B-20-630 - 0008 BUFFUM STREET - Building Permit The Commonwealth of Massachusetts
Y OF
Board of Building Regulations and Standards SIALEM
W 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'Officid 'Use Only
Building Permit Number:.e" Date'Apphed:
Building Signature icial(Print ame) " Signature Date
1� SECTION 1. SITE'INFORMATION
1.1 Property Address: O 1.2 Assessors Map&Parcel Numbers
_ i8m 5�
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Sa'
A�
Zoning District Proposed UsqJ 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 OWNERSHIP'
2.1 Owner'of Record:
amj�i
Name(Print) ICity,State,ZIP �—
,�f-F�.�, S� 97j- 9?g- sg217
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check alhthat apply)';
New Construction❑ Existing Building 0 Owner-Occupied ❑ Repairs(s) 2 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: q�,+no FO&F MAL F= T"irf
e
SECTION 4 ESTIMATED"CONSTRUCTION COSTS
Estimated Costs:
Item Official Use:=Only
Labor and Materials
1.Building $ l 1. Buad* Permit Fee $ indicate l ow fee:is detennmed:"
2.Electrical $ ❑Standard'"City/Town Applicatio` Fee
❑"Total Project Costa"(Item"6)x"m tiplier x
3.Plumbing $ 2 Other Fees: $
4.Mechanical (HVAC) $
5.Mechanical (Fire $
Suppression) Total A11 Fees.$
y� �^c���, Check'No - Check Amount.' Cash'Amount:
6.Total Project Cost: $ �l �C.C/ ❑paid m Full "❑Outstanding Balance Due:
JUN 34 Pm 12:37
.SUN
SECTION 5: CONSTRUCTION SERVICES
5.1 yC-onstruction Supervisor License(CSL) / J
V Vnrref..) lexrl,of License Number Expirati n Date
Name of CSL Holder
'List CSL Type(see below)
Type Description
No.and Street `
U Unrestricted(Buildings up to 35,000 cu:ft.)
Q R Restricted l&2 Family Dwelling
-iCity/Town, te,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 Hom Improvement Contractor(HIC) f f;m J U
CL6�;W J 4 C' HIC Registratt/on Number Ex rati n Date
HIC CompUy Name or HIC Registrant Name
No.an treet Email address
Q26 • ti 0 q7F-75t-ZIf 3 S�
City/Town,St de,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 ..........A 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 AloiOrAl Ar5�4 4r,/
to act on my behalf,in all matters relative to work authorized by this building permit application.
G/egg o
Print(Mne 's ectronic Signature) ate
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's true and accurate to the best of my knowledge and understanding.
Print wner'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"
f
The Commonwealth of Massachusetts
Department of Industrial.4ccidents
> 1 Congress Street,Suite 100
Boston,MA 02114 2017
www massgov/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):
Address: ISO
City/State/Zip: 0%U Phone#:
Are you an employer?Check the spidopriate box: Type of project(required):
l.VJ l am a employer wiih employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in 8. ❑Remodeling
�; • ` any capacity.[No workers'comp.insurance required.]
3.❑1 aat a homeowner doing all work myself.[No workers'comp.insurance required.] 9. ❑Demolition
4. 1 am a homeowner and will be hiring contractors to conduct an worknn m 10❑Building addition
❑ � y property. C will
ensure that all contractors either have workers'compensation insurance or are sole 1 LE]Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.�Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
area co 6.❑we 14.❑Other
corporation end its officers have exercised drew right of exemption per MGL a
152.¢1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box 1/1 must also fill out the section below showing their workers'compensation policy infomoation.
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-conuractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide then workers'comp.policy number.
P Y p g mpensation insurance for my employee& Below is the policy and job site
J am an ere to er that is providing workers'co
information.
Insurance Company Name: 1f;y-ek PCs
Policy#or Self-ins.Lic.#:� llll�,� jo ,/1 ! Z 6 Expiration Dater Z
Job Site Address:
.City/StateJZip:
Attach a copy of the workers'compensation policy declaration page(showing the Poh'e number a 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 ofperjury that the information provided above is true and correct.
Si-nature:
Phone#: 51 7Sf'-75V`7 d7 .
