B-20-810 - 0007 1/2 ADAMS STREET - Building Permit °:
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The Commonwealth of Massachusetts .;
Board of Building Regulations and Standards Ti
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Massachusetts State Building Code, 780 CMR M
Building Permit Application To Construct,Repair, Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
Zis Section For Official Use Only
\ NIBuilding
ermit Number: Date Applied:
. CA �A
Official(Print Name) Signature Da e LO
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
AcQr,,m S ,
C"VN 1.1a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq f5 Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
4
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Oi Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal 010n site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
.
Name(Print) X, City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work —
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SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $+�01
'_`�"- 1. Building Permit Fee: $ Indicate how fee is determined:
'0
2.Electrical $ too ❑Standard City/Town Application Fee (�, /
❑Total Project Costa(Item 6)x multiplier. -[ x G
3.Plumbing $
0 Q 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire -
Su ression $ Total All Fees:$
6.Total Project Cost: $ (J' Check No. Check Amount: Cash Amount:/
❑Paid in Full ❑Outstanding Balance Due:
4o Z,0
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
04 S License umberO 5 �j1 Expiration Date
Name of CSL Holder 11
List CSL Type(see below)
AV 6(f Cr . CZLPO
No.and St/reC / Type Description
Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZI M Masonry
RC Roofing Covering
WS Window and Siding
_ SF Solid Fuel Burning Appliances
q� rj •q�j'�-(p S(� . SN ��c$� I Insulation
Telephone Email address n9t14 . D Demolition
5.2 Registered Home Improvement Contractor(HIC)
l SYS5 T'
S 4Z' w L C-0 N.S'�, HIC Registration Number xpir tion Date
HIC Com��any Name or HIC Registrant Name
17 i'S h4kecr'Y (Guje - .cj` MSI-0rJ �`7���o�vrCa •i✓C�
No.and Street' Email address
S�:Irsbor t
City/Town,State, IP 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...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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:
I. 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.mg L og v/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"
� J
r CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
i
98 WASHINGTON STREET,2ND FLOOR
TEL: 978-745-9595
KIMBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUILDING CONMSSIONER
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# 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:
(name of hauler)
The debris will be disposed of in:
(name of facility)
b b f-S Yt9 w ej o l/V1 C S S
7�"(address o facility)
Signature of applicant
A Z, c rj
(today's date)
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Commonwealth of Massachusetts
Division of Professional Licensure
Board of Building Regulations and Standards
Constru�t�>�i 4,orvisor
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CS-095500 �' a pire�s:04/2512022
SCOTT STOW
9 BAYBERR ANEW `
SALISBURY WA o'.196
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(3t5�t:10wry
Commissioner
4"VWje41*
Office of Consumer Affairs and Busines71Re9ulation
1000.W'ashingfon Street Suite0
Boston, Massachusetts 02118
Home Improvement Contractor Registration
Type: Individual
r Registration: 154857
Expiratinn; 10/0812021
SCOTT STO E --+�
D/BIA SCOTT STONE CONSTRUCT10"
9 BAYBERRY IN :" ,
SALISBURY,MA 01952
Update Address and Return Gard
117
'�, ��e tConxono�zmrxzt./�i,t����a�:aefii�sn./ld .
Office of Consumer Affairs&Business Regulau*a
HOME IMPROVEMENT CONTRACTCMI
TYPE:JndividuV
Reaistrafian L Exciration
154857 5 3 10ioczl` „1
SCOTT
-D%BIA SCOTT STONE CONSTRUC s`�!
SCOTT STOiu EaC,S"z 4
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9 BAYBERRY IN
SALISBURY,MA 01 �x
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Scott Stone Construction. DATE: Aua42020
Quality At it's Finest INVOICE#
t:=r. •:�.��n¢ksto�e�o!�s¢ruc��on.�om
..4: Bathroom remodle
Bayberry Lane
Salisbury Ma,01952 BILL TO: Tom Balabon
Phone:978-985-6517 7 whipple way
Fax:978-462-3525 Kengsington N;ulr
978 609 0227
D ESCRIPTIONS a _ "
L
x , r �•� ,s + �. �. ,� �' .��".Q_:° -�>� ""mot"� a+�.,r �.,a��3s=� `�`�." 5�'e ,:
�New_subfloor 314 Plywood
11./2"too floor = 1 1/4 wood I
11/2"cement board Tile
`Insulate exterior walls R 21
s
1-7rame for recess med cabinet
ishim for shower installation 4
# I.
11/2"sheetrock on ceiling
11/2"sheetrock walls.
j. coats joint compound
r
cZ sand 45
C
jrapertape ( i
kInstall the floor(customer supply tile)
}contractor to supply thinset spacers and labor ) E
Grof ut the(customer to choose grout color)
1contractor will purchase grout and install grout
i—
ivsta l new vanity. (Plumber tohook up water lines and install faucet and plumbing)
rumber,to install toilet(existing )
.-Jtsfall existing:trim on window and door(if new trim re evaluate material cost..
, staif existing,bathroom door I g
�=;€'tsiail`new baseboard in bathroom i
- t
leiectrican to install new bathroom vent ( i
1 l I
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Materials and labor I 4,375.001
To start $1458.00
s4idwav $ 1458.00 i I
urt compietion $ 1459.00 I ��
} h"
s 0.00%1
Make all checks payable to Scott Stone.If you have any 'AuL s TA
questions concerning this Contract,contact Scott Stone,
978-985-6517, smstone77@comcast.net
TOTAL
qz vo.00
Any permit fees will be extra
All material is guaranteed to be as specified by manufacturer, and the above work is done by code at e
.contractors discretion.
Full Payment is due upon completion. If payment is not made within 3 days of completion late fees wi I be adde
Any alteration or deviation from the above specifications involving
x.ra cost will become extra charge over and above the estimate. Dump/Dumpster fees are an additional cost
Roofing Cost are based on a 1 layer strip, If strip is required. Unless stated otherwise in contract. ®4
All agreements contingent upon delays beyond our control. Purchaser agrees to pay all cost of collection,
including attorney's fees. This proposal may be withdrawn-by us if not accepted accepted within 10 days.Changes
of material cost may change, if cost have gone up and proposal was not excepted in a timely manner.
Owner agrees that if they breech the contract before work is started, contractor may demand 25%of the contract
price as its stipulate amp es for breacn.
signature: el�WZA� Date: 1�4- Xd0
The Commonwealth o M J assachusetts ,
Department.of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
UV www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information C Please Print Leeibly
J
Name (Business/Organization/Individual): eok� C,->tOPC
Address: I �14
City/State/Zip: I rS bui- Phone
Are you an employer?Check the appropriate box:
Type of project(required):
1.O I am a employer with employees(full and/or part-time).• 7. New COnstCUChOri
2.�am a sole proprietor or partnership and have no employees working for me in $• [lemodeling
any capacity.[No workers'comp,insurance required.]
3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
4.O I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10[D Building addition
ensure that all contractors either have workers'compensation insurance or are sole I LE]Electrical repairs or additions
proprietors with no employees.
12. Plumbing repairs or additions
5.O I on a general contactor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insurance.$ 13.Q Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.0 Other _ (?444RVOhX
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#I 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 acne of the sub-contractors and at=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.#: p �0 Expiration Date:
Job Site Address:-7 l)—lAD)i4wv; { City/StatetZip Sq It Yd( S,S .
Attach ti 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,Q25A 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.
do hereby cerajy under the pains and penalties of perjury that the information provided above is true and correct
Si nature:
Date: o
Phone#: 1M,
Official use only. Do not write in this area,to be completed by city or town offmiaL
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 M