39 WALTER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
y, One-or Two-Family Dwelling
J _ - This Section For,Official Use Only -
t Biuldtng P mtY Number;, 'ZE .. Date Appl
It
wta
1 Building Of ictal(Pniit'Naame) 's...."r-.. . . � . - . .•: Signature -74—D
�(\ 4" tz s 'SECTION i s SITE INVOItMATIO.N,'
�! 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers N
1— 39 WALTER ST SALEM,MA 01970 27
27-n 46-809 r
1.1 a Is this an accepted street?yes_ no Map Number Parcel NumberCo
1.3 Zoning Information: 1.4 Property Dimensions:
R9
Zoning District Propose Use Lot Area(sq ft) Frontage(ft) ` —d
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
- �„� 4 , ,. SECTION2 rPROPERTYOWNERSHW,'
2.1 Owner'of Record:
GORDON RINGER SALEM, MA 01970
Name(Print) City,Stme,ZIP
39 WALTER STREET 978-594-5633
No.and Street Telephone Email Address
SlCT1ON 3e DESCRIPTION.OF PROPOSED WORK'(check all that apply)W
L'
New Construction❑s Existing Building BS Owner-Occupied Pf Repairs(s) If Altemtion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other g Specify:Replacement
Brief Description of Proposed Work :
REPI ACE 25 WINDOWS - NOSTRUCTURAL CHANGE
SECTION;4:ESTIMATED GONSTRUGTION'COSTS 4„ r
Estimated Costs:
Item (Laborand Materials)t t t OffieialVse Only , to
1.Building $ 39 872.00 1 Building Permit Feer$'' lndioate how fee is datermined.
2.Electrical $ ❑Standard Cityt I o n ApplicaYton Fee: ` ' _T
❑Total"Project Cost' (Item6)x multiplier x
3.Plumbing $ 2. Othei Fees $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ion Total All Fees!$
Check No. _Check Amount: Cash Amount:
6. Total Protect Cost: $ 39,872.00 ❑Paid m Full ❑Outstanding Balance Due:
m4 t t t r,I
SECTIONS:.CONS.TRUCTIONSERVICES e
5.1 Construction Supervisor License(CSL) 90125 10-06-16
Jamie Moirn License Number Expiration Date
Name of CSL Holder U86 Gardiner St List CSL Type(see below)
No.and Street
Type _ .Y bescription:y
- -- -
Lynn, MAO 1905 U Unrestricted(Buildings u to 35,000 cu.R
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
508-351-2214 I 1 Insulation
Tele hone Email address D I Demolition
5.2 Registered Rome Improvement Contractor(EIC) 170810 12-23-17
Renewal by Andersen HIC Registration Number Expiration Date
BIC Company Name or HIC Registrant Name
30 Forbes Rd
No.and Street 508-351-2214 Email address
Northborough, MA 01532
Ci /Town,State,ZIP Telephone
_ SECTION 6:WORKERS'COMP_ENSA_TION'IN_SU_RAN_CE AFFIDAVIT(M.G.L:Z 152.§ 25C(6)) _ F
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.......... No...........0
SECTION 7a:OWNER AUTHORIZATION-TO BE COMPLETED WHEN,
t. '° OWNER'S AGENT OR CONTRACTOWAPPLIES FOR BUII:DING PERMIT
1,as Owner of the subject property,hereby authorize Jamie Morin
to act on my behalf,in all matters relative to work authorized by this building permit application.
