B-20-510 - 0005 BRADFORD STREET - Building Permit r The Commonwealth of Massachusetts
r Board of Building Regulations and Standards CITY OF
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'Official�Use Only '
Building Permit Number. a ,Applied.
lb
1
B ding• iaL(Prurt Name) Signature Date
SECTION 1 SITE.NFORMATI N
1.1 Property Address: 1.2 Assessors Map&.Parcel Numbers
s- I31a�l�o�d s t
l.l a Is this an accepted street?yes ,/ no Map Number Parcel Number
1.3 Zoning Information: IA 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:'.PR_OPERTY OWNERSHIP
2.1 Owner'of Record:
Bill I-ems, MA 0(,1-7o
Name(Print) City,State,ZIP
S 6.(,d o(J S f 1SI qr3 o911 kv Ccw.
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF._.PROPOSED WORKS(check all that apply)' 4
_.
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) IR Addition ❑.
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of ProposedWorO: ct sGowtw
A.1 4;)e Roo 4,
I
;.• SECTION 4'ESTIMATED CONSTRUCTION.COSTS
Estimated Costs
Item Official Use'Only
l.Building ;
-Labor and Materials
1 1 n,. .
1 Z.moo o Bui dt g Permit Fee $ dndicate,how fee is deterrntned
$
2.Electrical $ {❑Standard City/Town Ap jication Fee
❑Total Project Cosr'(Item 6)x molt plter , x
3.Plumbing $ K 5-0 0 2 Other Fees: $
4.Mechanical (RVAC) $
S.Mechanical (Fire $
Su ression Total All Fees:$
z
6.Total Project Cost: $ :,Check;No Check Amount. ash Amount
` ❑Paid to Fu11- ❑'Outstanding Balance Due;
� Zv
i
SECTION 5: .CONSTRUCTION SERVICES . .
5.1 Construction Supervisor License(CSL)
CS^ I o93lQ8 q -0-Z1
Al e t s O k C License Number Expiration Date
Name of CSL Holder
List CSL Type(see below) V
S BEI k��t Drive `
No.and Street Type ITescnpt�on`
A+kkj a,,, NH 0 3 S 1 J U Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 FamilyDwellin
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
aZT 7211 6� 01 kGs�tti ev�(co�fravf�a� �9�A,,/, I Insulation
Telephone Email address D Demolition. � .W
5.2 Registered Home Improvement Contractor(HIC) 6 0 tt q y
S i I v, C a 44v t 01r f.h r 1 ,_ D eA f k w e tip HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name /
I Lf,-orc 21 csi/Va Ql {4i�vl�eaf-k-c y.re
No.and Street Email address
Pe,.l 044 MA 0(aG0 q78' d742 `1(8'2
City/Town,State,ZIP Tel hone
µ
SECTION.6:WORKRS'E COMP ENSATION 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 ..........Er No...........
SECTION 7a:OWNER 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 � r
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/d ss
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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 decksl porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
y
The Commonwealth of Massachusetts
Department of IndustrialAccidents
I Congress Street,Suite 160
Boston,MA 02114-2017
www.mass gov/dia
Workers'.Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMI ING AUTHORITY.
.Applicant-Information, "Please Print Lembo
Name(BusinesslOrganization&dividual): o v ;,A J Z',c U�t► {� ><��r� fN N r
0
Address:
CiState/Zip: �A a 1aQ
- �' �- ° �S zy Phone#:
Are you an employer?Check the appropriate bolt: Type of project(required):
l Tn tmn a employer with Z employers(t„n and/orpart-time).0 7. ❑New construction
2.01 am a sole proprietor or partnership and have no employees working for me in 8. Q Remodeling •'
any capacity:[No workers'comp.insurance required.] ~
3.❑i am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. ❑Demolition
4. 1 am a homeowner and will be hiring contractors to conduct all work 10❑Building addition
❑ my property. 1 will
ensure that aU conmwmrs eithahave workers'compensation insurance or are sole 1 LE]Electrical repairs or additions
proprietors with no employees.
12.❑:Plumbing repairs or additions
5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub c an
ontractors have employees d have ers work 'imp.insuraice.t
6.M We are a corporation and its officers have exercised their right of 14.❑Other
gh exemption per MGL c.
152.§1(4),and we have no employees[No workers'comp.insurance required.]
Any applicant that checksboii#1 must also fill out the.section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing aU work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this bon must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. if tire.sub-conb=Mrs 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 paWy and job site
informadom
Insurance Company Name Srrtcfy ZLAskrawce Co, ,Pg" /� r,�eltrs
Polic -#:or-Self--ins.Lic.#s V Q 7 H� H G 11 5 3 Expiration Date:... 2
y _ 1.0. t� - 02.0
Job Site Addrew S Iead_o r cQ City/State/Zip: Set 1 e /0 R a l G 7 0
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 certify under thepains and penalties ofperfury that the information prov d above is true and correct
Signature: _ / G.._- tr� -Date —
-.
Phone.#: i:7 1 -q 7 1- R(S'Z
Official use onlw Do not write in this area,to be completed by city or town offlciaL
` City or Town: PermitlLicense#_
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#:.
f a
CITY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
98 WASHINGTON STREET 2ND FLOOR
f TEL.: 978-745-9595
IC MBERLEY DRISCOLL
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUU DING COM ESSIONER
Construction Debris Disposal'A fidavit
(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# i _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 IVIGL c 111,S150A.
The debris will be transported by:
G Mello D rsposa, j
(name of hauler)
The debris will be disposed of in:
G Mella 7'yvsre-f Sfgtiu�
(name of facility)
Zvi Easf /"iPrN St Ric 133 Ge-arS AA 01?33
(address of facility)
Signature of applicant
(Q-�-zo
(today's date)
KV
t ;t
Office of Consumer Affairs
ad
neAthbuoPlaceBSuusition1es3s0 10 Regulation
Bos'ion, Massachusetts 621 b8
Home lmprovemen .C7'bn ractor Registration
Y � 3 Type lndlvltlual
Reglstatlon 160444;
SILVA CANDIDO&ORTINS INC' # � lrat,on 07/28/2020
DB/A KITCHEN TUNE UP,`
, i.
12 LENQX RD c+�. . "�
P.EABODY MA 01960
Update Address,and R'ett m Card
sdA 1 61 20M-05/17
.!,1l(Qi0,7789T2(✓!t!LC2G{✓L Q �LLJtiftG(�(lJP3
Office'of cdmum r-Affairs&susiness,Regulat on
HOME IMPROVEMENT:CONTRACTOR Registration void for individuai.use oniy
TYPE.,individual, before the'expiration date. if found return:to:
fgalstration, ;;Exgiration Office of Consumer Affairs and,Business;Regulation
t60444 07/28/2020 One Ashburton.:place-suite 1301`
SILVA CANDLDO&ORfINS iNG BoMori MA 02108
DIBIA KITCHEN TUNEUP � r• .
MATTHEW SILVA s
12 LENOX RD
PEABODY,MA olsso �- Not'walid withoutsignature
Undersecretary. .
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Stavroula Orfanos
From: andreewalch@gmaii.com
Sent: Tuesday,June 9, 2020 8:39 AM
To: Stavroula Orfanos
Cc: 'Matthew Silva'; 'Bill Walch'
Subject: Contractor Permission
To whom it may concern,
I am writing to grant our contractor, Matthew Silva/Kitchen Tune Up, permission to work on our property at 5 Bradford
St. in the coming weeks. He will represent our interests with the building department on an upcoming project to
renovate our master bath.
Please let me know if you have questions or concerns.
Thank you!
Andree Walch
1