1 BARNES AVE - BUILDING INSPECTION C,t<- Q0 t orb
The Commonwealth of Massachusetts
n Board of BuildingRe and Standart
Regulations RECEIVED crry of
Ik SALEM
Massachusetts State BuildingCode, ZONAL SERVICES
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovajl 8r Li mgisgt 2
One-or Two-Family Dwellin��1a J f ( 1
['his Section For Official Use Only
Building Permit Number: Date p ,lied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property % ld �, 1.2 Assessors flap& Parcel Numbers
1.1 a Is this an accepted street?yesno Map Number T Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use For Area(sq tl) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provtded Required Provided Required Provided
1.6 Water Supply:(MLO.1,c.40, §54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zonc?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNF,RSIIIPt
2.1 Ownert 'I cur
9
Name(Print City.'
No.and Strcet 'I'elep to '� � Enatil Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ E.xisting Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:__
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and .Materials)
I. Building $ 1. Building Permit Fee: $. Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x_
3. Plumbing $ 2. Other Fees: $
q. Mechanical (IIVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fees: $_
Check No. Check ,\mount: _Cash Amount:
(>. 'Total Prolect Cost: $ Cl Paid in Full ❑Outstanding Balance Due:
,QJT q t (rJAaTtntto FSR. Coo- r"T
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructupik Supervisor License(CSL)
L,icense eb r Expu, on to
Name of CSL Ho '
l / �f^ List CSI,Type(see below) '
No.and Street' I/`{ 1°a Type Description
U Unresiricted(Buildin s u to 35,000 cu, ft.)
Gty/L�t,ZIP R Restricted 1&2 Fainily Dwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home-jjnprovementCon actor(HIC)
�- HIC Registmtroi N amber Exp' a[i ate
HIC Com M *Dc t.' t erne
No.an .Ireetkimail address
Cit /Town,S "fele hone
SECTION ORKERS'CONIPENSATION 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[he denial of the Issuance of th uilding permit.
Signed Affidavit Attached? Yes .......... 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 K&�
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) )are
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By en n my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
conta' ed ' th' app cation ' true and accurate to the best of my knowledge and understanding.
Prin wt er's or Ant orized Agent's Name(f'lecrronic Signature) 0CIL
utU C
NOTES:
I. 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 find under M.G.L. c. I42A.Other important information on the HIC Program can be found at
www-1n&Ss.eov/oca Information on the Construction Supervisor License can be found at www.ntass.eov/dos
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/haths _
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"
` QTY OF SALEM, MASSACENSETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET,31D FLOOR
TEL. (978)745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and 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,S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
UDKE: 02�
(name of hauler)
The debris will be disposed of in:
U �4r
(name of facility)
(address of facility)
Si nature of applicant
/Date
'.:.• f '�C!"�.�'fi Eletii'!rd7�iv2bYlF'G2 Sj/�-�.''�Ya c.} Gvd'(�w:
r3`a�
of`h'EdE:lstvial ArcilllciOs
QjC�cE ®ffS87r2,F$d�'eE�E���
dOQ k3 asl2areg3vw stk„ ,
�.� Boston, MA 02111
Workers' cComlpensatnon linsurance Affldlav t. BudId ers/Corrntmal:tins/�Il��Ex��nanas/Il Il sannIlA�n°s
Apj&ant IInfornnnation s 6 Mease PAM LeF_ib
Name (Business/Oig,inzation/Individual):
Address:
City/state/Zip: Phone ': tbj �57b -4 ,f� l
Are y an employee'?Check tle�propriate box: 'Type of project(required):
I. I.am a employer with h 4. ❑ I am a general contractor and I F. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.$ T ❑Remodel ng
ship and have no employees These sub-contractors have 8. ❑Demolition
working forme in any capacity. workers' comp. insurance. 9. ❑Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ of repairs
insurance required.]t employees. [No workers' 13. Other
comp:insurance required.]
*Any applicant that checks box#t must also fill out the section below showing their workers'compensation policy information.
I Homeowners who submit his affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such.
XContractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'camp.policy information.
I am an employer that isproviding workers'compensation insurance for my employees. Below is the policy and job site
information. p—
Insurance Company Name: 111411%�l/fin J
Policy 4 or Self-ins.Lic. 4: " Fxpiration Date:
Job Site Address: L . City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that 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 andpenalties ofperjury that the information provided above is true and correct.
Si nature: Date:
Ph
Of 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):
I.Board of Health 2.Building(Department 3.City/Town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone 4:
=06i':"G
k ontrlwiiori Superviqfir Ng
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HoME IMPROVEMENT CONTRACTOR
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CRAIG�.NINDO-WS Ei
RONALD CRAIG
-
q PARK RIDGE DR-
HUNTINCTajq, MA 01050
Castle the Window People
Finance Report
Job# Sale Date Sales Rep 1 992LRep 2
128368 8/8/2014 WISENEWSKI, MATT
r
nformation Balances
e Julien &MillsSale Amount 2,707.00
e Adjustments 0.00
01970e (508)641-6084 Net Amount 2,707.00
e (978)745-2342
rk ext. Payments 812.00
Mrs.Work ext Balance 1,895.00
[Dates
Approved Released Cancel Saved Reject
8/12/2014 8/12/2014
Bank Terms Amount Financed
CASH
Notes
08/12/2014 08:00 DMC REMOVE 5 WOOD WINDOWS, INSTALL 5
WHITE WINDOWS/WHITE CAPPING
1-C2LT, 1-C3LT(1/4-1/2-1/4)CENTER FIXED
NO GRIDS
REMOVE 3 MULLIONS
CONSTRUCTION: REPLACE LIP/SHELF FROM MULL REMOVAL
HOUSE BUILT IN 1848 BS
EST START 10/7, EST COMP 1017
CUSTOMER MUST SIGN CHANGE ORDER
'v Z? $FERTIF e8 � `� •€ ke` t �-�ieti 03T€Y•261f._.�I
THSS CERTi(TCATE IS ISSUED AS k Ph ATTER OP IN�rOR69k51OH ONLY AND CCNpR s No ROM A�� T'2E COVERAGE
HOLDER• THIS CERTIFIC�TE' GOES_ NOT AFFIRMATIVELY OR NEGATWELY AME14% _
.AF FORDED€Y THE POUCHES BELOW. THIS CERTIFICATE OF IF&UR1hPeCE DOES HD`F COHB'�tTUTE&L`,OIt7nACT G `.$�EF7
-fH€lSRIIfHfl{HSURkR(�),AUTHORIZED REPRESENTATIVE OR PRODUCES AfiD Th£CERn�F1CATE HOLL%EP.--
IMPORTANTI N 11!e cert1Aeete holder're cn AOWTICNALIFdEUMI,Ihspollcy(is )mustBe endQ7Pc-� If 9USR6'�f TiJS ISVF'a.EVE3,
eU`u)e®FtO IIIC .:"FiiB En(�COfIdfID:lS Df ti,t P511Gy, UI99 pUIICler=f yregc,ira en�lJcr��rmL A'iELm==�l er hl-.e ^ufiscts-r:>,:=
rr of maier nahU W IIG cu*H`E"S 11o1der irl lieu o`:UaF 6nAa e_�cnt(s).
CCNTAGr
RROOUCEPT Nunes-
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GARELLAS 4N5 AGCY ING, y��ere ` e. Iu0N_�_ .—_s -
ZOFPARK AVENUE -
WEST SPRINGFISL3,MA 01085 Ian
NSUREAISIAPFO109trOLdAERAGS NAICB
.N?JR ER A:TRAVRERS PROPERTY CA_41AL1 I LOMRANY OF
AMFR,LC
CFRAIG ROIdALODBACRAIO
WINDOWS
[N�VIVM
PO BOX Z92
HUNTINCTON,MA01050
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THIS 13 TO CERTIFY THAT THE POUCIES OF INSURANCE LISTED BEL OW HAVE BEEN ISSUED TO THE INSURED NAMED
ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REOUIREMENT, TERM OR CONDITION OF ANY
CONTRACTOR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE IAAV BE ISSUED OR MAY PERTAIN,THE
INSURANCE AFFORCED BY THE POUCIES DESCRIBED HEREINISSUBJECT,TO.ALL THE TERMS, EXCLUSIONS AND
CONDITIONS OF SUCH POLICIES.LRAITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.. "
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AFrr PgOPq,ETOR•�ARiNewekECUTry✓' - E.L.EALN ACC,OFNT $160,600
OFFCERLIEUSSR 6=LUOFu9 TAT R(A 7PJUE 03.15.2014 03.152015 F.I.00iSIRE•EAFAIFLOYFP $$60,666
(Uerdbmf in NN1 L:1 56877428
IYK�smiOa eller LLObEASE•PQ.0 LWM $166.666
OESCRIP7:01I OF OPERATIONS f 1I
OESCRITT ON OF OPER An ONS I LO CATIONS I VF CUES(Aff=h ACORO 10I,AdWb-1 RamF,%s scma,n,ll maro.p+a�,,..7.Ime) '
THE WORKERS'COM RENSATION POLICY DOES NOT PROVIDE COVERAGE FOR CRAIG,RONALD
FFANCELLATION
SHOULD ANY OF TIIE ABOVE DESCRIBER POLICIES 8E
CANCELLED BEFORE THE E�FIRATION DATE THEREOF,
NOTICE WILL BE DELIYERED IN AGCCROANCE VATH TH
POLICY PROVISIONS.
A HE MSQdTATIVE
rd IOISB•2070 ACOAD CCRpORATIDFI.All riUhls n�wrrve,L
aCCHU25('(01111051 me ACORD nnme and !uqu its m6islured marks CI ACORD