B-20-526 - 0017 BERTUCCIO AVENUE - Building Permit The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code,780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This'Section For,Officiat se Only
Building Permit Number. Date A plied .,
V ' V
Buildmg Official(Prin gnature ate
C,\
L�/1J SECTION 1 SITE:INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
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 ft) Frontage(ft)
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,§54) 1.7 Flood Zone Information: • 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
_-
"SECTION 2: PROPERTY UWNERSIHP'
2.1 O ner'of Record:
Name(Print) . City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK..(checkall=that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ ' Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Un,its Other Specify:
Brief Description of Proposed Wgrk2: -on e4
-.SECTION:: ESTIMATED CONSTRUCTION'COSTS`'
Estimated Costs:
Official Use Dn1y
Labor and Materials `
1.Building $ �r --� 1 Building Permit Fee:$ � : � Indicate'h- fee is determined:
2.Electrical g ❑Standard iCity/Town Application.Fee;
❑Total"Project„Cost3`(Item 6)x mulfpher, X
3. Plumbing $ >2 Other Fees: $
4.Mechanical (HVAC) 'List:. _ "7
5.Mechanical (Fire $
Suppression) Total All Fees: $
CheckNo. Check.Amount Cash Amount:
6.Total Project Cost: $ 3, 5 rj`1. ❑Paid in Full 0 Outstanding Balance Due.
Y1
SECTION 5.;CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) O. 2:1M L)_ a O
�.1 P C 5 :Q License Number Expiration Date
Name of CSL Holder
�1 List CSL Type(see below)
0
No.an"a Street Type Description
C � U Unrestricted Buildings up to 35,000 cu.ft.
a J V i lJ` R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone �� Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) M 51�Lip �WAyn '1 1
o ` n 1 • O�n �1 a HIC Registration Number sExpiration Date
HIC Company Name or IA Registrant e 1
No.a}}��d-_S�treet Email address
Ot�J'V
City/Town,StAte,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.Y152.§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.
\ ` pl 1
I,as Owner of the subject property,hereby authorize)
to act on my behalf,in all matters rela ' e to work autho ' ed by this building permit application.
Print Owner's Na le(Electronic Si afar ) Date
SECTION 7ti:_O! NE OR AUTHORIZED AGENT DECLARATION
i
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
con ained in s application is true and accurate to the best of my knowledge and understanding.
co=
Print Owner's or Authorized gent'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 m the Home Improvement Contractor IC Program),will not have access to the arbitration
g P (HIC) g )�
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. 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"
6
• r
1hs G`tarnrn eswedtla.of Massrachusetts
17eparunentwf..Industrial Accidents
a O l:ce of.Investlgattions
600 Washington Street.
Boston,MA 02111 `
W.W1V.hzass.gOv1dia
Workers' Compensation Idsulirance davit::Builders/Contractors/Electricians/Plumbers
A " Iicant Information . Please Print Leglibi
Name'(Business/Otganizadon/individuai)':L GS are 0cf*L 4� 4 �
Address: 1`;140 Ca.rnntt.. S 01VIL
City/State/Zip:k10 66LCt'! C( : 2L EQ 1 Phone#
Fe
mployer?Check the appropriate box:
Type ofproject(required):
mployer with SU 4. ❑ I am a general contractor.and I
es(full and/or pa t-time)." have hired thcsub-contractors 6. ❑New construction-
le proprietor or.partner- listed on the attached sheet. 7: ❑Retuodeling:
pand have no employees 'These sub-contractors have g ❑Demolition
working for me in anycapacity. employees and have workers'
I
NO workers'comp,insurance comp.insurance.t. 9• ❑Building addition
required,] 5 :o We area corporation and its 10:❑Electrical repairs or additions
officers have exercised their
3.❑ I am a homeowner doing all work; l f.❑P.lumbing repairs or additions
myself[No workers'comp. right of exemption per`MGL
insurance required.]t c. 152,:5.44),and we have no MCI Roof repairs
employees.[No workers' 1356ther
comi.instn ance equired,]
'Any applicant.ihatchecks box fl must also fill out the section below.showing theirworkets'.compensation policy'informetion.
t Homeowners who submit this affidavit-indicating they are doing all work and.thenhire outsidecontractom must submit a new afiidavitindicatingsuch.
4contrac1ors that check this box must attached an additional sheetshowing the name ofthasub-contractors and state whetheror not thoscentitics have
employees. If.the sub-contractors have employees,they.must provide;their-workers'comp:policy number.
I am an.:employer:that providing worlters'compensation insurance for my employees Below rs the policy and job site
information f Insurance Company Name: f`CS S GL° 1.t .2G l('jL (/S
Policy#or Self--ins.Lic 7#: IS y4,40 ocj Expiration Dale;
Job Site;Address: I 'C r, C,1 I J
City/State/Zip:5a
Attach a copy of the workers':compensadon policy declaration page(showing the policy number anderpiration date).
