7 WILLIAMS ST - BUILDING INSPECTION 4wre: The Commonwealth of Massachusetts Townof
Board of Building Regulations and StandardsMassachusens State Building Code. 780 CMR, 7'"edition
ButWing Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish aOne- or Tiro-Faindy Dwelling
This S ction For OtTicial Use Onlg Permit Number: Date Applied:
Buddin Commission for of Buildings Date
SECTION 1:SITE INFORMATION
1Y roQerty�1�ress: 0 4— 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street'.r yes_ noMa_ P Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(R)
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.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system 0
Public❑ Private❑ Check it es0 P po y
/ SECTION 2: PROPERTY OWNERSHIP' r�
2.1 Owne�nf _' �' ;-
Name(Print) Address for Service:
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Aileration(s) 0 Addition 0
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify:
Brief D�prion of Proposed Work': t
SECTION 4: ESTIMATED CONSTRUCTION COSTS
=rnrmaantdEstimated Costs: Official Use Only
Labor and Materials
f 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
al E 0 Total Project Cost(Item 6)x multiplier x
g S 2. Other Fees: f
ical (HVAC) S List:
"i (Fire S Total All Fees: S
n
eck No. _Check Amount: Cash Amount:
C
6. Total Project Cost: S �,j/,ph Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) JR
1q (/ ""IfNumber d
N:)mc of CSL- Hplder
Type(see below)
Address Description
Unrestricted u to 15,000 Cu. Ft.)
Restricted 1&2 FamilDweltinSignature Masonry Only
RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Companegisl tnName � Registration Number
y a or IC R
Address . Q �•�'
r*7 9--777—S-C.3.Z Expiration Date
Signature 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 Issuance of the building permit.
Signed Affidavit Attached? Yes.......... 0 No........... 0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR C NTRACTOR APPLIES FOR BUILDING PERMIT
1, - G , 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.
4,e ` J44 �// � ?.
Signature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
1, 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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury
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 W 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 IO.R6 and 110.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.) 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
J. "Total Project Square Footage"may he substituted for 'Total Project Cost"
CITY OF Sa13.3.AN1, A-kSSACHUSETrS
jiva SIG DEPaAC�IE�T
p
120 WASHINGTON STREET, 3'4 FLOOR
a� TEL (978) 745-9595
Fast(978) 740-9&16
KIJSBERI.EY DR3SCOLL
THt3Mas ST.PtERRB
AAYOR DRtECrOR OF PLBLIC pROPERTY/St:IIDLNG CONMUSSIONER
Workers' Compensation Insurance Affldavit: Builders/Contractors/Electricians/Plumbers
.Applicant information Please Print Legibly
Name (Busmu-.a.Organizatiorvindividual):
Address: 5-3
City/Staterzip: A — ' _ oif-2-J Phoneki: 47 Y— 777—
Are you as employer?Cheek the appropriate box: Type of project(required):
1.C] I am a employer with 4. 0 1 am a general contractor and 1 ft_ 0 New construction
nployees(foci
and/or part-time).' have hired the sub-contractors
2. 1 am a sole propriettu ur partner-
listed on the attached sheet: ❑ Remodeling
ship and have no employees - These sub-contractors have V. 0 Demolition
working for me in any capacity, workers'comp.insurance. 9. 0 Building addition
[No workers'comp. insurance We ate a corporation and its 10.0 Electrical repairs or additions
required.] officers have exercised their
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs"additions
myself. (No workers'comp. c. 152,$1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.[No workers' 13.0 Other
comp.insurance required.]
-rtny applicant ihAt cheetw bane at mtwt alvu fill uddt tha aeetim below showing their workers'tontpenWiott policy information.
I I l.wneuwwxa who udi ni this affidavit indicating they era doing all work and then hire onside contractors must submit a new affidavit indicating such.
:C,muauwn that chuck thia hon most 311=114dan aadiounal shed showing the norm or the subrnntri cuirs and thalr wwktre'comp.policy infomwtiw.
1 um an employer that is providing workers'compensation insurance for my employees. Below Is rhe policy and Job slle
informalion.
insurance Company Name: "/' /r
policy#or Self-ins. Lic.#: T T L/ 4 /S"F 7 e 4(01 Expiration Date: 3 All
Job Site Address: City/StawZip:
Attach a copy of the workers'compensatloa policy declaration page(showing the policy number and explrsdoe data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a firm
of up to 5230.00 a day against the violator. le advised that copy of this statement may be forwarded to the Office of
lnresugatiuna of the DDA for insurance coverage verification.
1 do hereby cerrify oder r e pains aitd allies o perjury that the informarlon provided ubove is true and correct
Cionalllm
Phone#
t)flicial use only, Do riot write in this arra, to be cunip/eted by city or town oJJiciat
City orTuwn:
Issuing Authority(circle une)t
I. [loard of Ilealth 2. Building;Department 3. City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other _ ---.
Contact Person:,_., - —. __—. Phone#:
Lic./Reg./Ins.
Proposal
SEARLES CARPENTRY
Leroy Searles
53 Centre.St.
Danvers, MA 01923-1419
978 777-8032
Proposal Submitted Date: 5/27/09
Name: Esther Thyssen Address: 7 Williams St. Salem Ma 01970
Phone: 518-424-7458
Job Name: Job Location: Phone:
Specifications & Estimates:
I) Build new deck with two sets of steps.
2) Build frame using 2"x8"pressers treaded lumber 2"x8"are 16"on center.
3) Dig approximately 4 holes 12"x4' deeps and fill with cement.
4) Install new 2"x8"against house and fasten with ''/:"by 5" lag bolts.
5) Build two steps half way around.
6) Install new 5/4 x 6 pressure treaded lumber on deck and steps. 9-3 d 'e -
7) Install new post and handrail using pressure treaded lumber.
8) Install new lattice around bottom of deck using pressure treaded lumber ( Y f S
9) Removal of all debris.
TOTAL MATERIAL & LABOR
DUMP$2,830.00
We PROPOSE hereby to furnish material,labor—complete in accordance with above specifications,for the sum of
Two thousand eight hundred thirty dollars,IS 2,830.001 payment to be made as follows;one half to start,and''%at
half-way point,and Y.(balance)upon completion. (Any alterations involvin atra costs must be in writing,including
extra charges.)
Leroy Sedirlei or Agent
ACCEPTANCE OF PROPOSAL;The above prices,specifications and conditions are satisfactory and are hereby
acre ,ed: Vou a e puthorized to do the work as specified. Payment will be made as outlined above.
2
Signa# a 61 Signature
CITY OF SALEM
s PUBLIC PROPRERTY
� .
DEPARTMENT
12: N I f I I.V I V, \I
III 9'8 'l;.);,l; 11 \\. 'i'8 '4:',i4,�
Construction Debris Disposal Affidavit
(fe\luired l'or all demolition and renovation work)
In accordance \\ith the sixth edition of the State Building Code, 750 CNIR section 1 1 L5
Dcbi is, and the provisions of MGL c 40, S 54;
Building Permit K is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
✓� � �
A-- !
1 name of hatter)
I he debris will be disposed of in :
(name of Iaeility)
IadJre.. of facllitvl
�ualme .d prnuu .gtpllcmt
v
lalr