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105 BROADWAY - BUILDING JACKET SuperTab® Ovoweddab Fddera 90%Larger Label Area • •�•^• /// BMEAD KEEPING YOU ORGANIZED Na."M wrpam" slob rum GET ORGANM AT SMEAD.COM MuLmmoomm � UNIT �� . � v��T 1 I I r- -- -� Certificate Number: B-14-927 Permit Number: B-14-927 Commonwealth of Massachusetts City of Salem This is to Certify that the Single Family Building located at Building Type 105 BROADWAY in the City, qf Salem .............. .......---...............I........ Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY Unit #1 JOSEPH GA GNON This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires ....---....................Not APPlicable ........... unless sooner suspended or revoked. Expiration Date Issued On: Thursday, August 28, 2014 a Commonwealth of Massachusetts City of Salem 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641 Return card to Building Division for Certificate of Occupancy _ Permit NO. B_14.927 PERMIT TO BUILD FEE PAID: $420.00 DATE ISSUED: 5/22/2014 a This certifies b that GAGNE JOSEPH R GAGNE MARIA K r has permission to erect, alter, or demolish a building. 105'BROADWAY Map/Lot: 320130-0V as follows: , Renovation PHASE 1: COMPLETE INTERIOR RENOVATION (ROUGH) INCLUDING w STRUCTURAL COMPONENT. NEW FRONT & REAR EXTERIOR STAIRWAY,.WINDOWS, ROOF,' " `�ELECTRICAL $ PLUMBING > „ _ Contractor Name: GAGNON JOSEPH DBA B F. Contractor License No: 031807 A 4 . 5/22/2014 c. Building Official -' Date @ This permit shall.be deemed abandoned and invalid unless the work authorized b this 1rr BC y permit Is co, menced within months after issuance.The Building official may gram one or more extensions not to exceed six months each upon wrdten request.. All work authorized by this permit shall conform to the roved application and the _ e PP d, approved construction documents for which thik permit has been granted. ` All construction,aHerations and changes of use of anybuilding and structures shall be in compliance with the local zoning.by-laws-and codes. This permit shall be displayed in a location clearly wsible',from access street or road and shall be maintained open for public inspection for the entire duration of the work until thecompletion of the same. 3. - I The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on fhis permit. « - H IC#: Persons contracting with unregistered contractors do not have aocessao the guaranty fund'(as set forth in MGL c.142A). Restrictions: r- Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. i U f each of Massachu City of Salem c 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 X5641 _ Return card to Building Division for Certificate of Occupancy A Structure CITY OF SALEM BUILDING PERMIT ExcavatiPERMIT TO BE POSTED IN THE WINDOW on Z `7 , � Footing "1 T INSPECTION RECORD Foundation Framing Al 2 _1611�y V a n_ Mechanical - - r - O Insulation '� INSPECTION: BY DATE Chimney/Smoke Chamber Final Plumbing/Gas x g Rough:Plumbing 00111�7. O Rough:GasSK � G. 0 Finale Electrical ' Service Rough Final Fire artment Preliminary .2 l Fin 0 Health Department Preliminary Final Certificate Number: B-14-927 Permit Number: B-14-927 Commonwealth of Massachusetts City of Salem This is to Certify that theSingle Family Building located at Building Type ......105 BROADWAY. .. in the City of Salem Address Town/City Name IS HEREBY GRANTED A PERMANENT CERTIFICATE OF OCCUPANCY unit #2 JOSEPH GAGNON This Permit is granted in conformity with the Statutes and Ordinances relating thereto, and expires ............................Not Applicable unless sooner suspended or revoked. Expiration Date Issued On: Thursday, August 28, 2014 °i� Commonwealth of Massachusetts ` = City of Salem 120 Washington St 3rd Floor Salem MA 01970(978)745-9595 x5641 Return card to Building Division for Certificate of Occupancy Permit NO. B_14.927 - PERMIT TO BUILD FEE PAID: $420.00 DATE ISSUED: 5/22/2014 This certifies that GAGNE JOSEPH R GAGNE MARIA K t has permission to erect, alter,'or demolish a building . 105 BROADWAY._ Map/Lot: 320130-0 ' as follows: Renovation PHASE 1: COMPLETE INTERIOR RENOVATION(ROUGH) INCLUDING STRUCTURAL COMPONENT. NEW FRONT 8r REAR EXTERIOR STAIRWAY,WINDOWS; ROOF, ELECTRICAL 8r PLUMBING Contractor Name: GAGNON JOSEPH DBA: : Contractor License No: 031807 y % /lvw � 5/2212014 Y ui ding icial Date r= 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 riot to exceed six months each upon written request.. - All work authorized b this i y permit shall conform to the approved application and the approved construction documents for which this permit has been granted. All construction,alterations and changes of use of anybuilding and structures shall be in compliance with the local zoning,by-lews and codes. 