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22 GROVE ST - BUILDING INSPECTION r The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY a' OF SALEM �j Massachusetts State Building Code, 780 CMR, 7 edition � M Revla•ed January Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. ?/108 One-or Two-Family Dwelling ,,�((•``�'!1 / This Section For Official Use Only Building Permit Number: Date Applied: r } Signature: ' OC `/ Building Commissioner/Inspector of Buildings Date SECTION I:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers as Gro:-e sar*e3tr I.la Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: loning District Proposed Use Lot Area(sq li) Frontage(11) 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❑ Check if yes❑ Municipal❑ Onsite disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: Gm, e s, . 51 Name(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alleration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units I Other ❑ Specify: Brief Description of Proposed Work': ,- l �, k C l+ SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Labor and Materials) Official Use Only I. Building $ I. Building Permit Fee: $ Indicate how fee is determined: �. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (FIVAC) $ List: 5. Mechanical (Fire $ Suression Tutal All Fees:$ Check No. Check Amount: Cash Amount:_ 6. Total Project Cost: $ tT',4o(�) ❑Paid in Full ❑Outstanding Balance Due: �J /14 11 C©n�YfCld� lad 1—re^ce r SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) CG w't f-Q, License Number fispimtion Date Nano of CSL-I folder List CSL Type(see below) GaIG �rr� Ce SA . Type Description Address U Unrestricted(up to 35,000 Cu.Ft.) it R Restricted 1&2 Family Dwelling . ig!n1atureG ('CC �{�7� M Masonry Only RC Residential Roofing Covering "telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Reggistered Home Improvement Contractor(HIC) �J< C r�e�\ C c t�,rg I IIC Company Name or HIC Registrant Name Registration Number G 3 �C, hpv f a S� , ewe Address ci8s P n imtion Date tat re 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 lssuan5p of the building permit. Signed Affidavit Attached? Yes .......... 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 SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION i 1, as Owner or Authorized Agent hereby declare at 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 not 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 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.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halt%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 S.UY.,,NI, A—us.kcHUSETTS • BU DLNG DEP.IRT\MNT 130 W.IUHLNGTON STREET,Yo FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KI\I3ERLEY DRISCOLL MAYOR Tliomu ST.Plzm DIRECTOR OF PIBLIC PROPERTY/BlAILDLNG CONNISSIONFR 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 11 1.5 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: Sc GPnfr-'( cc.V\"O n (name of hauler) The debris will be disposed of in .ark S (name of facility) (address of facility) signature of permit applicant date d.bnvif dew !� CITY OF SM_E.NI, , L1SSACHL'SHTrS BI:IIDLNG DEPiIk'r?,LF_iT 130 WASHIINGTON STREET, 3m FLOOR \ Rase TEL (978) 735-9595 FAx(978) 730-9846 KI%BE U.EY DRISCOLL THOMAs ST.Pmum MAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LMRSSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers r licant information Please Print Le lbly Name(Busilx'organiratiowlndividual): -� J ` � P^z, - Address: G a 4'n-Ac J'� City/Statc/Zip: S6(�Pw� O(S7� Phone#:ia- ��7� Are you an employer?Check the appropriate bot: Type of project(required): �,/1 4. ❑ I am a general contractor and 1 6.7. N construction 1.0� t am a employer with ❑ employees(full and/or part-time)." have hired the sub-contractors Remodeling 2.❑ I am a sole proprietor or partner- listed on the attached sheet. ship and have no employees These sub-contractors have H. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑ Building addition No workers'corn insurance 5. ❑ We are a corporation and its( p• l0.❑ Electrical repairs or additions required.) officers have exercised their right of exemption r MGL i!.❑ Plumbing repairs or additions }.❑ 1 am a homeowner doing all work B P per myself.(No workers'comp. c. 152,§1(4),and we have no 12.E] Roof repairs insurance required.]t employees. LN'o workers' 13.001her comp. insurance required.] •Any appticua nw clucks bus rl must also rill uta the uutim below showing their workM compmwiun Policy intnmatiun. t Ih>.tteuwoas who submit this dfidrvir indicating they ars doing all work and then hire outside contractors must submit a new an davit indicating such. :('unnrscton that check This box most anached an additional shit showing the name of the subcontractors and their wurken•camp.policy information. I am an employer that Is providing workers'compenradon insurance jar my employees. Below Is Ilto policy and fob sire injormadon. n _ insurance Company Name: Policy llor Self-ins. Lic..0: �'�•�G, Expiration Date: Job SiteAddress: a'O� /�Sk S9 City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to 5250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. i da hereby certify under the pains and penairles of perjury that the information provided above it true mrd c orrece Sisi tlure- phone p r d Official use only. Do not write in thir area,to be completed by city of town offh•/aL i City ar Town• Permil/l.lcense Y_ — Isssulag Authority(circle uric): I. Board of health 2. Buildinr Department 3.Cilyiratvn Clerk 3. Electrical Inspector 5. Plumbing limpector 6.Other -- -----_. _ Contact Person: _ . ._. ... Phone M: Information and Instructions %lassachusclts General Laws chapter 1 i2 requires all employers to provide workers' compensation for their employees. Pursuant to this si4tuie,in emplvred is detined as"...every pctxon in the service of another under any contract Whirc, ' capress or implied,oral or written." No e,npluyer is defined as"an individual, partnership,association,corporation or other legal entity,or any two or more ,,f the t0regoiug engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the ('eceiver or trustee uI .un rtidividual,parmership,assoeiatioa or other legal entity,employing emplo)'ees. 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 renewul of it 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. NIGL chapter 152, a25C(7)states"Neither the commonwealth nor any of its political subdivisions shall corer into any contract f'or 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•contracior(s)name(s),address(es)and phone nwnber(s)along with their certifncatn(s)of insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the members or purtners,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 confimmtion of insurance coverage. Also be sure to sign and date the•affidavit. The affidavit should he 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 u workers' compensation policy,please call the Department at the number listed below. Self-insurrbd companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please he 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. I'l,asc be sure to till in the permit license number which will be used as a reference number. In addition,an applicant that must submit multiple pennitilicetse 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(he 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 tilled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture 1 i.e. a dog license or permit to bum leaves ctc.)said person is NOT required to complete this affidavit. I lic t yf f ICC W Investigations would like to thank you in advancC for your cooperation and should you have sly questions, please do not hesitate to give us a call. The Ocpartment's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 011lee of Investlgadons 600 Washington Street Boston, MA 02111 "fel. # 617-727.4900 ext 406 or 1-877-MASSAFE Fax N 617-727-7749 www.mass.gov/dia I air slaft wm DWF ARCHITECTS 1 Ticehurst Lane Marblehead, MA 01945 781 639 3493 fax 781 631 9856 Date: 1/20/11 To: City of Salem Inspectional Services Attn: Mr. Tom St. Pierre, Inspectional Services Director RE: 22 Grove Street Salem, MA Existing Two Family Residence. BUILDING CODE ANALYSIS The following review is the existing two family referenced above. The construction is type 5b unprotected. The use group is R2. Drawings by HH Design Group Architects dated January 16, 2011 for your department's approvals have been submitted that depict the locations of an existing front entrance, existing rear entrance and large existing rear balcony with stairs to grade. It is determined that the internal front stairwell to the second floor is not necessary, as two other presently exist on the second floor for the required means of egress to grade. Sincerely, Hesign r�hitects David M. Haliotis, Assoc. AIA Cc: dch. �r c NA 3299 BOSTON, MA emA µ 6` F— C�ctT 1 fn�c� wcZ\►�=tto" - (ga�,sa�s� � w Ktt�1EN 2 .