B-20-607 - 0007 VALE STREET - Building Permit The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
7O One-or Two-Family Dwelling
This Section For Official Use Only
`)W Building Permit Number: Date Applied:
Building Official(Print Name Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
7 lia/e. S IC
1.1 a 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:
Zone: _ Outside Flood Zone?
Public� Private❑ Check ifyesMK Municipal-QB"On site disposal system ❑
SECTION 2: PROPERTY OWNERSIHP'
2.1 Owner'of Record
Name(Print) City,State,Z
6,f k, 29 S-oa 377/ saugdr#-S lc QCO 11e-f—
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Iteration(s) 11 Addition ❑
Demolition Accessory Bldg.❑ Number of Units / Other ❑ Specify:
Brief Description of Proposed Work2: r v fctn
r
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only ;
(Labor and Materials
1.Building $ �QU��- 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ O G ❑Standard:City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ p G v®�' 2. Other Fees:I
4.Mechanical (HVAC) $ j O®� �—� List:
5.Mechanical (Fire $ Total All Fees:$
Suppression
Check No. Check Amount: Cash Amount`.
6.Total Project Cost: $ 7 &4(j G a G, 1 ❑Paid in Full ❑Outstanding Balance Due:
�> JUN
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
'i�'�I cP�� /r L✓ co Yvi License Number Exp'ation Dfite
Name of CSL Holder
List CSL Type(see below) Z/
No.and Street Type Desc;iption
�f C/o UQ r d� j O U Unrestricted(Buildings u to 35,000 cu.ft.
T R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
qq ^^ SF Solid Fuel Burning Appliances
pM ,'J,C0 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) �' 2S �Ga
HIC Registration Number 'Expirttion Date
HIC Company Name or HIC Registrant Name
/b,` SLiG u.S Pew 6W. ` 1 (1) P lam[,G 4
No. Stre ^ V mail addkss
Ci /Town,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...........❑
SECTION lac OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorizeaWlc3j
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print OvIner's Name`ectronic Signature) Drate
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.
Prmt 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/dpss
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) 9O 0 (including garage,finished basement/attics,decks or porch)
Gross living area(sq.ft.) .�Sb Habitable room count S�
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths /
Type of heating system Number of decks/porches 02
Type of cooling system Enclosed Open rr
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
1
The Commonwealth of Massachusetts
Department.of Industrial Accidents
> 1 Congress Street,Suite,!00
Boston,MA 02114-2017
r •
www massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Pltimbers..
TO BE FILED WITH THE PERMITTING AUTHORITY.`
Applicant Information Please Print Leldbi ,
Name (Business/Organization/Individual): a
Address: b rme"
City/State/Zip: VU a, Phone#s 97�S�o�- 77q
Are you an employer?Check the appropriate box: Type of project(required):
1.O 1 am a employer with employees(full and/or part-time;* 7. New construction
2.O I am a sole proprietor or partnership and have no employees working forme iii $, LtZemolition
odeling
any capacity.[No workers'comp.insurance required.]
3.❑i im a homeowner doing all work myself'[Noworkers'comp:insurance iequired.]t9.
10[]Building addition
4. 1 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. repatrs Or addtttonSproprietors with no employees. 2.1!4��tncal
Pbing repairs or additions
5.01 am a general contractor and I have hired the sub-contractors listed on the attached sheet: 13.0 ROOF repair's
These subcontractors 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.Q Other
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.
tContractots that cheek 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! k/y, /4
Policy#or Self-ins.Lic.#: C C(.l Date: l�,)-lq 0"46
Job Site Address: (v f k
Attach a copy of the workers'co ensstionpolicy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MOL c. 152,§25A is a.critninal violation-punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the,formof a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this•statement may be.fo warded to the Office of Investigations of the DIA for insurance
coverage verification.
do hereby certify under the pains and penalties of perjury thaf,the i>>fgrinadon provided above is true and correct
Signature: �}� Date:
phone-,#: / `e -J d� J 7 7t
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#:
II
I
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 COMMISSIONER
i
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)
e*ro a 4�
(address of facility) T
Signature of applicant
(today's date)
Commonwealth of Massachusetts
` o Division of Frofessianal Licensure
n a� ®' dr 'pf S1iFldrttg>,Ria �tl�b�1ffi end StBe�CkaFdJs n°
CS- "Id717 �Y-es.. 0812612021
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JAMES J NEWCOMS .
151 SHAVVSWg'EN I
! INOC)VER MA101810
C-Om li«siolsec AA� -.
6Mce of'Conaum-or Affalrs.&Business Regulation
HOME IMPROVEMENT CONTRACTOR
TYPE,Itndiaidual
04 i1 09126M20
JAIu1ES .N Xml
JAME
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._
151 SHA'V4 SHEEP!R1®
ANDOVER,MA 01810 Undersecretary
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Sally Murtagh
From: Wayne Saunders <saunderstile@comcast.net>
Sent: Thursday,June 25, 2020 3:37 PM
To: Sally Murtagh
Subject: Fwd: Licences
Sent from my iPhone
Begin forwarded message:
From:James Newcomb<jjnewc@gmail.com>
Date:June 23, 2020 at 7:18:49 AM EDT
To:Wayne Saunders<saunderstile@comcast.net>
Subject: Licences
1
`i Construction Supervisor
Unrett*ted -sultdings of any Use group which Contain
F less tlran,36,000 cubic feet 1991 cubic€oetersi of enclosed
space.
i
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t
Failure to possess a+current edition of the Massachumfts,
State Building Cade is cause for revocation of this ficense.
For info r tion about this license .
Cali (61I)72t,3p visit w".massgoy1d$4
w
Registration valid for-%ndiv iduat use only
before the expiration date. If found return to-
Office of ConsumeT,AffWrs and Business Regutation
1000 Washington Street-Suite 710 '
Boston,MA 02110,
M
i�ot valid without signature