SEE CONTRACT ��I
Print Owner's Name(Electronic Signature) Date
SECTION'7b:'OWNEW OR°AUTHORIZED AGENT DECLAVATI,QN-
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and ac to o the best of my knowledge and understanding. /� /
JAIME MORIN 8 _J 1 —/(�
Print Owner's or Authorized Agent's Name ctronic Signature) Date
NOTES:
1. 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 nnr have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor 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 half/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"
CnY OF SAIHNI, NIASSACHUSEM
BummG DEPAaTA ENTN T
' 130 WAMINGTON STREET,3"E3.00a
TEL(978)745-9595
FAX(978)740-9846
KINMERLEY DRWOLL
MAYOR THOMAS ST.PIF M
DTILWWR OF Pt:It K PROPFUT/8LIMMG CONOSISSIONat
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code,790 CMR section 111.5
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:
Renewal by Andersen
(name of hauler)
The debris will be disposed of in :
Renewal by Andersen
(name of facility)
30 Forbes Rd, Northborough, MA 01532
(address of facility)
sisnattua of permit applicant
date
dcbrinfr m
Ren,Mal Agreement Doeurnen# and Payor-ent Terns
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Bwycsb)'hereby jolndy aad uv=ally agaves w purdwe der prex3ttm ondlor sert+ires of atentwal by Antiemen U;C dlWa Renewal 6g
akma,Of llrsstme(° ttartatr'',in accotdaaot wide de acrim Budcobdiflatu dewAbcd Jn dds Agmtobtat i2oeutucut ma I aymew
Turns,Notice of Csns mium,B mmiwd C3r&r R'mTip%%wmmiyc Terms and t omixio s of'Sale, L;4-Safs Sxme,'C imy if LhUtgo
6teiklm and any mhev dmvom r srradead ro rids Domwcu,,die a ms of%40ck are all vgmd to by dLeparies and
mmd heminn Py reCer�lmlacgivdyt r}in; "^). B4uyvr(%)Yxoeay mars ern sign n comple on cm d Scats after C`.ontme w Peas
�plesrd A work mdlu this r r® ant:.
` omi job Aji mount: 539;1372 Fly akuft dds agnssrnent,you a l c dot t1n Bd4ras c Vuc� anek dLa Ainmwt
l=i7rdwW ffmi be uo&by I> 1 4k,b?9ik CI9.C`*cmdh 4"+,A or cash-
Due:
aesoxlved: $14,000 Due: 525,672 FAci med5earu_ F16mazedcbfflpktbwt:
Ammkda:PieanwA so $-10,weels 3-4da.Ns
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1113 $14,000 deposit dePa7
18 S 13,269 Ssar
113 513,289 full comptatlon
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YOU,THE I UYMIMAM' CEL 1M, 57'1 IS, CRIONATANY77WA1[yT,LATERTHA `14RI)k IG"T
OF M0812016 f RTBE'1'1-r RD BUSDIESS DALY AFTER THE DATE OF THIS TRANSAMON,
l U'ER. CHEZ?lYOUCE SOF Ct NGELUMON FORM FOR:A14
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Checkfall, EXTERIOR White,INTERIOR White,mare Sash PJI:
High Performance SrnartSun Glass, No pattern, Hatrdware:
while, Scene.RuUvoe Wth ExSerlor Color. Match, Full
Screen, Grille Sityllet.me Grilles, Misr:Aluminum Map,
AtumJnum WWVa
Master VRindowe Double-Hung, Equal. Flat Sill trisert,Traditional
Cheekrail, EXTERIOR White,INTERIOR White,his:sash Ail:
h "orrnance Smartwm Glass, No PatternHt%rdware:
V&te, Screen:TruScenetwitth Exterior CuCar Match. Full
Screen, Grille Stylet AkrGrille% MhK:Aiumirrren Wrap.
