24 WINTER ST - BUILDING INSPECTION q f cic 35 5Li
e
'Che Commonwealth of Massachusetts
I Board of Building Regulations and Standards.,. f?ECEIV ,I) CITY OF
Massachusetts State Building Code, 780CMI�NSPECTIOPI�,L SERevise ur ft�f -
2011
Building Permit Application To Construct, Repair, Renovate �p sh
One-or Two-Family Dwelling 0C �z' S S
(� This Section For Oficial Use Only '
n
_
lv J Building Permit Number:• _. [DateAppllEdi '
^ -Building 011icisi(Print Name) Signature. - Date
U ) sEG rm I SITE INFORMATION",
( I.1 Property Address 1.2 Assessors Map St Parcel Numbers ?c
^ - i:.. �— � u4
�J L la Is this an acce ted street9 yes no Map Number Parcel Number
IJ 'Zoning Information: 1.4 Property Dimensions:
Zoning District r Proposed Use Loti\rca(sy R) Frontage(R)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard- -
ReyuimJ - Providal Required Provided. �Rcgoiled Provided
1.6 Nater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Informadom 1.8 Sewage Disposal System `
Public❑ Private O. Zone: _ Outside Flood Zone? Municipal 0 On site disposal system O
Chedt if "eso
SECT[ONip PROPER'FYOWNERSRIP!,
2.1 Owner'of co d. 'ZU _/ }/
0 VL
City,State,ZIP
pa - Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED NORK;(check all that apply)
tionO EXtsting Building O Owner-Occupied O 3tepairs(s) O Alteration(s) Al' Addition O O Accessory Bldg.C3 Number of Units Other O Specify:
on of Proposed Work':
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
i. Building S &000.oo 1. Building Permit Fee:S Indicate how fee is determined:
Standard Citylfown Application Fee
2. Electrical S J5&0,0& ❑Total Project Cost"(Item 6)x multiplier x
J. Plumbing S '300. ,me fla father Fees: S
4.iMcchanical (HVAC) S OAA- List:
5.Mechanical (Fire S Total All Fees:S
Su ression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ( Lj5 a °� ❑Paid in Full 11 Outstanding Balance Due:
av CDtNT
SECTION 5: CONSTRUCTION SERVICES ry
5.1 Construction Supervisor License(CSL) Oy�«N ZL_ ZS
7UbbtBS ✓u License Number Expiration Date
Name of CSL Holder List CSL'rype(see below)
S
1$ � el"'a't DU`e Type . Description .
Nu.and Street
U Unrestricted(Buildings u p to 35,000 cu. 11.
jo k^C-S- O(QtS R jE Restricted 1&2 FamilY Dwelling
•
Cityfrown,S ,ZIP M Masonry '
RC Roolma Covering
WS Window and Siding
A C SF Solid Fuel Burning Appliances
I �Y OSL- 3'To11 I Insulation
Tele hone Email:uldress I D I Demolition
5.2 Registered Home Improvement Contractor(HIC) /2TV--3 lh0-7-(6
7-" 40, din-� Ce =P—K- HIC Registration Number Expiration Date
II�Company Name HICR gists Name
S7�u
hlu,and Street Email address
OVA—
P.4
. &Z/4 hA-ff «4tz S'7& Psz ?sir
ti/Town! State ZIP Telephone
SECTION 6:WORKERS'.CONIPENSATION INSURANCE AFFIiDAVilt(M.4.11L c.Ib2.i 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 Istuance of the building permit.
Signed Affidavit Attached? Yes ..........❑ No...........)d e �Qke o
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED.WHEN,
OWNER'S AGENT OR CONTRACT ORA1PPLIE9FOIf BUILDING.PERMIT
1,as Owner of the subject property,hereby authorize
t9 actonmay behalf,in all
matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) - Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,l hereby attest under the pains and penalties of peq'ury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
ykWCf 3t 15
Print Owner's or Authorized Agent's Name(Electronic Silinature) Dale
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
notreureuistered in the Home Improvement Contractor(IIIc)Program),will LW have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Oiherimportbnl mfo7maTion onlhe HICI'rogram can a io`un"a
- ---- --
www.mass.eov.'oca Information on the Construction Supervisor License can be round at wtv+v.mass._ov;'dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.f.) (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
1. "Poral Project Square Footage"may be substituted rar"'rutal Project Cost"
t ,
The Commonwealth ofAfaysaehusetts
Deparonent ofladustridUceiidents
I Congress Sweet,Suite 100
Boston,MA 02174-2017
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/.Plumbers.
TO BE FH.ED 74M THE PlltNM7WG AUTHORITY.