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 w work until the completion of the same. , The Certificate of Occupancy will not be issued until alrappficable signatures by the Building and Fire Officials are provided on this permit. d , H IC#: x'Persons contracting with unregistered contractors do not have acces5rto the guaranty fund”(asset forth in MGL c.142A). j Restrictions: # .• Building plans are to be available on site. All Permit Cards are the property of the PROPERTY OWNER. i :. aii' :ares of Massachu ., a City of Salem 120 Washington.St,3rd Floor Salem,MA 01970(978)745-9595 x5841 n Return card to Building Division for Certificate of Occupancy n Structure CITY OF SALEM BUILDING PERMIT ExcavatiPERMIT TO BE POSTED IN THE WINDOW t on r Z `7 1 1� Footing l T Fes. INSPECTION RECORD Foundation { f Framing Mechanical •,� , µ 0 Insulation y INSPECTION: BY DATE Chimney/Smoke Chamberoch ' Final fj R. v Plumbing/Gas Rough:Plumbing Rough:Gas^ c Finale -- ;_ Electrical ' Service - • _. - Rough Final Fire artment PreliminaryP1002cell`J T Fin - O Health Department La Preliminary Final '4 CITY OF SALEM, MASSACHUSETTS BOARD OF .APPEAL 120 WASI IING I ON S I Rl'i�1 0 rn 1.0197(XZ- mm FN Djuscnii, J;u.:978-7-1.5-9,59,5 + f;.\X:978-740-9846 F \L\roil rn June 10, 2014 a Decision U, CD, City of Salem Board of Appeals Petition of JOSEPH & MARIA GAGNON, requesting special permits per Sec. 3.3.5 Nonconforming Single- and Tivo-FilmelyResidential Structures and Sec. 4.1.1 Tilble Of Dim e nsion Requirements of the Salem Zoning Ordinance, to allow the renovation of an existing non ill conforming single-family residence into a two-family residence, with less than the required minimum lot area per dwelling unit, at the Property located at 105 BROADWAY (R2 Zoning District). A public hearing on the above Petition was opened on May 21, 2014 pursuant to M-G.L Ch. 40A, § 11. 'F'lle hearing was closed on that date with the following Salem Board of Appeals members present: %Is. Harris (acting Chair), Mt. Dionne, Mr. Duffy, Mr. Watkins, and Mr. Copelas (Alternate). The Petitioner seeks Special Permits per Section 3.3.5 NoncoqFa7,qinu Single- and Two-Famil 1�exielenfial and Section 4.1.1 Table of Di�,iensio&jl lZequim9lents of the Salem Zoning Ordinance. Y Statements of fact: 1. In the petition date-stamped April 28, 2014, the Petitioner requested a Special Permit per Sec 3.3.5 Noncoqbt7ljjjrg Single- and Txo-Family lZe.4denlial Stnidion of the Salem Zoning Ordinance, to change all existing nonconforming single-family residence to a two-family residence, and a Special Permit per Section 4.1.1 Table of Dimensional keqUitCluelitS of the Salem Zoning Ordinance, to allow less than the required minimum lot area per dwelling unit at all existing non-conforming property. 2, Mr.Joseph Gagnon, petitioner, presented the petition for the property at 105 Broadway. 3. The petition proposes to renovate and rehabilitate all existing single-family residence to be a two- family residence. There would be no change to the footprint or dimensions of the existing building. 4. The submitted plans include the addition of a driveway and three off-street parking spaces on the property. 1 5. The required minimum lot area per dwelling unit for the R2 zone is 7,500 square feet. 'rile existing lot is nonconforming, as it is only 5,000 SCILiare feet in size, with one residential unit. 6. The Proposal would increase the number of residential units to two (2), which would decrease rile lot area per dwelling unit from 5,000 square feet (existing) to 2,500 square feet (proposed). 7. The requested relief, if granted, would allow the Petitioner to renovate rile existing non-conforming single-family residential structure into a non-conforming two-family residential structure, and would allow a lot pare per dwelling Unit of 2,500 square feet. 8. At the public hearing, one abutter spoke in support of the petition. "rhe Salem Board of Appeals, after careful consideration of rile evidence presented at the public hearing, and after thorough review of rile petitions,Is, including the application narrative and plans, and rilePetition presenration and public tcsrinjojl�I, makes the followinger's provisions of the City of Salem Zoning Ordinance: findings that the Proposed Project meets rile City of Salem Board of Appeals June 10, 2014 Project: 105 Broadway Page 2 of 2 Findings I. The slight increase in density does not outweigh the project's beneficial impacts. 