Failure to secure coverage as required under:Secdon25A of:MGL.c.152 can lead to the imposition of criminal'penaldes;of a
fine up to>$1,500 00 and/orone- ear'y imprisonment;as well as-civilpenalties ut he 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
Investi ations of the D for insurance covers a verification,
I do hereby cent ` t pen of Try.that t bn proyided_above is true and correct
Signature::
Date,• �?.'.. '
Phon
Official use only. Donut write in this area,to be completed by—cif
yor fown.afftctat
City or Town: Permit/License
Issuing Authority(circle one): '
1.Board of Health.2.Building.Department 3.City/TownClerk 4.Electrical Inspector.S. to
Plumbing Inspecr
6.Other
ContactPerson: _.. Phone.#:
CITY OF SALEM) MASSACHUSETTS
BUILDING DEPARTMENT
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
(requiredfor 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:
Aw k Copt'�r
(name of hauler)
The debris will be disposed of in:
(name of facility))-
N'C\6--u
(address of facility)
Signature of applicant
(today's date)
b M • window WOCIC)Of BOS�Ot1 MA HIC;Registralion
Offices&Showroorns Number!
O;l5A Cummings Park O 295 OId Oak Street ❑1,000'Boston Ttrrnpike.... 166026
Woburn,MA 01801 Pembroke,MA 02359 Shrewsbury.MAb1545 Fedaral IDYL
(781):932-4805 (781)826_6281 (50. 845.6676 62-4898432
r." 1-m.WlndoivWorld6fBostomcom
Customer: fY t r OR�` Cr7 FLC �
Phone
Install Address: P 7 8 EYL7ti.G `rsr Phone S7f6
City:_ f L Fx Sta1e;MA ZiP O(2 E-mall
i
WINDOW WORLD GLASS OPTIONS
1000 Series Single•hung Ail-Weld $249
MOD Series DH All-Wetd $2�c _sue 8616lne'Oita-Dual Pane $129 7 7y
4 4000 Sol DH All Weld $289(`?jy __Tdpta Pane l
_6001)Serial Ail-Weld $299
$309 r
_2'Lite Slider $420 WINDOW OPTIONS
_3 Ute Slider, t+A:rA r!y nra ra,,+,
$669. —Glass Breakage Warranty(4000/6000) $151NCWDED.
®� Picture/Fixed Life (0-83 UI) $4t9 _1/2 ScreeDs $g—INCLUDED j
Picture/Fixed Life:(64-130 UI) $539 _Foam fnsulatlon an Jambs and Head $11'WCLl1DE0
_Case g $359 �OoubhaStrength;Glass(4000/6000) $16—INCLUDED:
_Casement tzlris S49(ON Sash Rall)$379: _Double.locks(>.26.'� $5INCLUDED`-
_2 Lite Casement' $659. _Full Screens $25
3 Lite Casement 'rrn.ra.irdi rri,,a rn} $1029
Colonial Grids{Ciinloiired/Fiai) $65
_Basement Hopper $469 Prairie Gritls
_Bay Window-soffit Mount/INS Seat.$2859 $75
- Slmulated.Divlded:Litio_Bow Window-Soffit Mount/INS Seat$2999 ;
_Garden Window $2179 _T6m09rec1 DH Sash(BSO)(TSO): $76
Bay,Bow,Garden Oversize. Obscure!Glass(8SO)`(rS0 .
{+109 UI) $979 ) $75
_Beige/Almond "$4 J Orte1 Slyfe'(40/60 or 60/40) $TS
Wood Grain in1ii(Sedes:40010/600600ry)$too _Foam Enhanced Frame $35.
(LlghtOaklDadr04l ffy1FaxWoad PRE1978BUILTHOMES(ARPSAtl OVAT!���.1-.�
RichMaple) MY HOME WAS'BUILTIN THE YEARtnitl ®p
8rownEztenw(Arch Bronze/gmericanTerm)$100 _
_OesignerColorExtenor, $179.. MISCELLANEOUS
_Speciality Window $ A Custom ExleriorAluminum Cladding(T+xD+Bend)
Window Color Gt,J i w fi ❑Textured$90' ❑G-8 Smooth$90 s Ill
i
InsideFacing Color
Muldii E Multc Bend`Ciadding J 20
NON:CUSTOM DOORS #
_Install interlor/ExteriorStops $50
_Yfnyl Roging Patio Door SfL or sit $1219 Install Interior Caslri
Vinyl Rolifng Patio Door,80. Sim9 S►arts At $95
_Add to base pdceioItCulomRoOngfatioO nor St259 —Repair>Sifl Jamborreplacestllnosing $75.
