BAKERS ISLAND - BUILDING INSPECTION (2) q
4\ — The Commonwealth of Massachusetts
k Board of Bmlding Regulations and Standards I c Ht
- ,�, Mt NICII'.\1 FI 'I
Massachusetts Slate Building Code. 780 ('MR. 7 edition
l ��I-.
Building Permit Applica(ion To Construct. Repair. Renosate Or Demolish a tri n d.hnu,.0
One- or Tito-Fantih Dtu el irn
'I his Sectit yr Of .ial Use Only
Building Permit :Yw ee
HuddmF Cuuuni.wntr Inslxemr of Bud res Date
SECTION I: SITE INF'ORINIA HON
LI nrpertr:�\dtlrcss•� J/I 1.2 :\sss Slop & Parcel .Yrunlers2)
GG d `1
I.Lt Is this an accep(ed sucet., ve.s Map Number P:u:el ,Numl,ci
1.3 Z�n/i�ng Information: LJ •Property Dimensions:
i lorung District Pntpoaed Use Lot An:a(sq It) Fruniagc ;C)
1.5 Building Setbacks (ft) it
Front 'tard Side Yards Rear Yard
Required P vtJed Required Provided Required Po"IJed
--j
1.6 Water Supply: tM.G.L c 40. §51t 1.7 Flood Zone Information: - 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone:' tilunici al yy,,,, l )
Public ❑ Private❑ Check if yes❑ P' W On +ile Jis weal satcm ❑
SECTION 2: PROPERTY OWNERSHIP'
' 2.1 Owners r'of Record:
Namz tPrinu='GLu Address for Service" P Ovl ✓A 2
'fr- -77� ! i n�
Sienantre Telephone � -
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(,) ❑ Alteratiun(s) \JJiti'm Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Spedly:
Brief Description of Proposed Work': PD�101-p Q �'d,,)IA Q QI
SECTION d: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
I Labor and Materials)
I. Building S /5 ! I. Building Permit Fee: $ Indicate how fee is determined: ;
❑ Scmdard City/Town Application Fee
3. Electrical 1 ❑ 'rota) Project Coat' (Item 6) x multiplier x
3. Plumbing S ?. Other Fees: S (
4. Mechanical iHVACI S List: _
5. Mechanical (Fire — ------
Su t reuion) Total All Fees: S
Check No. Check Amount: _ ('a.h \nt„uol.
j b rotal Project Cost: S /5 �-� 9 ❑ Paid in Full ❑ Outstandtne Bal;utce Due:_— _-
SECTION 5: CONSTRUCTION SERVICES
�.1 LicenscdConstructionSupervisorlCSLI — /9/aJ T J_/2
_J�
r.
P I.Iol CSL 1\pr lsrr hr III r,I
--_____� 40•cJ �� IA rc Ural roan
\.1Jre>s l 1111011irlydwrlr�
// ~
K Resumed I.F' F.umh Dlr Alum
n Unlr
Rt' — -�
— dc i Rc(2r. J:nual Koohne lor rl ln._
frlcphunr9��. z�-'l - zyyl \\S KrvJ:ni oil \%wdmr .inJ SI'luic --_—
SF Inn.il SoIIJ Furl ISw nor_ \pIrI LIn.. Ind,J l,n 1, u
D Rr,iJ.n!I,il 1)PIIh II'[wil
5.2 Regist ed %loin •Improv •ment Contractor 0110
IIIC Con ipano Hanle or HI(�Regutraut Name Reg.su-a( on N Mihrr
\Jdress -� 200--- - -
_ � 9 � z���u�I Ex'pnanon D.ilc
Signature „ '� 'rclephune —
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152. § 2506))
Workers Compensation Insurance affidavit must be completed and submitted with this application. F:ulwc no I)II—de
this affidavit will result in the denial of the Issuance of the building permit.
Sighed Affidavit Attached? Yes .......... ❑ Nu ..... .- 0
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 hchalf. in all mallets
re!ative to •.vork authorized by this buildng permit application.
I
`:i¢naturc ut Owner _ Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Jzel _ as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my know!cdge and
behalf. > _ [ � � ----- )�
Print Name .i
Signature of Owner ur Authurize0.4gcnt Umc
(Signed under the Cains and penalties of era )
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hues an unregulered contractor
(not registered in the Hume Improvement Contractor (HIC) Program), will not have access to the :Irbrt ation
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be hound in 780 CMR Regulations I IO.R6 and I IO.R5, rnpecn cely.