Aluminurn VNra
203 Master 1hF3 owrpouhle-Hung,'Equal. Flat.Sill lnsert,Traditional
Checkrol.l, EXTERIOR White INTERIOR White, Sash All;
HJglh Performance Smart5un ti lass, No Fatten, Handwarer
Whlre, scroom:Trus+ceriewith Exterlor Colne Mat h..,Full
Screen„ Grille Stylet No Grilles, Mist:Alumdtun WtaN
Mora inum%iwa
,04 Guest room Vfirrdaw: Double-Hung, Equal, Flat Sill insert,Traditional
CheC.klall, EXTERIOR White,INTERIOR Whitt,Gain 'Sash PJIe
High Performance S®rartSun glass,. No'Patlem,, Ha"arw
White, .Scream:TruSR,ent nvJth Exterlor Color match, Full
Scmenr Grille Styles MmC,r111es, Misr:Aluminum Wrap,
Aluminum WVra
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�Checkrall, WERIOR Whitt;,,INTERIOR whlteY Glow.Sash Ail-
Ngihi Perforrnanse Sm dSun Glass, No Patters, Hardware:
while, Screen:17uSceeie width Exterior Cour Match, Full
Screen, Grille Style: MolGdin, Mlsc:Aluminum Wrap,
Aluminum"a
CVfICe 1 hWo.ws Double-Ifung. Equal. Flat Sill insert,Traditional
chedrail, EXTERIOR Wh%e,INTERIOR White; GU=Sash Aik
High Performance Smad%n Glass, No Pattem, Harr4vnom
U%ite, Sxreem:TruSceriewM Exterior Calor Mach,Full
Screen, Grille Stylet NaGrrlles, MisiE PJumirium Map.
Alum Inum"a
2D7 1[2 b@th Vffmdaw:Double-Hung, Equal, Flat Sill lnsera,Traditional
C1he(kfall, EXTERIOR White,INTERIOR Whitt GIVW Sash All'
High Perforinanse SmartSun Glass, No Pattern, Hiudwarer
White, Screen.,TruUen vrlth Exterior Color Match, cull
Sween, Grille Styles MG Gnlles, Mise Alurmywm lrthaA
Aluminum Vera
'Full bath Vllfudaw: Double-flurxA Equa4 Flat Sill InserC Traditional
Cbeckrall., EXTERIOR LWhilt<,INTERFDR vehile,Glass'Sasli All:
High Rerfonnarice Snmardim Glass, No Patterrh,Tempered
Cilass„ Hardwarw White,Screelit Tru%entuullh'EAerior Color
Match, Full Screen„GdUe Sefie: No Grilles, Miss Aluminum
Wrap, Aluminum Wra
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Renewal Itemized Order Receipt
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209 !Kitchen W ndow: Double-Rung. Equal, Full-Frame,Traditional
Check rall, grickmoull IWaditlotal, EXTERIOR VVI ANTERIOR
White, Glass: Sash AN:High Performance SrrrarcSun Glass, No.
Fatter in, hardware,WMe, Scream: TmWrle with Exlerior
Cukor Match. Full S€reeFc Grille Style, No des. Mlsc: Mr 90
230 'Kilcchen Wfnidaw: Picture,.Full-Frmne. EXTERIOR White,INTERIOR
While, Maui sash:AN.HI PerlwmanM 50r wtim Glass, No
Pattern, Grille.Style:atn Gnlles, Miser Nein
2191' 'Kitchen Wfndow: Douhle4lrargT Equal, Flat Sill Insert,.Traditional
Checktell, EXTERf418 wlhlle,iNTERIGR white,GIErst:.'Sash All;
High Performance SmartSun Glass, No Pattern,Tmweted
Glaas, Hardwarv.. white,Screein; TEuScene with E:Ptervor Cobr
Match, Full Screen,Ga1.5e^S'e'yier No,Grilles, Mtzc Aluminum
%Wap, Aluminum Wtra
2112 mmofICe 24IIRndow: Double-Hung, Equal, Full-Frame,Traditional
Checkrail, EXTERIOR NYlrete, INTERIOR WfI Glass:Sash All:
High Perlortnance SmartWil�iless, No Pltlerd. HardltlPam
White, Scrsrem TiIth Exterior Cobor Addy,Full
Screen, Grille Style: No Gnlle-% Mist: Mf 99
213 Ipinninq Window: Double-Hung,Equal, Full-Frame, Traditional
�Checktsll, EXTERIOR White,INTERIOR'kWhtte,0Ifltmie.Sash AJI,
High Performance SmrartSun Glass, No Fatter, Haadware:
White, 5traenc Tru5tvnewith Exterior CoroF Malta, Full
Screen, GFill'e StlrEe:Nn Grilles, MISS: Mf 90
961 I46 gyrase 6? '18