O _
jj`icial 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, MASSACHUSETTS
BUILDING DEPARTMENT
98 WASHINGTON STREET,2ND FLOOR
TEL:`978-745-9595
KIMBERLEY DRISCOLL
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBLIC PROPERTIES/BUILDING COIvMSSIONER
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:
/ _z'
(name of hauler)
The debris will be disposed of in:
1-
(name of facility) '
0
(address of facility)
Signature of applicant
�1 �_J/ z0
(today's date)
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LAUGHUN5@Co' CAST.NET LAUGHLIN HOMES C twass.t�EG # 16 i s25
FED ID #$7 205,4365-1 V4,
•MEMBER BEVERLY CHAMBER OF COMMERCE - P.O.BOX 252 - x
Beverly M---- ac 5
WWW.LAUGH LINHOtdESINC.COM� WARREN PEARSON CS #CS$0896 3 __
SINCE 1978 °(978)828-3979 ' s281 t�
SPECIFICATIONS SUBMITTEDTOfs� H0N
STREET: ,- JOB NAME? B C/ o' l'a ' `X` o
CITY,STATE,$?P: _ .1 LOCATION:
RC ECT:_, OkTEOFPLANS: B� J PHONE: 71
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Inllation of a complete Certainteed Shingle loof to the entire housea � '�
sta `
Color. �s a'
i I.Includes strip` Id shingles,provide dftu mL.pFsrte r an +th►att9;�7s� ®(�vaAhly�a dpa - Lml pfees.
ra uleo t � - IA-',*Includes Install: 4*AjA4 AjfI
-ice and water membrane to main house eaves,around chimneyandinvpa�eys� °
,
rG
-tarpap r' ase and flanges to stacks A/ C t tA&IV 6 s
-8"aluminum dripedge to all edges_Color: W A beg— a
,AVre7 drsJ-
-starter shingles to all rakes and fascias t- ��NGr�,(i� �� 7
-cobra ridge vent to all heated ridge areas �f A V. s�O , —1XP'*R
=repair.reinforce as necessary and neatly seal chimney(lashings,any step and apron flashin s. _
tn•e procure permit,customer reimburses permit cost.
S'_ re s/
Z6r
- Ae
Option It kner odi4e P� �f s l GN
Re-roof:same specifications as above,but Iverine i existing of a ext"ludes ice:and Water
membrane,:and tarpaper base. 6 '��® �� �Lvj //td GGrtrim,
Color: cfi 1. e" `:✓eft: t Bh®"':;00 CA1""
AM
Customer responsible to cover/tarp attic items and cleAdany resulting debris in attic. orv +
Ten Year workmanship guarantee trait ferable
(Customers)Email:
Signature CONTItACT PT RICE
Date AvorlC will begin: _T sc edu to. Date Ivor be/su^b_sMtan4tiajR completed:
PavtzBetgt Schedule: Initial Payment: due rrpio,i ere,:irivfcantms i a
We Accept Credit Cards Pavment 2:. dire aporrcompletiolt aaf
dire a 011 Cauir lethm 01 cQir rat t'
�l'aynTant 3: _ P P ,
The la++rcquac:that all[ionic Improvement contractors unit subcontractors shall be mgeitered be the Directoror Home improvementCoariaetoir Rtitstration,artd that j:-•_
any inquiries about a contractor or subrontructor reli f og to a registration should be directed to-office or Consumer Affairs and Business Rega itiord IO.Parit Plma,`
•itoamGtlO.Bmtoir,MA(1.1Ib1A17)a173-NT011,
it is the eontraciorb obligation io nhtmn anF and oft neecssun'construction reloted permits,should the ou'nersecure their oivn constractton-rebtt�penalu or deal svlth:.
unregfslert.d contrnciori the owner tih�Jl �un_al�from accrue to the guarantee fund, � +
�Liidtss othendsc noted in this document.the contract shall not b nplp that aay licit or other smurihy interest has hcen placed on the resideuce. {.
A icltirncc ui i'bnuaci DO NOT SIGN THIS C:(?N';RACI'4FTHERF ARE BLANKSPACES ' z
The al„rce pnc p:iht coons and a editions a art lucidly �[/
and irchcrrh+ auipled luu:irrnothorizcdtodr the+�i+ri
to p+ulirJ f a+lpeni sill he made as oullin A at+tnr.
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_ Dst�of:lctept,tnn _ -�?t ". P� �•
You ntnt cancel tltls ugrecmcni.it•it has been signed tit a riirtp ilk at a placr'uther than un address or the seller, cony file moip office br-branch thereof,proeided
you aaiily the contlartor in writing at hit main ofGrc ur braneb by ordinary mull posted.be telegram sent or by denture,not later than raidnight.of the th5rd business alay r
roliolving the:cigning aftbis aj recment.Sec aflached Notice of C'nncellnlian farm for an ez3tlpnation of this right
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