7 CHESTNUT ST - BUILDING INSPECTION s CLG (o ff b r1 RECEP&D
The Commonwealth of Massachusetts t CITY OF
Board of Building Regulations and Standards
Massachusetts State Building Code,780 CMR T01b AY nLN 1 0
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
n One-or Two-Family Dwelling
u / This Sect)on For Official Use Only
Building Permit Number. Date Applied:
Buildmg'Offtcial(Find Name) �.Signature
SECTION 1:SITE INFORMATION
1Address:
� _ S�e�L4 1.2 Assessors Map&Parcel Numbers
1. Is tht an accepted street?yes--L/— no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft)
Front Yazd 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 OWNERSH111'
2.1 ZS t e of Record: r ,//
'S a1AA S 6�Ci' S uIt i 74 G..-le/yr ///LL
Name(Print) City,State,ZIP
S C� FK
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ i Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work: i M
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only ;
Labor and Materials
1.Building $ 8�S�.c¢� 1. Buildipg Permit Fee:$ Indicate how fee is determined.
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost9(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: - r i �
5.Mechanical (Fire $ Total All Fees:$
Suppression) -
�� o a. Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 1� ❑Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
t
5.1 Construction Supervisor License(CSL)
X, A rt t/1{. ilv /� Jp�7?D
�45�r1ceq'ta5/i.II$Sa License Number Expiration Date
Name of CSL Holder
I c9 %I C' List CSL Type(see below)
No.and Street J T Des`atphon'
v t v S13 U Unrestricted(Buildings up to 35,000 cu.ft.
Restricted 1&2 Family Dwelling
City/Town,State,ZIP - M Masonry
RC Roofing Covering
WS I Window and Siding
Solid l Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improve nt Contractor(HIC)
� 15 � � 3 �-r7-i-�
f'J CWS60 HIC Registration Number Expiration Date
HIC y Name o'HIC gisf� 9ne
' 6 f�
No/(Y✓��''��lJt ��Q /r/��S 7� 7 Email address
City/Town,� State ZIP (J J Telephone
SECTION 6:WORKERS'COMPENSATION I1�ISIJRANCE AFFIDAVIT(M.G.L.0.152.§ 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 f the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION`7a:OWNER AUTHORIZATION TO UP COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR 13VILDING PERMIT
I, as Owner of the subject property,hereby authorize 5r SdA -e%
to act on m I ehalf,in all matters relative to work authorized by this building permit application.
5-1 a-/6
Print zr's Name(Electronic Signature) Date
SECTION 7bl OWNEW 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.
Print er'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.govloca Information on the Construction Supervisor License can be found at www.mass.eov/dns
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"
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: S
Constructionn Supervisor �
" JASON M SANTOSUOSSO
18 GAIL STREET -
TOPSFIELD MA 01983 "-
r-.-qz7,K CA-- Expiration.
Commissioner 0/10612018
cIe 1z o���Ga c�u�ae
Office of Consumer Affairs and Business Regulation
10 Park Plaza. = Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 156563 -
{' DB Expiration: 2017 Tr# 267963
SANTOSUOSSO CONSTRUCTIONPh�.Y
JASON SANTOSUOSSO Ir, -
18 GAIL ST
TOPSFIELD, MA 01983
pdate Address and return card.Mark reason for change.
scut O 20�11 - Address ❑ Renewal ❑ Employment ❑ Lost Card
V/[C ((i0)IU/raJ[IX/Ca�l�O�C�/r�r1XlCILGJC!!J '
Office of Consumer Affairs&Business Regulation - License or registration valid for individul use only
OVEMENT CONTRACTOR before the expiration date. If found return to:
Wegus=T 156563 Type: - Office of Consumer Affairs and Business Regulation
piration:-711.7f21)17- OBA 10 Park Plaza-Suite 5170
- - Boston,MA 02116
SANTOSUOSSO C614STRUCTIOW5
JASON SANTOSUOSSO �-
18 GAIL ST ---"--"- , o
TOPSFIELD,MA 01983 -- Undersecretary Not lid without signature
The Commonwealth ofMassachuseus
t Deparbnent oflndustrialAccidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILM WITH THE PERMTrnNG AUTHORITY.