I When ,ubs(annal work is planned, provide the Information below.
Total tl oors area ISq. Ft.l (including garage, finished basemen Uattics. decks or porch)
I Gross living area tsq. Ft.) _ Habitable room count
Number of tueplaces Number of hedruoms
Number of hathroums Number of hall/haths
kpe of healing system --- Number of Jerks/ poi,hcs
I'vpe of cooling ,y,lem - F]Iclo'ed --- __Uprn ------ -- --
z. .aural Project Square Footage- rnav he ,nbsOtu ed for Folal Project Coo t• __-
August 20, 2008
Posy Walton
2600 Secota Drive
Hampton, VA 23661, Tel. 757-723-1200
RE: Contract to do work on cottage at Baker's Island, Salem, MA
Address: Map 089, Lot 114
Work to be performed.
1. Old siding to be removed and new siding to be installed on sides of structure as
discussed (See Attached Sheet)
2. Replace six (6) windows at bunkhouse with new Andersen CR23 casements as
discussed. (See Attached Sheet)
3. Replace Kitchen window with Andersen P6035 flanked by C135 casements on
either side as discussed. (See Attached Sheet)
4. Replace plywood on east side of bunkhouse as required.
5. Work to commence and be completed by end of fall 2008.
Terms:
Bid Labor $ 8,000
Bid Materials and transportation 7,259
Total $15,259
One third of labor plus materials and transportation due in advance
One third labor due at halfway point
One third o .f labor at conclusion
Certificate of liability insurance is to be provided.
Please sign cop' end return.
Thank on
Robert T. Aeavens, A Constr Supery Lic # 6945 Posy Walt n Date: Q/o2l�D$
385 Magnolia Avenue, HIC Reg. # 149273
W. Gloucester, MA 01930, Tel. 978-281-2441
Page 1 of 1
��,m Ass�ssars ���bwS2
a
8 FFL '24'
(54) 5:
9
1 14 QQ LL
'
FfL
t1 �
:13. I ki l�'. h�96j 1
18
OFP
S (1'44)
!6Y
I. 00J IS Wkelve- S: r>w; 1 s io be epla�ed
2,4Z. wlvljov ,S bz1h9 rQplgctd
http://salem.patriotproperties.com/sketch/5000/158001.jpg 8/20/08
CITY OF SALEM
s
PUBLIC PROPRERTY
DEPARTMENT
I 1. 9-8.-1 ;;�); • 1:,\.. '0-8.-1_-'N-11,
ers
N orkers' ('un3pensalion 111su3-ance it: Builders/ContractorsiElectrici nsiPl L eb hl
%,,nii ant Inlormetiun o4
N.Illlc I Ifn.inr,s t h',_.mvanl�n hlJls ideal I:
.\ddFC5i:
0ty st:ue.zip: 9� r
Phone #:
\re y%ou an employer:' Chrck the appropriate box:
Type of project(required):
;. ❑ I wn a general contractor and 1 6 ❑ New construction
1.❑ I am a employer w ith * have hired the sub-contractors
employees (full and'ur part-time). 7. It Remodeling
mJ on the anachcd sheet.
_. ] I ,tin a sole proprietor or partner-
I here sub-contractors have 8. ❑ Demolition
,hip and have no employees workers' comp. insurance. 9. ❑ Building addition
,lurking for me in any capacity.
9. ❑ We are a have
exercised
and its IO.❑ Electrical repairs or additions
(No workers* sump. insurance officers have exercised their
required.) 11. Plumbing repairs or additions
1.❑ I am a homeowner doing all work right of exemption per [v e n ❑ g P
C. 152, $I(4), and we have no R.❑ Roof repairs
myself. [No workers'comp. employees. [No workers'
insurance required.] 13.❑ Other
sump. insurance required.]
•;\ny dpphCJlll that checks box pl must also till out the section below.showing(heir workenl'compensation policy infumnution.
t I coma pliva who submit boxthis affidavit indicating they are doing ell work and then hire outside contractors most submit a new affidavit indicating such.
:Coumu.tors that.heck this hex must altac hcd an additional sheet.hewing the name of the sub
-cuntrachxs and their workers'comp. policy in fortnalion.