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TtAnE -351-22o0 IFar 905-iM12 t#bpEostunOpm6mmoAaieWimp-CDM
3184 Dinning Vd@ndaw. Double-Hung.Equal, Full-Frame„Teaditiaaeal
0CCk1011, EXTERIOR V&Lte, INTERIOR White,QUM Sash All'
High Performance SmartSan Glass, No Pattem. Hardware:
White, Scraiaw Tru5cele mlth Exterior Color MaIdi, Full
Screen, Grille Style::Na Gilles, Miw Puff 90
21S ILf VWfrxdaw: Double-Hung, Equal, Full-Frame,Tiradrlional
Checkrail, EXTERIOR Ydhite,INTERIOR Whito,Gtas.sash All:
Mlgh Perfortnarltt 5mg(Mun Mass, No Pallerw% HowdWam
While, Screen.-14cenewith Exterlur CoW Match,Full
Screen, Grille Sttrlec No Grilles, Mdos: Mf 90
2116 U NIEErrdow: Double-Stung,Equal, Full-Frame,Traditional
Chech rall, EXTERIOR White,,INTERIOR Wphlte,6T :Sash All-
1-figh Performance SwmrtSsnn Class,. No Pattem. Haadwarer
White, krtrin.TruSCerienyitli Exterior Cobbv Matl4t,Full
Screen, Grille Style:Mofirilks, Mise: Mf 90
2117 ILd Wyklaw: Double-Hung, Equal, Full-Frame,FcaditiioTaal
ChKk fall, EXTERIOR 1ldhlte,INTERIOR!White,.Qlusus Sash All'
M jh Performante SmartSun Glass, No Pattem, Hardware:
White, Streirm,TrurSe oeaseth Exterior Colbr• Matdt. Full
Screen, Grille Style: UcpGrille% Mise:Mf 99
219 Lf VWSndaw: Picture.,FuWFrauw, EXTERIOR White,INTERIOR
White, Glass: Sash Ad:HRgh'Perlarrilante 5m*t5+m Glass, Ho
Pattern, Grille Stype,No Grilles, Mise: Mf 90
t4'18 ftme 1 F A'8
Renewal [Itemized Order Receipt
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219 IU hbrindow: Double-Hung. Equal. Full-Frame.Traftonal
104tCkrall, EXTERIOR white, INTERIOR WhI%0a1m .'Smh All,
High Performance Smart Sun Glass, No Patten; Haadwore:
YUNW, &coon.Trow,*with Exterior Color Mattih, Full
Screen, Grille S,tyiec NG Grilles. Rrllsc: Mf 130
3dt IHall!" VW dow: Double-Riurr% Equal, Full-Frame, Tradlifianal
+Cheekrail, EXTERIOR White,IWER"White.Glass:Sash Al 1;
9gh Performance Smad5un Glass, No Patti+m Tmvered
Gllas3, HRlydwarr whke,scman„ Trukene"th FAerior Color
Match, Full Screen_Grille 5We: No Grilles, IHis Mf 99
'Fiamlly room. YYlydow: Double-Hung,Equal, Slope Sill insert,Traditional
Chec*Hall, EXTERIOR White, INTERIOR Whhlttp GTasr.Sash All:
High'Performance SmartSun Glass, No Pattern, Hardware:
White, Ure". '11WS ne Wjh; Exterlor Color Match, FulI
Screen, Grille Style: We Grilles, Mist*Alumiaaum Meg
Aluminum Wra
30 Caitlyn 111i Double-Hung, Equal,Slope Sill Insert,Traditional
Chr krall, EXTERIOR White,INTERIOR Whitt, M.5ash All:
Hlgte Pen1brmante Sma un Glass, No Patterer, Haadware:
white, Screen.TrUSCene WAb Exterior Corr match, Full
Screen, Grille Styles.HG Grilles, itllse,Alumiew r Map,
Aivaninum Wra
GaM81115 :?me a t is
6WA=dersen
Itemized Order �teceiptAwRmv"hrAmdrmacf6=mwbvAr&vsmUc: 39 W51
HIC WC181'J1 9 N�.a01924
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V w,w W3E1-22001 W MI 99018F fiPbAErstontlpr�ali�A�E�enr_ery.com
3N Williams Ism Wkndow: Double-Flung, Equal, dope Sill Insert„Traditiorial
Che[l:rail, EXTERIOR White,INTERIOR Vyhl"l 4lltw.Sash All°
High Performance SruanS un Glass, No Panem, Flamderare;
9Mlhite, SScretrn.'.Tru,SclrrE Wth Exierlor Cohor Math, Full
SaeLn, Grille Style, Mam6nllr.� Misc-Aluminum 9iir'rap,
Aluminum"a
305 w1ham5 mm MITrWow. Douhle-Flung, Equal, Slope Sill Insen.Traditional
Checkribil, EXTERIOR White.,.INTERIOR whits;Gum Sash AIL-
FIO Performance Setarl'9un Glass, No Panem, Harciwwe:.
