, WALLS, CONTROL #-P16-0207 L
FENCES OR DRIVEWAYS AS THEY DO NOT ALWAYS INDICATE MGA
PROPERTY LINES.
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First Floor Plan
Bathroom & Kitchen Renovations William Grover, Architect sneer. .1
22 Clifton Ave 12 Carpenter Street Job Number:161003
Salem, Massachusetts 01970 Salem, Massachusetts 01970 Date.Oct 1s,2016
(978) 745-6370 Revisions:
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Bathroom & Kitchen Renovations William Grover, Architect Sheet: A" 2,
22 Clifton Ave 12 Carpenter Street Job Number: 161002
Salem, iWassachnsens 01970 Salem, Massachusetts 01970 Date: Oct 15, 2016
(978) 745-6370 Revisions:
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Second Floor Plan
Bathroom & Kitchen Renovations William Grover, Architect Sheet: A-
22 Clifton Ave 12 Carpenter Street Job Number: 161002
Salem, Massachusetts 01970 Salem, Massachusetts 01970 Date: Oct 15, 2016
(978) 745-6370 Revisions: