30 BROAD ST - BPA-2008-962 2 FL BATH n �
The Conunonw ealth Of N'IaSSaChtlstllS
Board of Budding Regulations and Standards Pt ut
VII�Nhll'.AI.II l
� Massachusetts State Building Code, 780 ('MR, /il� edition tits
Building Permit Applicuuon TO Construct. Repair. RCnovate Ur Denxdish a R,i iWd l:uu:,l:,
One- nr Tu o-Family Do elling '"Os
This Section For Official Use Onlv
Buildings Permit Ntl&cr: Date Applied:
��Signature: — x� -- -.- -- ----
11 dui Con n t"lonei/ his ctor ul Building's Date
SECTION 1: SITE INFORJIA HON --- _--
1.1 Address: S� 1.2 :lrssessors .Nlap & Parcel .Numbers
ddrO ----
I.la Is this all al'l Cpted street! \'Cs lit) Map Number P;trcc ,Nniuhcl
1.3 Zoning Information: La Property Dimensions:
Zoning District Proposed Use Lot Area (sq ti) Fronwge i li l
1.5 Building Setbacks (ft)
j Front Yard Side Yards Rear Y:Ird
Required Provided Required Provided Required P1o\1ded
1.6 Water Supply: (M.G.L c. 40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone.' Municipal ❑ On site disposal systein ❑
Public ❑ Private❑ Check it yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) Address t'or Service:
Signature
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ E.xisting Building ❑ Owner-Occupied ❑ RepttirsU) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specily:
Brief Description of Proposed Work:
SECTION A: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
l Labor and Marerwls) _
t. Building `$ S'�oo I. Building Permit Fee: $ Indicate how (ee is delermm d:
❑ Standard City/Town Application Fee
? Electrical 5 001) ❑Total Project Cost) (Item 6) .x multiplier - x
3. Plumbing S ' J00 1. Other Fees: $
d. :Vlechanical LIVAC) .S List: —
i
5. Mechanical (File
Total All Fees: S X
Su)�ressiun) / ✓
!!11 Check NO.I�J Check :Amnon( Cush Am::unl - -- I
0. Total Project Cost: S d bV Paid in Full 0 Outstanding Balance Due.�/�!r/���
SECTION 5: CONSTRUCTION SERVICES + _�
�.1 L+icensed Construction Supervisor ICSIJ � � ZQ
!lh M11 I; Li'Cnlse ZNumber ILA nr:1uun Date
.Name of(" Holder l W L,�
L.ul CSL I)'pe (xee belot+) _
\d Dcscri rtlun
C,> 1. l�:nrcunclrJ to t la 15.0001'1] hI i j
K Re,llleted I,@' F:umh D,kelhne
Sic�n,:/cure�y (. \1 Maso n} 0111.
RC Rc.,iJCnu al Ruullnu l'ut Brine
TClcphone N:S Re>ideni�,d A1luduo ,md lulnc _
SF Revdenual SiJid PLeI Hunan" \pphanee It .t.dldunu
D RC>Idcnt rI Dcuwlmon
5.2 a<istered Home It t roventent Contractor 0110
l 2 0 0& Z --
HIC Company Name or MC Registrant Name Regastruuun Number
Addles, Ste"{-
Gapuauon Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. 152.
Workers Compensation Insurance affidavit must be completed and Submitted with this application. Failure to pnr+ide
this affidavit will result in the denial of'the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O No .......... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I.� i_. au+ne "ham k �4 vt♦ oes 4wd1 a as Owner of the subject property hereby
audtonze -Y� 1-4 Cr S __ to act on my behalf. in all matters
relative to //wq��ork authorized by this building permit ❑�pl ication.
� _.,:-�1. t e,,2-,,
Siertat Ie of Owner r Dute
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, S'W tk� &#t „r 9'b 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 knowledge Lind
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Simed under the sins and penalties of erurvl
NOTES:
I. An Owner who obtains a building permit to du his/her own work ur an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor (HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important intoi ination on the FIIC Program and
Construction Supervisor Licensing (CSL) can be found in 730 CMR Regulations I WO R6 and 110.R5. respectively.
_' When substantial work is planned, provide the information below
Total flours area (Sq. FLI (including gnage, finished basement/attics, decks or poich 1
Gross living urea ISq. Ft.) Habitable room count _
Number of fireplaces Number of hechoom, — .--_
:dumber of bathrooms Number of hall/hash,
Type of healing system_ Number'It deck>/ porches --- ----_--. j
Type of Culling system Fncloscd _()pen
3. "Total Project Square Foolage" may be substituted for 'Total Project Co,t'
t w
CITY OF SALEM
PUBLIC PROPRERTY
r' DEPARTNIENT
3 ;
`dJtr Hl l-1 :hkls, �,I I
... VLv�,r< I':. U'�,li;�l;;,,�juu rl • c.vihvt. ALv.:.v m .i-i :,:Ih�
Workers' Compensation insurance Af idal'it: Bullders/CUntractors/Electricians/Nlu Rlbers
\ ) )hkant Inl'ortnation Please Print Leei
Va117C lncanc^.1; l lr_.uu/soon.InJn�pnluoll: 1 tt tr7J 1� l- 1 X� `� a
:address: i�1 C-41
City,Suite Zip: s1���4 Q�7 Phoned: � ��' �� ' � �✓I �
.tire cou an employer:' Check the appropriate box: rope of project(required):
I.[ 1 all, a employer with 4. ❑ 1 ant a general contractor and 1 6 ❑ New construction
employees(full and/or part-time).* have hired the sub-contractors 7. [ Remodeling
2.❑ I ip a sole proprietor o partner- listed on the attached sheet.
ship and have uu employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a havcore
exercised
and its ME] Electrical repairs or additions
required.) officers have exercised their
i ,ht of exemption per MGL 1 I.❑ Plumbing repairs or additions
right 3.❑ I am a homeowner doing all work P P'
myself. [No workers' comp. C. 152, $1(4), and we have no 1 L❑ Roof repairs
insurance required.] t employees. [No workers' t3.[-1 Other
comp. insurance required.]
\uy.Ippleant that checks box.HI mint also till out the section below showing their workers'compensation policy information.
1 I lumaowncrs who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
4'0n11a1t01s,hat.heck this hum must attached an additional sheet showing the name of the sub-contractors:md their workers'comp. policy information.
I and an employer that is providing workers'compensation insurance for my employees. Below is the policy and job.site
in f Lrm ation.
Insurance Company Name:
Ilolicy #or Self-ins. Lic. it: �j Expiration Date:
,/�
.lob Site Address: 30 t/r000 1? City/State/Zip:
:\ltach 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
tine up to S 1.5oomll and/or one-year imprisonment. as well :rs civil penalties in the firm of a STOP WORK ORDER and a fine
,it up to j'50.00 a day aeainst the violator. Be advised that a copy of this stalelnerit may be forwarded to the office of
Imo csli_:uions of the DIA for insurance coverage ccnfication.
l do hereby rerti%-in er the pains uad pr nalties uJ perjury that the inf)rnmtiros prvrvided above is true and correct.
_ttln ,
1_I_II,l ��l Skk-131 r
01ficial use only. Do not write in this area, to he completed by city or town official,
('iiv or Town: _.___------ ----- --- Permit/License
Issuing .\uthority (circle ( ne):
I. Boanl of llealth 2. Building Department 3. Citt/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
0. Other --- _.--
Contact Person:_--- _—_-- ------ Phone #:-- -
Information and Instructions
w:cns Grncral 1_❑cos chap(cr 1 j_ rrgwres :ill emplo%elS m pros ide workers' CntnpenSaIion tier (heir eniplovices.
I'.trSuant to (his etatltte, .(n retPlo,ee is ,letined as et ery person in the set iCe of :jilt thcr under any eon tract of hire.
e\press or implied. oral or ii ri tics...
\n :niplurer is dclined as ":ui indiS;dual. p.inncnhip, :tssoci:uion. Corporation or Other entity. or am nw or more
of (he toicgoing cnga_ed in a joint enterprise, and including the legal representatives of a deceased employer. or the
rccciccr or tnutce of an individual, partnership, association or oilier Icgal entity, cniploy ine employees. flotvever (he
u ncr of a duelling house ha%ing not more than three apartments :aid who rcsidcs 111Creln, or the occupant of the
diiclling house ofanother ivho emploNs persons (o do maintenance. construction or repair work on Such dwelling house
r m (he grounds or building appurtenant ;her
yyo,•shad not because of;itch employ men( be deemed to be an employer. •
\l(iL Chapter 152, 2i06) also states that "every state or local licensing agency',shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the'cotfitui)inceelth for anv
applicant who has not pruduCctt,acceptable evidence of cotnpliance'with the insurance coverage required ",� ,,,, i .
.\ddi(ionally. \IGL chapter IS_, �_-C17)'.<iaics "Neither the CUn1n1Un\\Yalth nor any ofts piiliiit�l subdivisions shall
enter into any contract for tilepertimnance of'public %%oik until acceptable eN idence ofcompliance with the insurance
rcquirenientS of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if
necessary, Supply sub-contractor(s) name(s), address(es) and phone nuniber(s) along with (heir 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
be 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 obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be 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 he sure to till in the petmit/licensenumber which will be used its a reference number. In addition, an applicant
that nmst Submit multiple permit/license applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant bhould 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 its proof that a valid affidavit is on file 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 (his affidavit.
The (Mice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
the Dvparunent's address, telephone and tax nuniber:
. The Commonwealth of Massachusetts, +
Department of Industrial Accidents
Ofllce of Investigations f. +' • '
600 Washington Street
Boston, MA 02111
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
KC%ised 10-0 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
•` PUBLIC PROPRERTY
�.�.- DEPARTMENT
\l •...R (,- %,�Q
r
Construction Debris Disposal :Affidavit
(required ror all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CNIR section 111.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit H _ _ is issued with the condition that the debris resulting from
([its work shall be disposed of in a properly Licensed waste disposal facility as defined by NIGL c
111, S 150A.
The debris will be transported by:
- Umntr of auler)
r
I'I:e br,; will be disposed of in
NprT� SGAE ��Tr
^ (nlc:r ul lla�rty)
Hey Tom,
The print out for the throom and the specs for the tub, sink & toilet are attached.
We're going to be using the Brosco Tru-divide, tilt in window with the Low-E energy
panel. We're not put up a storm window but we do want the full screen, not the 1/2
screen.
The electrician that we're using is Roy Spittle Associates out of Gloucester. Just let me
know when you think you'll need them. I'm going to give them a call (Monday) so that
they know we've started the process.
On the floor installation, you're first quote stated $4- $6/ square foot, now that we know
we're going to be using real hard wood flooring—do you have some samples you can
show us so that we can decide on what type of wood to use? We like to use 3" —5" wide
boards in there and will be staining them dark— unless we go with a walnut like the
kitchen.
The second quote had $500 for the tub the —does that include the tile and installation?
Last question, the guy doing the demo popped a small hole in the kitchen ceiling, are you
just going to have the plasterer fix that when they come in?
Thanks
Kevin &Steve