10 PORTER ST - BUILDING INSPECTION The Ce tlnionwealth til Massachusetts
CY
Board oBuilding Regulations and Standards OF SA
fLEM
Massachusetts State Building Code, 730 CMR, 7"edition Revised Jnrrt urs
Building Permit Application'ro Construct, Repair, Renovate Or Demolish a l• =ou'v
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Nu e
r: Date Applied:
Signature: CV / /
Building Commission Inspector of Buildings Date
SECTION I:SITE INFORMATION
1.1 Property Address: S NA iVl A 1.2 Assessors Map& Parcel Numbers
IV e o r 7e f g Tnz�.
L l a Is this an accepted street'?yes_ no
Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
(Y Zoning District Proposed Use Lot Area(s,4 11) Frontage(Il)
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? Municipal llf On site disposal system ❑
Public PQ Private 13 Check if yes13
SECTION 2: PROPERTY OWNERSHIP' to
2.1 Owners of Record: )L` OrAe-r S(r2,¢.1 5 a.&VV\ m!r
TBrQI1� lM
Name(Print) Address for Service:
-42rI — 2F6 oq8�
Signature. Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition 13Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: e Iero h .v
Re_ynov,z itlz hr ' TJ 11
c��tn r � bin�
L _
SECTION d: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
1. Building S 4?00 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S Da ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 500 2. Other Fees: S
y. Mechanical (IIVAC) S 6 List:
5. Mechanical (Fire S 0 Total All Fees:S
Su ression
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 00 ❑Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Cunstructlon Supervisor(CSL) odd 2a- ,3 (,/ / ;I-
rzyc) Cir\lk'CL61 License Numher F:cpiration Date
Nance W C:.IL-I luWer
List CSL I}'pe lice below)
Lea
is PC Description
r
Il 1 1!nrestricteJ(up to 35,000 Cu. Ft.
as39 7�tol R Restricted 11 2 FamilyDwelling
�S1
Signature h1 Mason Only
7
RC Residential Rooting Covering
telephone - WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
S,2 eeggls ered Home Im rovrment Contra_c�o� 1IC)
/23 6 3
I IIC Company Name or HIC Registrant Name Registration Number
Expiration Date
Signulure 'rciephone -
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... Nu...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 7-S raA\1 rv\ R v�x D-V\-Q as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relatttiiivv�vee�to�work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, Moo a-\yC-Lr,-F1 ,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.
Pri a
M r
2� 211/ 2C?(/
Signature 'Owner or Authorized Agent Date
(Signed under the painsand Denalticsof 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 Ifome Improvement Contractor(11 IC)Program),will nu 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 1 IO.R6 and I IO.R5, respectively.
2. When substantial work is planned,provide the information below:
Total flours 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 heating system Number of decks/porches
Type of cooling system Finclosed Open
3. "Total Project Squire Footage"may he substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
a�
-- DEPARTMENT
1W:;N:I`Y:11111(:,n 1
\t N,nt
12C WAR .1161k CSrxtkl' • SALEM,M.sss.u:nl st.-1 nJ197�
11•.1.: )78.113-9393 • 1:%.x 973.74Ct9Y411,
lvurkers' Compensation Insurunce .untiovit: Builders/Contractors/Electricians/Plumbers
lipnlicant Information Please Print Leeibiv
Nil ITIC Indlviduu4: WDS Roth 1rAPa-D6i1C—Kj
Address: 5D (�11J1 Y -Sra-r-e`l # L(Z
City,Slatc:7.ip: (y+jN, t"tA Dl7 )02 I'huneii: _791 ,361-Z901'
Are $a an employer?Check the appropriate box: 'Type of project(required):
1. I ant a employer with 4. ❑ 1 am a gcncral coulractor and 1 6, ❑ New construction
employees(lull:md/ur put-tinic).• have hired the sub-contractors
2.0 1 ant a sole proprietor or partner- listed on the anachcd sheet. 7• ❑ Remodeling
ship and have no employees These subcontractors have S. Q Demolition
working for me in any capacity. workers'comp, insurance. q. ❑ Building addition
I No workers'sump. insurance 5. ❑ We are a corporation and its
required.) otlicers have exercised their 10.0 Electrical repairs or additions
3.0 1 ant a homeowner doing all work right of exemption per MGL I LQ Plumbing repairs or additions
myself.(Ko workers'comp. a 152,q I(4),and we have no 12.❑ 1 repairs
insurance required.) t employees. (Ko workers' '
comp. insurance rcyuire-d I 13. ether ALTE�T/1?N
•Wiry ap pluutd thus chucks ba Al m110 also Wiwi the su6ian hcluw dowing their wutkwi wntpua,,u"I1wllcy inliomariw
'I lumaiwnen who sld,mil this 4171davit indicating they act doing alt work and then him outside raamcton moat.uhmit a new a111davil indi,:ating such.
d'„nulchw that check this box mltw aslachcd an additional Acel showing the name of the sub.eon1ra01aa and their svurkeW camp.main y inrnrtnanun.
/torr an ralp/ayrr that Lt providing rvurkrrs'cumprnrnrion iuturnnce jar my enrpluprrr. Brhnv!s rhe policy and fait.rib
iujunnuriun.
Insurance Company Vame: �v4["CJLL(AtAtl.iP �j l C
Policy 4 car Sclf-ins. Lic.n: 1 k,yD 'Z010 ZI)i 1 Expirmwn Date:
)cab Site Address; l p �7v't"(+:fL ST(L�c- 1., C•ilyrStateiZlp: SAL-rt. , ri A
Attach it copy of lite workers'compensation policy declarallon page(showing the policy number and expiration date).
Failure to sccurc coverage as required under Section 25A ut'JIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to 51.500.00 and/ur one-year nnprmitioicnt,as wull as civil pcoullics in the loan of a STOP WORK ORDER and a fine
Of up to 5250.00 a day eguinst the violator. Ilc advised thut a copy urthis statement may be lurwardcd to the Office of
Incrsngam,ns of dlc DIA Cor iosur rcc covcra-a; %e1'ilicauon.
/du hereby err t m ler rltr rti s(rad peau/tier ofOrd"ry that Ilse information provided above is true Wad tarred.
1) t•- 2^lrf^1Al/
Official ase du/y. Do nor write in thio area, ru be cutupfeted by city car ra,vn ofJfelaz i
Citi or'I'nwn: Permit/l.icvnic g._
Issuing Authorily(circle one):
1. Iluard nr Ilvalth 2. Building ncpartulcul .1. (NI Ibnu by
4. L••lectrical Inspector i• Plumbing; Inspector
6. Other
C.'al:lcl 1'Aunc Y:
l
Information and Instructions
\I;nssjcliasctts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to finis strtule,an empfgree is defined as"...every person in the service of another under any contract of hire,
e%press or implied, oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
,d the tbrcgoing engaged in a Joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee Of.'"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
ho employs persons to do maintenance,construction or repair work on such dwelling house
.Iweliing buu;e of another w
all not because of such employment be deemed to be an employer."
or on rhe.-rounds or building appurtenant thereto sh
MGL chapter 152.§25C(6)also states that"every state or local licensing agency shag withhold the issuance or
ss or to construct buildings in the commonwealth for any
renewal of a license or permit to operate a busine
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionally, \,IGL 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 our the workers' compensation affidavit completely,by checking the boxes that apply to your situation and, if
necessary,supply sub-contractor(s)naiads),address(es)and phone nunber(s)along with their certiftcatc(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
\ccidents for confirmation of insurance coverage. Also be sure la sign and dale 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
seif-insurance license number on the aeEro2riatc line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided u space at the bottom
uC de affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
I'l.ase 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 pennitiliceiuc applications in any given year,need only submit one affidavit indicating current
policy information of necessary)and tinder"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 at7iduvit 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
(i.e; a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I 11 t)Rice tit Investigations would like to drank you in advance fur your cooperation and should you have any questions,
please Ju nut hesitate to give us a call.
The Mpartment's address, tciephonr and fax number:
The Commonwealth of Massachusetts
Departrnent of Industrial Accidents
Office of Investlgadons
600 Washington Street
Boston, MA 02111
Tel. N 617.727-4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
Rt%iecd :.10-05 www.mass.gov/dia
CITY OF SUENI, AxsSACHUSETTS
BUILDIING DEPARTNtEINT
130 WASHNGTON STREET, 3�FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI\iBERLEY DIUSCOLL
MAYORTHo.+us ST.PIF.RRs
DIRECTOR OF PUBLIC PROPERTY/BVILDLNG CONWISSIONER
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 l 1.5
Debris, and the provisions of MGL a 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 :
Sr iN� hecyc(�v\
(name of facility)
y pts ►�cv..ev-' �V'A-�ti P krt�y Jeetn.tcvv>_ Iv11q a2 I S
(address of facility)
signature of permit applicant
date
Icbnvtf Jk
C.L. G. ASSOCIATES
411 SL4LEM ST. WAKEFIELD, MA 01880 • (781) 245-9895 (978) 931-7414
CLOSET
BASEMENT UNIT 2
ENTRANCE 18'-1
1 UNIT 2
11•-7" TOTAL
677 S.F.
ATH
*NOTE: THE CONDOMINIUM ROOM(
UNIT SHOWN HEREON IS
DESIGNATED FOR SINK
RESIDENTIAL USE.
UNIT 2 HW BOILER
TANK ROOM 15'-10"
1 HEREBY CERTIFY THAT 20'-0"
THIS PLAN FULLY AND
ACCURATELY DEPICTS a
THE AS—BUILT LAYOUT, FURNACE
LOCATION, UNIT NUMBER,
DIMENSIONS AND
APPROXIMATE AREAS ❑❑
OF THE UNIT AND ❑ 'COMMON STORAGE
COMMON AREA. AREA UNIT 1&2
485 S.F19._11"
I HEREBY CERTIFY THAT � WASHING
THIS PLAN CONFORMS TO ❑ MACHINES
THE RULES AND REGULATIONS STORAGE
OF THE REGISTERS OF DEEDS. 0'—,3 UNIT 4
ELEC. METERS
GRAPHIC SCALE 000000
10 0 5 10 STORAGE
STORAGE UNIT 5
UNIT 3 STORAGE
1 IN FEET 1 UNIT 6
I WILLIAM R. D'ENTREMONT P.L.S. CERTIFY THAT THIS
PLAN SHOWS THE BASEMENT UNIT OF THE #10 PORTER ST. CONDOMINIUM
AND THAT IT FULLY AND ACCURATELY DEPICTS THE LAYOUT, ITS
LOCATION, DIMENSIONS, APPROXIMATE AREA,
AND COMMON AREA TO WHICH IT HAS
ACCESS, AS-BUILT. OF CONDOMINIUM UNIT PLAN
3`OP�SH MgSSgC for
WILLIAM yN ILIDIO VALENTE JR.
S R. at
D'
No.39392 w 10 PORTER ST. CONDOMINIUM
�/ (/ �ih/✓Zo� No.39392 �
WILLIAM R. NTREMONTP.L.S. o sRF�fSrtR� SALEM, MA
oNgL LAA SCALE:1"=10' DATE: 314103
i� 9