1 WARREN COURT - BUILDING INSPECTION CFO
a�' Zg c 3 W
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards P g`EMME0
fol
(� EWilding
Massachusetts State Building Code, 780 CMR P0V V ICES
Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling 11: 109
1 This Section FocOfficial Use Onf
Building Permit Nurabej.'r Date pplicd L ^/
-Building Olficiei(Print Name). Signature•: '_ Date
{�f SEcrioN 1:SITEINFORb1AT10N
�j
I. Property ddress: �+ 1.2 Assessors Map S Parcel Numbers
I XA �A^Pst A
l L la Is this an acre ted streetl yes no Rap Nwnber Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District ' Proposed Use Lot Area(sq It) Frontage fit)
Building Setbacks(R) .
Front Yard Side Y" - - Rear Yard: ..
Required Provided Required Brovided. . . Required Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Public 0 Private O. Zone: _ Outside Flood Zone? Municipal O On site disposal system- O
Chedrif esO -
SECTION 2. PROP61RTyp%VNERSIlir"
2.1 Own rt of Rec d: ,,^
Ma S
City,State,ZIP ( .. .. .
N yal4 Telephone Email Address
SECTION 3.:DESCRIPTION OR PROPOSED'WORK;(check all that apply)
New Construction 0 Existing Building O Owner-Occupied O Repairs(s) O 1 Alterations) O Addition 0
Demolition O Accessory Bldg.O . Number of Units_ Other 0 Specify:
Brief Description of Ped Wyork=:
�V
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: - Official Use Only
Labor and Materials)
I, Building S 1. Building Permit Fee:S Indicate how fee is determined:
0 Standard City/Pawn Application Fee .
2. Electrical S 0 Total Project Cost'(item 6)x multiplier x
3. Plumbing S 2?Qther Fees: S
d.blcchanical (FIVAC) S List:
5.Mechanical (Fire Total All Fees:S
Suppression)
IN Check No. Check Amount: Crash Amount:
G.Total Project Cost: .5 „V 0 Paid in Full 13 Outslnnding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
-.1 'unstruction Supe isor License(CSL) 3 ZS 7,V1 (o J
J d2 v u 1 v` License Number Expi ation te-
ame of CSL Hold List CSL'rype(see below)_�
/t- 0 0O L �ogo(p r/ TYpr. . _ : - Description ,
.
U Unrestricted Buildin u g to 35,000 cu. It.
a� R Restricted I&2Famil Dwellin
ityrrowr Stute,ZIP M Masonry
RC Roolin Covering
WS Window and Siding
ff,�,, ' n 1 SF Solid Fuel Burning Appliances
^'23,S 3vsk 0/6Vr�c.(j��J alh R.IL Lri I Insulation
Telephone —V Email address D .. Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.mid Street Email address
Ci /Town State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.p4 c.152.§2$C(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 Wuance of the building permit.
Signed Affidavit Attached? Yes ..........13 No........... O
SECTION lap OWNER AUTHORIZATION TO BE COMPLETED.WHEN,.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT'
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Sigmture) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
Bye ring my name below,I hereby attest under the pains and penalties of perjury that all of the information
con ed in this application' true and accurate to the best of my knowledge and understanding.
. lL-I-- 7it>
it(1wner's or Authori gent's Name(Electronic Signmure) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or anowner who hires an unregistered contractor
(not registered in the Home Improvement Cmttractar(HIC) Program);will nu have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Otherimportant information onlhe H1CVrogram ca 0 ro0da
www mass.eov'oca Information on the Construction Supervisor License can be found at wtvw•.mass..ov/Jns
2. When substantial work is planned,provide the information below:
'notal floor area(sq. R.) N ,(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
]. -rotas Project Square Footage"may be aubstiluted for"Total Project Cost"
07Y OF SALEM, MASSACHUSE M
BEnDPx DEPAjmew
120TA9wgG7cNS7RESr,3 ORooR
AL(978)7959595
R'IMRRRi FyDjuSppj,1,
FAX(978)7449846
MAYOR SAS ST.PMW
DntEcrcR cFPuRucPAoFm1j;uErDmcam� S4OmR
Construction Debris Disposal Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Sedion 111.5 Debris,
and the provisions of MGL c40,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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(nam of hauler)
The debris will be disposed of in:
do 0
(name of facility)
(address of facility)
(,ems
Signature of a plicant
Date
L
The Commonwealth ofHassaehusetts
Department oflndustrialAccidents
I CongressStree4 Suite 100
Boston,AM 02114-2017
ww►v mtz=gov/dia
WWorkers'Compeussition Insurance Affidavit:Builders/Contradors/Elechicians/P)umbers.
TO BE FH.SD WITH THE PE RUTTING ADTHORM
Applies t s . Pleon Print Legibly
Name(Bus;DensKftaniiation71ndividuO): Bet o p in ( k. Gad± . ' .