While. Screen..TruSaenewaM Exterior Ca[ar Match. Full
Sueen, Grille Style: NG(irllles, Milsc Alumbnum Map.
Aluminum%Wa
306 SKond masm VInrlow: Qouhle-Hung, Equal, Slope Sill insert,Traditional
Omit roll, EXTERIOR White, INTERIOR Whl%Q1110 a Salh All;
High Performance SatautSun Glass,No Pattem, Flaadwrare.
While, kroon, TruUenevrlth Exterior Color Match,bull
Suxeen, Grille Style: No Grilles, Misc.Aluminum W(ap,
Aluwninum'Ntra
VAl 25 R DORS:'o SEE-CI;PhLTr G Misc,0 TOTAL 53 2
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The Comnionlvealth of Massachusetts
Department ofbodustrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.nlass.gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(BesineWOrganization/Individunq: Renewal by Andersen
Address: 30 Forbes Road
City/State/Zip: Northboro, MA 01532 Phone#: 508-351-2200
A� /
re.,you an employer?Check the appropriate box:
I.OG i am a employer with�0 4• ❑ I am a general contractor and I Type of project(required):
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.El am a sole proprietor or partner- listed on the attached sheet. 7. Remodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers'
com insurance.t g• EJBuildingaddilion
[No workers'comp.insurance P•
required.) 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LEIPlumbing repairs or additions
myself.[No workers' comp, right of exemption per MOL 12❑ Roof repairs
Insurance required.] c. 152,§1(4),and we have no
employees. [No workers' 13.0 Other
comp, insurance required.]
•Any applicant that checis hos al mast also all old the section below shmving their workers'compensolion policy inrormation.
r Homeowners who submil this affidavit indicating they are doing all work and then hire outside contractors must submit a new naidavit indicating such
tcontractors no check[his box must attached an addilioaal sheet slmwing the trete of the subcontractors and state wheaicr m not those enlities have
employees. if the subcontractors have employees,amy must provide their workers'comp.policy number.
I ant on employer dint Is providing Ivorkers'compensallen hnarance for ntp employees. Be/otu Is the policy oad Jab site
lrl/brmation.
insurance Company Name: Old Republic Ins. Co.
Policy it or Self'Ins.Lic.#: MWC 30543700 Expiration Date: 10/1/16
.lob site Address: 39 WALTER STREET City/state/Zip: SALEM, MA 01970
Attach a copy or the workers' compensation Polley 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 ora
Fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form ore STOP WORK ORDER and a fine
of up to$250.00 it 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.
111,01 hereby c rlh�an er the pales and penalfles ofperlagy that die iafornlallon provided above Is trite and correct
S' lure: —�� l
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Ofjlelal rase onht Do Trot Ivrlter in ails area,to be completed by city or tolva ofj Blot.
City or Town: Perm it/License#
Issuing Authority(circle one):
1, Board of Health 2. Building Department 3.City/Town Clerk 4, Electrical inspector' 5. Plmnbing Inspector
6.Other
Contact Person: Phone#'
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