Apolleant Information please
pyind+ b
Name(Bosiness/Oigm izaation/Indivi&W):� c�l+ACs• 9?eo i C_C,.+l'G[.Tb�f �O .4i/i C,
Address: SGw/ E✓2wye
City/State/Zip: J ✓ e2 S 1(S . Phone#: 47 S - S S2 3 So
Are you nn employer.Cheek the appro;*U box: of re ett cored
rys Type p 1 (�1 � )�
1.L.J I am a employer wBi_ loyees(fall and/mpat-time).' - 7. Q New conSGuchon
2.01am asok taopriefororpermerahip and bsvoeoired) ee wotkmg formeio 8; (¢f R,eIIlpdC]m.$
any eapaeity.[No waka,'�•inamaae requited] 9. lition'
,IL'J
3.01 am a homeow�dotog all worknwarg.lNo workwa camp.instaanx required]t Demo
4.E]Ism ahomEownerand will bebving contractors to conduct all workonmy,Woperty. IwrB lOOBuilding addition.
astne that all comnaors eitherhave warkess'compessation msmance m are sole 11.0 Electrical repairs or additions
perietorswith noemployeas• 12.0PlnmbiilgTepon' oradditio®'s
5.0 lam a general connector and lhave,hired the sub-eoIDnetme listed on thesaefied sheet: 13. Roofi airs
7b=sub-contractors have employees and be-woda's'eamp .
6.0 We are a corporation and its offices have exercised thekright of exemyti®perMGL e.
14.D Otbec
15Z§1(4),and w havem employee [No wedm s'toiio:i� .] .
`Any applicant flit chichi boa#1 most alio Sit the neuim below 00wmg their workan pohry m6®metioo. .
t Homeowms who submit this affidavi[indieaneg they we doing as Work and fled hve outside m�ttacs must aubooit a new affidavit iodiestmg such
tContractow that cbeck this box must stWJW an additional sheet showing the namnic ofthe avbsonLegora and state ivlirda or not those entities have
employees. Ifthe sub—tactors have employees,they,amort p ov ore 8= works n':ea" policy m ndber- .,....
I am as envoyer Awisproviding workers,Compawation mauranee for my ea,pioyees Below is thepolicy.andjab ski.
lnjormatlon. /
Insurance Company Name: t iM^j„ 'C t .e��C� V4 rGVG.w
Policy d or Self-ins.Lie.# Expiration Date:
Job Site Address: City)stateZip:
Attach a Copy of the workers'compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGT.c. 152,§25A is a t rmrmal violation punishable by a fine up to 51,500.00
and/or one-year imprisonment,as well as civil penalties in the from of a 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.
I do hereby certify under the pains
,-a�n_d pena/tNes ofperjary that the information provided above is one and Correct
- /amu �Lx l Dare V oceu,4-y 3 7�ot S
Phone#• ;W 752
[[6Other
cial use only. Do not write in this area,to be eonpided by ply or town o,0GelaL
or Town: Permit/Idcenae 0
ng Authority(circle one):
ard of Health 2.Building Department 3.Ctty/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
act Person: Phone S:
Information and Instructions i
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 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
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 consmonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the iosivance
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-contractor(s)nanre(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,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 confirmation of insurence 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 pemnit or license is being requested,not the Deparmrent 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 permit/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"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 proofthat a valid affidavit is on file for future permits or licenses. A new affidavit must be frilled 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.penrat 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. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
07Y OF SALEA MASSAC HL SEM
BEnDiNGDEPArimw
110 W4TREET,,3IDR
Fipp
PAX(978)740-9846
5-9595,
SIIv18ERLEYDRISODLL
MAYOR DIMAS STYE=
DmEcIcutoFFLaucrRomm/BuanndcsSfo, E=
Construction Debris Disposa/Affidavit
(required for-all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40,S 54; Building Permit g 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:
/Yr%lz �Jisasa ( .
(name o hauler)
The debris will be disposed of in:
lS VaYcj Rbtt- off CG- r,,4,Ay
(name of facility)
ZL( knu Mi n' t J — tSloycRs--6/ �,c.Ss
(address of facility)
'GLrace�a 1�Ci�-�
Signature of applicant
lPeC1eu,.lui 3rd Zot s
Date
CONOIT Commonwealth of Massachusetts :14L\ _
q Citv of Salem 19
m 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
Return card to Building Division for Certificate of Occupancy AV
Permit No. B-15-1337
PERMITFEE PAID: $91.00 TO BUILD
DATE ISSUED: 12/7/2015
This certifies that LUTTS PETER N
has permission to erect, alter, or demolish a building.,..,,_24,WINTER.STREET Map/Lot: 350083-0
as follows: Renovation REMODEL FIRST FLOOR BATHROOM
Contractor Name: Thomas Berube/T Be C be Contracting Co Inc -
DBA: t
PI
Contractor License No: 48684 i
g i
L f 12/7/2015
Building Official Date
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request.
All work authorized by this permit shall conform to the approved application and the approved constriction documents for which this permit has been granted.
I I 1 l
All construction,alterations and changes of use of any building and structures shall be in compliance with the local zoning by-laws and codes.
! 1 t
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public inspection for the entire duration of the
work until the completion of the same. I
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Offcials'are provided on this permit.
HIC#: 123223 'Persons contracting with unregistered contractors do not have access to the guaranty fund'(as set forth in MGL c.142A).
Restrictions:
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.