Full SubrSilf:(Single}replacement
French�AallSlldingPado0ooc51t.or6g. $1539_-.. - ... $175 -
�Frencli:Ra081idingPalio.DocrBn.: §ig _tnsulate!NeightBoxes $20._'
.__French Hall sildinilltio Dool s1749 - ;Mull to Form.Multi Unit:: -
$30. j._Custom'ExtedorCladding 5300 _Mullion Removal '$50
�SolarZone Elite S3D9. Metal Window Removal $75-
_6rlds:Patio Door $210 _NeW Construction Vinyf'Ranr l $175
_Woadgrafn Interiors $399 N_Conat:Ext.Ratio Fir.:
i.
Exterior Designer.CotOrs s599 $150.. -.
_IntarlorCasing 2ra 3112 _Rooffor8ay/8owWindoft $560
5279
,Handleset Options Removal of Existing Bay/Bow $250....
§ _Bay/Bow Conversion'Exf Rclro:Fit
_Inlerioi80nde(six foot orilY)' $859 $450
§ 4New Siding!Nill.Not Match)
Door Color ( v ROUND UP FOR WINDOW WORLD CARES
tnsrde outside �St_Jul Chlidren's.Research ifiti 1. $
Cmstomer declines:exterior Wrap and understan s painting and/or repair in be r iital f
Customer declines grids_ n windowsldoors liliti '
DISCLAn4tErhgrlomerisrespanstUelorthetallovAnginemulectionWbhthiscontracl P fithig staving Alarm Syalemdiieondectrecamtect BuUdNgPorrdltteesip l
mteess at$25A0;Humeownor and of QarNo Assoda�n Approval,HLstaic"CLApprovaL Gily 61 Boston pa�Wng&Ski pormit fees m connesion wiUi tiislaganoa, s
NO EXTRA.WORK-IF"NOT IN:WRITING) Clt$tOfiei agit'es t0 thB:.terr119 Of:payment as't0 10W3:
Extra Labor&Materials $ .. r '
Site Set,Up,Permit;:Dlaposal&Delivery Fees$ $389.00 .
Custom OrdetDeptik A8% $ 'It Ck# !
Project Start Payment 3396
Balance Dus Oay of installation
Amount Financed $11
' !tI window ylorld oI Boston antldpates starling this vmik oa 6 g dill cornpleted ln[�ys,SacudryinNresl Yes" No
Any deposit required la advance al the stariot the work'"ALL exceed 331/3%of the toinf.cont act ill drift actual cost of apyinatedal or epu7pmard of a; )
spedaldglworrxtstomiredenahrre,vihWhnarstbdadewin advanceNlhestaitot the
waiktoassitre that
t eprd ie ill pro. dorischedute No.Mial:payment.
shad be demanded unlliihe convect is soinpfeled to Ike sausfacUen of both partles
All home Improvement dordraclors and sulxanUacmrs shall be registered and that Inquires about a contract or subcontractorrelaUng to;a registration should be
directed4o:0111co of Consomor Allairsand Business:Rogulation.Ten Park Piaza,'Suite 5170 Baslon,MA 02116.Phone:(617).973-a7B0
No work shall begin prior la Iha slgNng of the centred and lransill le the owner of a copy oI sueI contract
021.yfindavi.World dt Boston under proylsbn of Chapter 142A of lhe:genera)laws Is required to apply for mw obtain all consVoitiotrrelatad patmlls ftdow"..o) t'
8ostonshatl not be deemed rasponslhlo'tor dalaysln Iheworkdescribed In this egreeme6t caused by regulaldry,permit Ora u oagencies;auLhodties orindMduals:
Nollce:Jl the PUACNASER(S)obtains k[s awn cofili llon related patmils for the wmk described under Ihls agreement dldoal0 with uiasglsterpd r ogli ideals. V
the PURCHASERS)Is'hereby advised that In the 64en1 of a dispute,)udgeroenl and nonpayment the.PUHCHASER(S)will hat he entitled to make adaknor
collecl{onlydmlhegearanty fund eslatifished by chapter 142A,rd.0l,
you l e buyer may cencet Ihlsdransactien at any time pr or to ntg 1 o t e Whir usiness ay attar he date olahis.lransact on:: t Notice otcanceilalian must he IR.wrlting postmarked no later than midnight`of the1011owifig third business day. C
S Is A CUSTOM R N ESL1 co
f
This vrindowVlorla�rrarchlseei 11 hde ehdetdl ovmedarido rated L&PBostun'O eratin ;loc.underlicensefromWmdowWor:d,Inc. !
2 is
Owner.,0o not stgn q am are any.'biank epacos. Dato
/ir E T
Salesman Donol sign it there are any hl nk spaces. Data. Ovmac Do not sign(f there are any:blank spaces. :pate i
"to P.nriv-ndnrn�l- 111h.Con.- -
.. Lin; Ptnk(:nnv-r:ialnmw ....