APP B-19-579 BASEMENT BEDROOM & BATH 1. lei
A The Commonwealth of Massachusetts
' tj Board of Building Regulations and Standards FOR
Massachusetts State Building Code, 780 CMR MUNICIPALITY
USE
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
t ,\ This Section For Official Use Only
'`(.1 Building Permit Number: Date Applied:
1
Staiij r J.. 4-6-/1
Building Official(Print Name) Si gnat Date
SECTION 1:SITE INFORMATION
1.1 Property Adddreps: I . 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
3 Required Provided Required Provided Required Provided
2/- _
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
W, Public 0 Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qxv r'of'k if1 r C/74-4 /
fA't `//(,6 S, /�/'
Name(Print) �,� City,State,ZIP /
No.kSCrJ
orbet Telephone / Email Address i< >
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction 0 Existing Building 0 Owner-Occupied 0 Repairs(s) 0 Alteration(s) 117 Addition
D
Demolition 0 Accessory Bldg. 0 Number of Units Other 0 Specify c $' 1,,A,1-t.4 ac•t14✓ e,u-i,3edio c.
Brief Descri Lion of Proposed Work': .,f c .-. r u(U 0 I 6,.K Z4 gam/ v'cla' )
�, b_ .D�i- S , __( I' CYz
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
(Labor and Materials
1.Building $ j v �-�/ " 1. Building Permit Fee:$ _ Indicate how fee is determined:
/ w ❑Standard City/Town Application Fee
2.Electrical $ c5 G
v,—ri
Total Project Cost3(Item 6)x multiplier x
3.Plumbing $ 5p� . 2. Other Fees: $ e ! l, 1/e
4.Mechanical (HVAC) $ List: �TJ!
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: Of yaid in Full 0 Outstanding Balance Due:
�'v
ji_)/... . .7,0 0 r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
/a.c:2oo d2p_.217
License Number Expiration Date
Name CSL Holder J Q
J(nd 1, / /6e's
List CSL Type(see below) (/(
No.and S t / T,� Description
i #(t- 6/ Q Unrestricted(Buildings up to 35,000 cu.ft.)Q" Restricted 1&2 Family Dwelling
City/f�eGn,State,ZIP M Masonry
RC Roofing Covering
/»4. J e � , WS Window and Siding
� SF Solid Fuel Burning Appliances
s!
'� tit Qer o41i I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
C ,l �e or HIC s J� ����7 IC Registration Number Expiration Date
HI Ca i P 1/ 74
No.and Street l Q. Email address
City/Todfn,State,ZIP 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 .., No...........O
SECTION 7a:OWNE AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
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 accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic 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 not 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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"
r
The Commonwealth of Massachusetts
_Wr*`..4MIN f Department of Industrial Accidents
_' = 1 Congress Street,Suite 100
..4,o'.v_� Boston,MA 02114-2017
www.mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /� Please Print Legibly
Name (Business/Organization/Individual):/ Cell///c /J`/l� ''�' .tip 7�Q^✓z"wi-i €✓t
Address: /9 C) `6'Pr / ,,--
City/State/Zip: /I/// /71 o/9v9-Phone#: ??/ g/-5—1=)-2 �y
Are you an employer?Check the appropriate box: Type of project(required):
I. 1 am a employer with employees(full and/or part-time).* 7. ❑New construction
2.M'I am a sole proprietor or partnership and have no employees working for me in 8. p emodeling
any capacity.[No workers'comp.insurance required.]
3.0 I am a homeowner doing all work myself.[No workers'comp.insurance required.]'
9. E Demolition
10 Q Building addition
4.11.1 I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.0 I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.E Roof repairs
These sub-contractors have employees and have workers'comp.insurance.:
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14. Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.11#: Expiration Date:
Job Site Address: `L`9 0 c'Cho\i'\.d- City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby ce ' unde the p i s and penalties of perjury that the information provided above is true and correct
Signature: '0r--, �,f..,---4
� Date: L ' '—
Phone#: 7 /�' /_.,, ---6 7 Cj
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
The Commonwealth of Massachusetts
—— Department of Industrial Accidents
1/44 j
=`�/ Office of Investigations
' 600 Washington Street
Boston, MA 02111
'•mot www mass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
L
Name (Business/Organization/Individual): Civ G 7 I c---- J)1" 441 ,/cf✓e A e A "
Address: /! , /�e f/- 5
City/state/Zip: —�% �1 fc 1 Phone #: , - f_�__
Are you an employer?Check the appropriate box: Type of project(required):
l.❑ I am a employer with 4. 0 I am a general contractor and I
employees(full and/or part-time).* have hired the sub-contractors 6. 0 New construction
2.(E3 I am a sole proprietor or partner- listed on the attached sheet. 7;.„0 Remodeling
ship and have no employees These sub-contractors have 8. 0 Demolition
working for me in any capacity. employees and have workers'
[No workers' comp.insurance comp. insance.$ 9 Building addition
ur
required.] 5. 0 We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 11.0 Plumbing repairs or additions
myself. [No workers' comp. right of exemption per MGL
12.0 Roof repairs
insurance required.]t c. 152, §1(4), and we have no ,� //
employees. [No workers' 13AB'Other 47-"e fa 7;e7
comp. insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins. Lic. #: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy 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 of a
fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a 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.
I do hereby ce fy under the pains and nalties erjuty that the information provided above is true and correct
Signature: ��� --- Date: ,,,94.....
z�/`
Phone#: 7 3') 9/ —d•
` .7
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF SALEM, MASSAGI SETT
01 BIDING DEPARIMENr
r 1 120 WASHING1CINMEET,392L001t
1 D.L.(978)745-9595
K1MBERLEYDRISCOLL FAX(978)740-9846
MAYOR TEAS ST.PIERRE
DIREcroR OF PUBUCPROPERTY/BIEDMIG CCIAMISSIONE
Construction Debris Disposal Affidavit
(required for all demolition & 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, S54;Building Permit II is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
waste deposit facility as defined by MGL c 111,S150A.
The debris will be transported by:
`1--) 5/1 e
(name of hauler)
The debris will be disposed of in:
r1-1/Y U4 <7 2
(name of facility)
(addresss'/ //// 1)q_tit/
/-\5
of facility)
y)
Signature of applicant
6- ) 9
(today's date)
Commonwealth of Massachusetts
'.� Division of Professional Licensure
Board of Building Regulations and Standards
Constructi'or1 Supervisor
CS-102004 Aires: 02/28/2021
ii
DAVID P SHEEHAN ••'
19 GILBERT ST-REET , .
LYNN MA 01902;.
()1(t.-.T.1
Commissioner l'
ropoaI Page# of pages
PROPOSAL SUBMITTED TO: JOB NAME JOB#
ADDRESS JOB LOCATION
DATE DATE OF PLANS
PHONE# FAX# ARCHITECT
♦♦
).e hereby submit specifications and estimates for: _
•
•
•
/%%e propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of:
$ Dollars
with payments to be made as follows:
Any alteration or deviation from above specifications involving extra costs Respectfully
will be executed only upon written order,and will become an extra charge submitted
over and above the estimate. All agreements contingent upon strikes,
\accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days.
acceptance of VIropo5a{
The above prices,specifications and conditions are satisfactory and are
hereby accepted. You are authorized to do the work as specified.
Payments will be made as outlined above. Signature
Date of Acceptance Signature
A-NC3819/T-3850 09-11