Applicant Information Please Print Legibly
Name(Business/Orgamzatimth. ivideal):
Address: l
City/State/Zip: G Phone#: ')e1 �1 6 7 7t}
Are you nn mpbyer7 Check the appropriate box: E14.E]Other
project(required):
1191am a employer with 3 employees(full and/or part-time).•
ew construction
2.❑Ism a sole proprietor or partnership and have an employees working forme in
MY capacity.(No workers'comp,instaance required) modeling
3.O I am a homeowner doing all work myself.[No workers' molition
omrp.insurance required.)1
4.❑I am a homeowner and will be hiring contractors m conduct all work on my property. I will ilding addition
encore that all contractors either have workers'compensation insurance or are sole ctrical repairs or additions
propru tors with no employees.
mbing repairs or additions
5-0 I am a genmal contractor and f have hived the sub�contrsctm listed on the attached sheet.
These sub-contractors have employees and have workers'comp.insmnnce t f repairs
6.Q We are a corporation and its offices,have exercised their right of exemption per MGL c er
15Z§1(4).and we have no employees.[No workm'comp.insmmce required.,
-Any applicant that checks box#1 must also fin out the section below showing their workee 'covpmsation policy infomtatim.
t Homeowners who submit this affidavit indicating they sic doing as work and than hire outside contractors must submit a new affidavit indicating such.
tCUnbutors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. Ifthe sub-contractors have employees,they must provide their worker'co'V policynumber.
lam an employer thin is providing w�voor�kers'compensation insurance for my employees. Below is thepolicy and job site
informadon. jra %MfaS 77i�a.nCT
hnsurance Company Name: (ego-6
Policy#or Self-ins.Lic.M ( Expiration Date:
Job Site Address: 5' `�1 r�STH✓at �-• GSty/Stetelzip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a minimal violation punishable by a fine up to S 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 ropy of this statement may be forwarded to the Office of investigations of the DIA for insurance
coverage verification.
I do hereby certify andpenaldes ofperjury that the information provided above is true and correct
Signature: ate:
Phone -7C,2) St?Q (n -77A
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#•
Information and Instructions '
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)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 commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required"
Additionally,MGL chapter 152,§25C(7)states'Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements 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)nane(s),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
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 lute. _
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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the pemut/license number which will be used as a reference number. In addition,an applicant
that must 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 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 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 pemut to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-727-4900 ext. 7406 or 1-877-MASSA-FE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
Ch Y OF SALE1V11, MASSACHLBEM
BummwDEPAimma
110TAS CWNSnW,3;ORO t
3kL(978)745.9595.
FAx(978)740.9846
BDv1QERLEYDRiSOOLL
MAYOR 7)XumSTJW=
DmacrcatoFPtauc /Buuw4Gcc mss<(7#�n
Construction Debris DisposaiAfdavit
(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 S4; Building Permit At 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:
(name of hauler)
The debris will be disposed of in:
Mee
(name facility)
�7L
(addres(of facility)
Sfignafure of applicant
S-(q
Date
Commonwealth of Massachusetts
3 City of Salem
120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 r5641
Return card to Building Division for Certificate of Occupancy \
Permit No.$5 B-16-563 PERMIT TO BUILD
FEE PAID: $56.00
DATE ISSUED: 6/8/2016
This certifies that JOHN & DONNA SEGER
has permission to erect, alter, or demolish a building-_7_CHESTNUT-STREET Map/Lot: 250562-0
as follows: Roofing STRIP & REROOF
(SHA approval on file) '.
6
Contractor Name: JASON SANTOSOUSSO -- --
DBA: SANTOSUOSSO CONSTRUCTION
,f � I
Contractor License No: CS-104770 t
I t
I 6/8/2016
r -
Building Official �' Date
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written request. \
I \
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
I f
All construction,alterations and changes of use of any,building and structures shall be in compliance with the local zoning by-laws and codes.
t 1
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open/for public inspection for the entire duration of the
work until the completion of the same. I I
I
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Oifcials,are provided on this permit.
HIC#: 156563 -Persons contracting with unregistered contractors do not have access to the guarantyfund"(as set forth in MGL c.142A).
Restrictions:
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.
Commonwealth of Massachusetts
3 R City of Salem
m 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 IF
Return card to Building Division for Certificate of Occupancy
Structure CITY OF SALEM BUILDING PERMIT
PERMIT TO BE POSTED IN THE WINDOW
Excavation 5
Footing INSPECTION RECORD
Foundation
Framing
Mechanical
Insulation INSPECTION: BY DATE
Chimney/Smoke Chamber
Final
f0A. Plumbing/Gas
Rough:Plumbing IF /
Rough:Gas
Final
Electrical ^�
Service \
Rough
Final
Fire Department
Preliminary
Final
-@0 Health Department
Preliminary
Final