!am in employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:--
Expiration Date:
Policy q or Srlf=ins. Lie. q:
City,State/Zip:
Job Site Address:
Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
Failure to secure co%crage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S I,>IIo oo ❑nd'or one-year imprisonment. is well as civil penalties in the form of a STOP WORK ORDER and a tine
Id (lla to l'_5nJa)a day 3-Pinst the \iolator. Be ad%i.,cd that a copy of tllll statement Inlay be forwarded to the Off-ice of
h;,c.n uatian, of the DI:\ for insur:ulce cos erage ,cnficauun.
/Ju herrhy rrni/i'nu •rrh1 pains I,nd peltaltie.s of perjury that the inforurution provided above is true and a orrect.
Date:
�n�n,nllra •
U/lit tal it unlr. Do mat I,rite in this area. ro be a unnpleted by city or anvn ofJiciaL
( its or fuss n: _. . -_._._ . — -
Permit)l.icense q . - -- - -- -- -- - --- —_ ..---
Issuing \uthorih (circle one): •
I. Board of licallh 2. Building mparhncot 3. ('ityffn,srn Clerk J. Elecirical Inspector 5. Plumhing Inspector
6. other - - - - --- ---- -
Phoneq:_.__ - -
Information and Instructions
\I.i—a,Lu>ctts (icneral I av%s chapter 1 s' rcquurs all cmplo\crs to pro\ide tv orkcrs' compcnsation f„r their elnploNees.
I'unu.uu to tus ,t.nutc. .in empluree a dctircd as ct cry person in Lite ,cr\ice of anollIcr under .tin contract of hue.
:\prc,s or mplhcd. oral or v\rnten... .
\^ emph,ler I. defined as in hnJn:dual. p.uti:cr,hhp, a,soch.mon, c,)rp.,ration or other Iceal entity. or .mv two or more
of hhc fohc_ouhg cn_agcd in a lohnl cmcrpri,c. and including the Ic•_al represcntan\c, of a decedacd cuhplo}er. or the
cccn cr or 0n1IeC of an uhdh\IJual• pat inernhip. a„Ucution or other Icgal enure, cntplo)utg cnhplovees. I lov\C\er the
,�•.�nee ,H a .11A V Illog house ha\hng not snore Than Three ,hparnucnts and ,\ho rc.ides therein, or the occupant of the
,bvci!uhg hou,e of another who enhplo., person, to do nhaunenance, construction or repair Mork on such dwelling house
,It on the _round, or building appurtenant hereto ,hall not he:ause of,uch enhplo,mcnt be deemed to he an cntplo}er."
\1(d chapter I51, �25C111 also ,late; that 'every state or local licensing agency shall withhold the issuance or
renew al of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
\Jditionally. SIGI. chapter I52• j250-) ,fates "Neither the commonwealth nor any of its political subdivisions ;hall
enter into dny contract for the pertivmance of public work until acceptable e\idence of compliance with the insurance
requirements of this chapter have been presented to file contracting authority."
\pplicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, supply sub-contractors) nume(sl, address(es) and phone number(s)along with their certificate(s) of
insurance. Limited.Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtainer workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
,elf-insurance license number on the appropriate line.
City or Town Official
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to till out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit,license number which will be used as a reference number. In addition, an applicant
that must submit multiple permivlicense applications in any given year. need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town).- A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
Applicant as proof that a valid affidavit is on tile for future permits or licenses. A new affidavit.must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit.
I he ( Mice of Imestigations would like (o thank wu in advance tor your cooperation and should you hd\e any questions,
plr.h,e do not hC*Ifdfe m give uS d call.
I he D) patnncnt', address, telephone and tax nwnber:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OITIce of Investigations
600 Washington Street
Boston, MA 021 1 1
Tel. p 617-727-4900 ext 406 or 1-877-MASSAFE
Fax k 617-727-7749
www.mass.gov/dia
� > CITY OF SALEM
A r PUBLIC PROPRERTY
DEPAR"I'MENT
I T 0 "A I I M, N1.\a\i
Construction Debris Disposal Allidavit
(rcyaired litr all demolition and renovation work)
In accordance %%ith the sixth edition of the State Building Code, 7S0 C'NIR section 1 1 1.5
Dcbtis, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall be Disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
t name of liauler)
The debris wwill be disposed of in
I��PA�a '� _
(name of facility)
UUulJrens of lacil ivl
v
,iguaturc of permit applicant
S 20 0
date