Address: r I� 6Ai
City/state/Zip: 0j0 one#:
Are yon yet?Chrek tae approprpate baa: - of project ZYPa P 1 (raluired):
. am a employe;wffiemployees(full and/orpam-tome).' - 7. Q New 69astruction
2.Q l am a"pmpridw"parmenlupandlmve w empbyeea worl®g forme m 8. odeling
fly capacity.[No w®kas'eomy.iodmaae required] 9. ❑Demolition
3.p!am a h unwivoa doing all work myself.[No wookaa'comp.iavmmcora9uked.]t
4.E]Isma bordowcoil
ner and ]be hiring contractors to conduct all work onmy property. twill 10 Bnr7ding addition_
m
eouae that all convacton citta hart workers'compensdion insaraoca mare sole 11.Q Electrical repairs or additions
proteietots wickmmployaes. 12.Q Plum - of additions
Plumbing>�tra
5.❑i®ageaaal coffi�oram Iheve hvW Poe euD-eoriwdavi listed on tie attached sheet: 13. Roof avti.�
brae subcontractor have employees and brave work'comp.tonand S
6.0 We are a cmpoiatim sod its offices have exercised fright of ezemplionperMGL c
14.Q Other
152,§1(4),and we harem employees.[No workers'comF'IDsmaoca regraed) .
-Any applicant met cheeks lies Bl must oleo fid om the secaonlasbw ehowmg thea worlisn pobcy haTaimation. ,..
t Homeowma who submit oris affi"t iodiatmg they are doing all walk and thea hhe outside contactors now aubmit a mw affidavit indicating Such.
lConvacton that check this aua must attached an additional shed showing fiz raweof the sub-controc ns and state Whedw or not tboae end"have
employees /fthe sub-axondms have employegs,they MWffo!i their-workas'.eomp.policy m®b?
lam an employer Jhatiaproviding nrrhers'compenaarion inswuncefor my eniplgyees. Below a thepo/iey andfob site
infortnarion.
Insurance Company Name:
Policy#or Self-ins. 1 Lijc.#: A L Expiration Date: 7^I
Job Site Address: IN r o'-Vl S _ CitydState/Zip' � m [s
Attach a copy of the workerscompensation policy declaration page(showing the policy number and expWatiom date).
Failure to segue coverage as required under VGL c. 152,§25A is a ta6nroal violation punishable by fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the fear da STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ido h ee under the pains and enahies ofperjury that the anjarmahon provided above is true and tyarerL
Pbone M
O,�Jidd ase only. Do not write in this area,to he completed by city or town offixio t
City or Town: PernxW ceme#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Otber
Contact Person: Phone#:
r,
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 writtep."
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 appurtenent 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 authcsity."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractors)narce(s),address(es)and phone numbers)along with their certificates)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partnere,are not required to carry workers'compensation insurance. If an LLC or LLP dors 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-insuredcompanies 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 pemrit/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)and under"lob 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 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 dqg license or permit to bum 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, Suite 100
Boston,MA 02114-2017,
Tel. #617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
�Ati'er COvr� �,�e�v�`l
r
r 1
�w� Cj�> �12�f2
� 3 ,�
�� u
� � �.�- � � s� �� ��
��
+ Unofficial Property Record Card Page 1 of 1
Unofficial Property Record Card - Salem, MA
General Property Data
Parcel ID 2"175-802 Account Number
Prior Parcel ID --
Property Owner DUFFY MICHAEL J Property Location 1 WARREN STREET COURT
Property Use Condo
Mailing Address 1 WARREN ST CT U2 Most Recent Sale Date 10/28/2005
Legal Reference 25012-404
City SALEM Grantor SARGENT WILLIAM B,
Mailing State MA Zip 01970 Sale Price 345,000
ParcelZoning Land Area 0.000 acres
Current Property Assessment
Card 1 Value Building 278 800 Xtra Features 0 Land Value 0 Total Value 278,800
Value Value
Building Description
Building Style CONDO Foundation Type Brick/Stone Flooring Type Hardwood
#of Living Units 1 Frame Type Wood Basement Floor Concrete
Year Built 1900 Roof Structure Gable Heating Type Forced H/W
Building Grade Good(-) Roof Cover Asphalt Shgl Heating Fuel Oil
Building Condition Good Siding Clapboard Air Conditioning 0%
Finished Area(SF)1569.7 Interior Walls Plaster #of Bsmt Garages 0
Number Rooms 7 #of Bedrooms 4 #of Full Baths 1
#of 3/4 Baths 0 #of 1/2 Baths 1 #of Other Fixtures 0
Legal Description
Narrative Description of Property
This property contains 0.000 acres of land mainly classified as Condo with a(n)CONDO style building,built about 1900,having
Clapboard exterior and Asphalt Shgl roof cover,with 1 unit(s),7 room(s),4 bedroom(s),1 bath(s),1 half bath(s).
Property Images
Disclaimer:This information is believed to be correct but is subject to change and is not warranteed.
http://salem.patriotproperties.com/RecordCard.asp 12/3/2015