21 GARDNER ST NUMBER 3 - BUILDING INSPECTION The Commonwealth of Massachusetts CITY
Board oBuilding Regulations and Standards OF SA
fLEM
Massachusetts State Building Code, 730 CMR, T"edition Revised Jonuart'
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• -1008
One.or Two-Family Dn'ellinx
(!� This Section For Official Use Only
v
Building Permit Number: Date Applied: -
Signature:
Building Commissioner/Insfiector of Buildings Date
SECTION I:SITE INFORMATION
I. Pr perry Ad ress: Sy .� 1.2 Assessors Map St Parcel Numbers
aT G�� ner
I.I a Is this an accepted street'?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
/oning District Proposed Use Lot Area(sq It) Frontage(fl)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided RCyuireJ 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? Municipal 13 On site disposal system 13Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP'C
l Owners of L& !erre �� rUalner U.f-,
�'aniGe �
Nu riot) Address for Service:
a Uig, _ 97g-2136-3769
Siggdl rc Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description ol'ProposedWork': Jae LQ
i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OITIclal Use Only
Item (Labor and Materials
I. Building S I• Building Permit Fee:S Indicate how Ice is Determined:
❑Standard City/Town Application Fee
. Electrical S ❑Total Project Costs(Item 6)x multiplier x
3. Plumbing
. 1'lumbing S ?. Other Fees: S (')r�{+�//J
4. Mechanical (IIVAC) S
List: e
5. Mechanical (Fire S
Su ression Total All Fees:S
Check No._Check Amount: Cash Amount:_
�/� 6.Total Project Cost: S /d DOD, 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) tO/ 57,g
License Number H.xpimtiun Date
N:une of CSI.- IIu1Jer List CSL1')pe(seehelow) U
I(�o Ft�SGN ERC
Description
address
l I nrestricteJ a to 35.000 Cu.Ft.)
R Restricted 1(k?FamilyDwcllin
Sig tenure Mason Only
Residential Rootin C'overinreiephone S Residential Window and SidinF RexiJential Solid Fuel Bumin A liance Installation
Residential Demolition
5. egisteredHome improvement Contractor(HIC)
LL/�tJiv CNlzP /60�5�(.0
I IIC'Company Name u PIC Re 'I,,'t acne Registration Number
lea � 2, �� r�t /` He1ti 2�!$F'0/r`f/S tz
Address �,
/0/7 7LOZ,27� Expiration Date
Si nature Telephone
SECT N 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 Affidavit Attached? Yes..........O No...........0
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.
Signature of Owner Date
n / SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
rthat
far)/Ge /1zpte/re, asOwner or Authorized Agent hereby declare
statements and information on the foregoing application are true and accurate,to the best of my knowledge and
La /elre-
m
Signatur of Owner 6r Atiforized Agent Dat
Si under the pains and penalties of r'u
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 Hume Improvement Contractor(IIIc)Program), will gel 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 730 CMR Regulations 110.116 and I IO.RS,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.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Foulage"may he substituted lift"Total Project Cost"
CITY OF sm&NI, NL-1SS.A aiUSE17S
ElumoLNG DEPARTMENT
130 W.A.sHLNGTON STREET,Y'FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KISBERLEY DRISCOLL
MAYOR THo.+us ST.Pmanst
DIRECrOROP PI:BLIC PROPERTY/BCiLDING COJLNIISSIONER
Construction Debris Disposal Affldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section l 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:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of ermit applicant
date
dcbnvlf Jew:
CITY OF S.U.B.N1
PUBLIC PROPERTY
DEPARMMENT
�l�Y NM.Y1 L
VAY08 t 1yA>wM[.TObI Sr1P�T
SK!!4 4ASU01lQR9 019.'0
TEL r*.745-9S"0 FAx 97L74o.9t46
HOMEOWNER LICENSE EXEMPTION
Please hint
Due c;2 11 Il
JobLacatinn a2/ Cz�cYlne!' cSf ��
Home Owner Address ra-)2
Home Owner Telephone R 7�?- 4.38 -3 9
Protons Mailing Address
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or leas and to allow such homeowners to engage an individual for
hire who.does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons)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 O®ciak 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 understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
,APPROVAL OF BUILDING NS ECTOR
See other side for state code
February 4, 2011
RE: 21 Gardner Street Condo Unit#3
To whom this may concern:
Unit owners#1 and#2 are aware and approve of the minor kitchen renovations being made to Unit 3.
Renovations include new cabinets, new counter top, reinstalling appliances and adding new outlets.