� co�aY2 0uvj o L�nTock�l •C.i) d wau5 d d o U.) inin ¢ ,N co (902 CtfJ. / VTI N N CQ f, ge LIQ 1aV 116 k Ca+oYC gla-Rk i f�- - O- A � oM2. � 3cdR.s�ae�� Am 1 Q: 3299 'i -CVSJ\T e) (vcaCc B) 9OSTON, e , a ouW"surds wm 0041 ARCHITECTS 1 Ticehurst Lane Marblehead, MA 01945 781 639 3493 fax 781 631 9856 Date: 1/20/11 To: City of Salem Inspectional Services Attn: Mr. Torn St. Pierre, Inspectional Services Director RE: 22 Grove Street Salem, MA Existing Two Family Residence. BUILDING CGDE ANALYSIS The following review is the existing two family referenced above.The construction is type 5b unprotected. The use group is R2. Drawings by HH Design Group Architects dated January 16, 2011 for your department's approvals have been submitted that depict the locations of an existing front entrance, existing rear entrance and large existing rear balcony with stairs to grade. It is determined that the internal front stairwell to the second floor is not necessary, as two other presently exist on the second floor for the required means of egress to grade. Sincerely, h ' H esign Gro p Architects David M. Haliotis, Assoc. AIA Cc: dch. fyo 3299 BOSTON, MA I t!n Nos 108 \ I ( 66Zs d (cai\cvci) (�s�cyn) { ffff i = f I -- f Y I_ <� -- "a n C� rn � � 9C4lnrt d rid/ ' b rW J I V to N N � �� .` V/ i COW NN J ' Kmm L N DcnNPJ Ln CD (n nd/a. 3 arh ar i GNx+ i oca- ZAS Sd 2h 1S\off _ — 6'3110$ J Yors�3� uS A-CORD-M CERTIFICATE OF LIABILITY INSURANCE GATE(MMIDDfYYYY) PRODUCER (M) 745-6464 THIS CERTIFICATE Is IssueD A MATTER O INVORMAT ON Rose Insurance ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR 66 Loring Avenue ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. P.O. Box 958 Salem MA 01970- INSURERS AFFORDING COVERAGE NAIC# NSURED INSURERA:E'SSEX INSURANCE COMPANY JJC General Contracting INSU SR B:Guard InMuraac® 62 Lawrence Street INSURER C: INSURER 01 Salem MA 01970- INSURER C1 COVERAGES- PERIOD INDICATED.NOTWrTH THEREQU RLEMENTOTERM 0 CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WH CHHAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FORETHISICY CERTIFICATE MAY BE ISSUED ORSMAY PE TA N, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. you EFFECTIVE POLIC E E(PI ON LIMITS TTSRD R ADD L TYPE OF INSURANCE POLICY NUMBER DATE awDOIYY DATE MLU 1000000 GENERAL LIABILITY 3DE9450 11/02/2010 11/02/2011 EACH fO�CCURRSNCE 0 PREMIBSCREW 0 0 500000 X COMMERCIAL GENERAL LIABILITY / / MOO EXP An ane asem- 0 5000 CLAWSMADE ❑OCCUR PERSONAL AADV 1 s 1000000 GENE AGGRE TT: a 2000000 DUCTS-COMP AGC 0 1000000 GEWLAGOROGATSINp.APPLIEBPSR� POLICY JECT OC / / / / COMBINED SINGLE LIMIT AUTOMOBILE LIABILITY (Ea a ZWMU ANY AUTO / / / / aODILYINJURY 0 ALL OWNED AUTOS or 'cn SCHEDULED AUTOS / / I / BODILY INJURY 0 HIRED AUTOS (Pm a**WII NON-OWNED AUTOS / / / / PROPERTY DAMAGE 0 (Pur 90c1denU AUTO ONLY-W ACCIDEN 0 GARAGE LIABILITY 1 / / / OTHER THAN ACC 0 ANY AUTO AUTO ONLY: AGG 0 RR IC 0 Ex ESSIUMBRELLA LIABILITY E TE 0 OCCUR CLA9AS MADE 0 DEDUCTIBLE 0 TH- ETENTION 6 11/16/2010 11/16/2011 X 19Y ITS B WORKERg00Mp¢NSATIONMIO joWC123500 100000 ENPLOVERV LIABILITY E.L EACH AC IDEM a 100000 ANY PROPRIETORIPARTNERIEKECUnVE / / / / E.LDIS E-PA PLOYEE9 500000 OFFICERIMEMBER EXCLUDED? S.L.DISEASE-POLICY LIMIT 0 B yes,deecn7+e W'Wdr SPECIAL PROVISIONS bbkM OTHER OOSOTBPTION OF OPPAATION6ILOCATO9N NENIOLE9IE%CLUSIONS ADOPA BY ENOORSEMPNPISPECIAI.PROVISIONS CANCELLATION CERTIFICATE HOLDER ( ) _ SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE 7,PIRATION DATE THEREOF, THE (978) 740-9846 EISSUING INSURER WALL ENDEAVOR TO MAIL 30 DAYS WRITTEN NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL IMPOSB NO OBLIGATION OR LIABILITY OF ANY MONO UPON THE City OP Salem INSU AGENTS OR REP 9 Tom St. Pierre AUTO RES rATIY tl ACORD C ORATION 1988 Pap 1 of: ACORD 26(20071081 INSO4501o11106