l
I
asoo& Holly Matulewicz
A
Todd Eptstein
Otfiee o onsumer A airssiaess egu anou �; .., License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
VSL'IING#
Registration 160856 Type: _ Office of Consumer Affairs and Business Regulation
Ex nation 9/8/2012 DBA y 10 Park Plaza-Suite 5170
Boston,MA 02116
ARPENTRYj. - '
THOMAS SHILLING }ti i'i ----- _
160 JERSEY ST
MARBLEHEAD,MA 01945
_ undersecretary - Not valid without si nature
Massachusetts- Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 101569 `
Restricted to: 00 -
THOMAS SHILLING
._180 JERSEY ST
MARBLEHEAD, MA 01945
Expuation:,2/27/2012
('onunlsxiuner Tr#: 101569
CITY OF SALEM
L
it PUBLIC PROPRERTY
DEPARTMENT
.I\I I:: N:rY:1x1,0-I I
I A
I?^�WAaraNG ulX i7aELT 0 Sou:H,M.tnAl.nt a�l IW197:
fi%j,:778.:13.9395 • P.cx. 97)C-74C-9,140
Workers' Compensation Insurance Affidavit: Builders/Contracturs/Electricians/Plumbers
'cunlicant Information Please Print Levibly
Vit171ell1uuicsrOrgantnlinvindrviduull: �cZ(/i/NO rlfJ7Clll
Address:
City,St: rc,ZiP:,05WgG� AV,44 %RFS I'hone it:_ to 1? 7Q/ -,9ZL7
:tire you an employer:'Check the appropriate box: FRnod
t(required):
1.❑ 1 am a employer with 4. ❑ 1 am a gcnural contractor and 1struction
entpiuyees(full and/or part-time).• have hired the sub-contractors
2.® 1 am a sole proprietor or partner- listed an rhe attachcli sheet. ing
ship and have no cmploycw These subcontractors have onworking tier me in any capacity, workers'comp. insurance. addition
I No workers'comp, insurance 5. ❑ We are a corporation and its
required.] Officers have exercised their 10.0 Electrical repairs or additions
3.Q I ,rata homeowner doing all work right orexentption per MGL 1 LQ Plumbing repairs or additions
myself.(No workers'comp. c. 152,§t(4),and we have no 12.❑ Ruul'repain
insurance required.] t cmployces.(No workers' 13.[]Other
comp. insurance required
•Ally uitpbead IbW cheeks boa BI must also till uul thc'moimt below dwwiny dteir umkus'cumpunuaiwt policy inliematiun
'I lumwrwners whu submit this olAdavit indiaaliny Ihwy ate doing all wart aW emn him outside awurxtofa most.uhmit anew atfdavil indica my%tch.
d\wuraceus that check this box mutt atxhcd an aldiliunal..hast.howing IN natty of the sub-contraaors and their wurkars'camp.mlocy inPormarium
falls an etupluyer that lr providing workers'coinpen.mlion inaurunee for uty enrpigrttx. Belem is the pu/8y and Job.cite
infurmution.
Insurance Company Vame: �''L
Policy III or Sclf--ins. Lic.d: l ff(lJ C7,Z(7 y_.. Expiration Date: /r.5 �?--
lob Site Address, _ City,Slnteflip: .Slim al'o1Q7y
Attach at copy of the workers'compensation policy declaration page(showing the policy number and explratiun date).
I-ailuro to secure coverage as required uudcr Section 25A uf.%lGL c. 152 can lead to the imposition of criminal penalties of a
tine up ht 51.500.00 and/or one-year imprisonment,as well as civil penullics in the form of a STOP WORK ORDER and a fine
or up lit 1250.00 it day against rile violator, lie advmcd thut a copy of thisalinement may be lurwarded lis the 01111ce of
Iml .%Iigjtioni e1 Ille DIA for iosurarce covcra;;u serlllcauun.
/do hereby certify under Ilse pains rntd perm/ties of pery'ury that the infurtnuden provided above it true and correct
wic, 2-17-11
I'I uu: v 1217 / Z..
official list ditty. no nor Write in this area.to be rdinp/eted by city or town official I
City or'1'nwo: Permen
it/1Jcse g._
Issuing;Aulhorily(circle nuc):
I. IiuurJ of Ilvalth 2. Iluildio., Ueparuncnl I.Cinyi I'uwu Clerk 4. L•'Icctrird Inspector i, Plumbing Inspector
6. Omer
Coitt:scl l'mon: _ -- Phoneq•
Information and Instructions
.Iassachu.ctu General Laws chapter 152 requires all employers to provide workers compensation for their employees.
Pursuant to[itis statute,an employee is defined as"...every person in the service of another under any contract of hire,
evpress or implied, oral or written."
.fin emplupee is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
r the foregoing engaged in a Joint enterprise,and including the legal representatives of a deceased employer,or the
ieceiver or trustee ut .ui individual, piumcrship,association or other legal entity,employing employees. HOwevcr the
of a dwelling house having not more
owner e than three apartments and who resides therein,or the occupant of the
owner
hove of another who employs persons to do maintenance,construction or repair work on such dwelling house
i grounds or building appurtenant thereto shall not because of such employment be deemed to Ix an employer."
or on he� b
SIGL chapter 152.§25C(6)also states that"every state or local licensing agency shag 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 cumpllance with the insurance coverage required."
Additionally. SIGL chapter 15-1, §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 certificatc(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 appropriatc line.
City or-town Officials
Please be Sure that the affidavit is complete and printed legibly. The Department has provided u space•at the bottom
Of the affidavit for you to till nut in the event the Office of Investigations has to contact you regarding the applicant.
I'I.ase be Sure to till in the permitllicense number which will be used as a reference number. In addition,an applicant
drat mwt submit multiple pennitllicense 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 naw 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. it dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
the t)Ilice it Investigations would like to thank you in advance for your cooperation and should you have:uty questions,
please do not hesitate to give us a call-
rhe
allThe Deparnnent's address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of faveildgatlons
600 Washington Street
Boston, MA 02111
Tel. # 617-7274900 ext 406 or 1-877-MASSAFE
Fax 11617-727-7749
It c.i nc d i-10-05 www.mass.gov/dia