2. proposal serves a community need — it is good use. transforming a house that is derelict and putting it to 3. There will be no additional impact on traffic flow or safety — the proposal addresses traffic and parking considerations. 4. The utilities and public services to the building will be adequate. 5. The proposal would make the property more in keeping with the neighborhood character. 6. There are no negative impacts on the natural environment, including view. 7. The proposal will have a positive economic and fiscal impact. (NOn the basis of the above statements of facts and findings, the Salem Board of Appeals voted five (5) in favor Ir. Watkins, Ms. Harris, Mr. Dionne, Mr. Copelas, and Mr. Duffy in favor) and none (0), to grant the requested Special Permits to allow the renovation of an existing nonconforming single-family residence into a hvo-family residence, with 2,500 square feet of lot area per dwelling unit, subject to the following terms, conditions, and safeguards: 1. The Petitioner shall comply with all city and state statutes, ordinances, codes and regulations. 2. All construction shall be done as per the plans and dimensions submitted to and approved by the Building Commissioner 3. All requirements of the Salcm Fire Department relative to smoke and fire safety shall be strictly adhered to. 4. Petitioner shall obtain a budding permit prior to beginning any construction. 5. Exterior finishes of new construction shall be in harmony with the existing structure. 6. A Certificate of Occupancy is to be obtained. 7. A Certificate of Inspection is to be obtained. 8. Petitioner shall obtain street numbering from the City of Salem Assessor's Office and shall display said number so as to be visible from the street. 9. Petitioner is to obtain approval from any, City Board or Cortunission having jurisdict on including, bur not limited to, the Plantung Board Annie Harris, Acting Chart Board of Appeals :A COPY 0F'1-1 DE:CIS[ON FL-1S BITN FLED WFI Vl TFtB PL_ANN[NG BOARD AND'CF[F CHY CLERK Appeal/inns this derision, i%mrp. dball be iNade para itil to Tedion /7 0l Ibe aeu,,,obu etlx General L,atCh r apter JOA, ,rad,hall he Jilerl u�i/lriu'0 dig's of/ilia3 of ibli deerdoa to the ollire of the Cite Clerk. Puraaal la Me;1 hl.oa bl.ell+'Gene rol(auu Chapter JOA, ,1 ediaa //, the ['mithm 0 Speeiel Penni!grnnled bestir shall uo!take ejjert outs!a rope o%the decwot beoreag lbe,erlilievle al the Glp Clerk boy been Islet!aeilh the F,az.� ,Snulb Regtilry a%Deeds. - CITY OF SALEM, MASSACHUSE'T'TS ' BUILDING DEPARTMENT 120 WASHINGTON STREET,3RD FLOOR TEL: 978-745-9595 KIMBERLEYDRISCOLL FAx: 978-740-9846 _ MAYOR THOMAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTIES/BUILDING COMMISSIONER ACTION REPORT - 105 Broadway February 26, 2014 At approximately 10:30 a.m. on Wednesday,February 26'2014,I was asked by David Greenbaum of the Salem Health Department to accompany him on a visit to the aforementioned property located at 105 Broadway on a complaint his office received of no heat and/or water at the residence. Upon arriving at the residence Mr. Greenbaum and I observed the front door of the residence slightly ajar,when Mr. Greenbaum knocked on the door it swung open to a vestibule area. After numerous calls to see if someone was in the residence we walked the exterior of the building and noted broken window and an open door to the basement. I asked my office to call the Salem Police Department for assistance to walk the property to determine if the building was secure and a basic wellness check for occupants' inside. Sargent Harry Rocheville from the Community Impact Unit (CIU) knocked on the door and upon opening the interior vestibule door; I and Sargent Rocheville smelled what appeared to be gas emanating from the unit. Upon closing the door the Salem Fire Department was called and Engine 5 and Ladder 2 responded to the property. I updated Mr. Greenbaum who was waiting outside of the residence as we waited for the Fire Department. After entering the building the Fire Department determined that gas readings were not present. I entered the residence upon the all clear from the Fire Department to determine the present life safety of the building(i.e. smoke detectors, carbon monoxide detectors and egress paths/stairways). It was determined that these items were deficient and further noted no active water,no heat, no active sewer system and only sporadic electrical service. Electrical cords running to the second floor from the first floor level up the stairway into a second floor bedroom were also noted as non-code compliant. Upon entering the second floor level multiple bottles of human urine (in excess of 100 gallon jugs) were noted in the hallway, bedrooms and bathrooms. Additionally the bathroom toilet was completely covered and the bowl over-filled with human feces. Photos were taken (see attached)of these deplorable conditions to show Mr. Greenbaum of the Health Department who was stationed outside the building at all times, though in phone contact with me, as to stay apprised of what 1 saw. At this time I determined the building needed to be secured for safety of the public through Salem Building Department authority. Mr. Greenbaum posted a"Notice of Condemnation"on the front door and Commissioner St. Pierre of the Building Department waited for the board up of the property. Mr. St. Pierre at approximately 3:00 p.m. of same said day furnished the Salem Police Department with a key to the secured residence. If you have any questions regarding this letter, please contact me at(978) 619-5648. Respectfully, Michael E. Lutrzykowski _ Assistant Building Inspector CITY OF SALEM,.MASSACHUSETTS lu BOARD OF HEALTH 120 WASHINGTON STREET 4'"FLOOR PublicHeatth STREET, Prevent.Promote,Protect. TEL. (978) 741-1800 FAX(978)745-0343 KIMBERLEY DRISCOLL Iramdin@salem.com LARRY RA MDIN,RS/RI?I-[S,(;HO,CP-PS MAYOR HEAT;rH ACIN r February 26, 2014 George H. Gagne Rita H. Gagne 105 Broadway Salem, MA 01970 Re: 105 Broadway Salem, MA 01970 Dear Sir or Madam: Based upon a complaint of no heat, no water service and no bathroom facilities at this address and in accordance with Massachusetts General Law, Chapter 111, Sections 127A and 127 B and 105 CMR: 410.000: Chapter 11, State Sanitary Code, Minimum Standards of Fitness for Human Habitation, a site visit of your residence at 105 Broadway was conducted. Present at the site visit were David Greenbaum, Senior Sanitarian, Elizabeth Gagakis, Sanitarian for the Board of Health and Michael Lutrzykowski, Assistant Building Inspector. At the time of the visit the front door was found unsecured and the Salem Police Department was notified. Upon their arrival a smell of gas was noted in the building. At this time it was requested that the Salem Fire Department respond to check the building for a gas leak. Upon entering the property the Fire Department, Police Department and the Building Inspector noted that there appeared to be no heat, running water or sanitary sewer system in the house. They also observed that there were numerous bottles of urine in the house and the toilet is completely covered in human feces. Based upon observations made by the Salem police and fire departments and the building inspector and in accordance with 105 CMR 410.831(D), the Board of Health deems this property unfit for human habitation. These conditions endanger or impair the health and safety and that the danger to the life or health of occupants is so immediate, condemnation is ordered immediately to the entire dwelling. All occupants of this dwelling are ordered to vacate immediately for living purposes. If any person refuses to leave the dwelling they may be forcibly removed by the Board of Health or by local police authorities on the request of the Board of Health. The Board of Health cites 105 CMR 410.831 (D) of the State Sanitary Code, Minimum Standards of Fitness for Human Habitation. To Wit: • There is currently no water service to the building and no working plumbing in the building. • There are numerous bottles of human urine throughout the building. • The toilet is piled several inches above the bowl with human feces. • There are no working smoke detectors or carbon monoxide detectors in the building. In accordance with the 105 CMR: 410.000: Chapter II, State Sanitary Code, Minimum Standards of Fitness for Human Habitation and Massachusetts General Law cited the Board of Health orders condemnation of your property. No dwelling or portion thereof, which has been condemned and placarded as unfit for human habitation, shall again be used for human habitation until written approval is secured from, and the Board of Health removes such placard. No person shall deface or remove the placard, except the Board of Health shall remove it whenever the defect or defects upon which the condemnation and placard action was based have been eliminated. Should you be aggrieved by this Order, you have the right to request a hearing before the Board of Health. A request for such a hearing must be received in. writing in this office of the Board of Health within seven (7) days of receipt of this Order. At said hearing, you will be given the opportunity to be heard and to present witness and documentary evidence as to why this Order should be modified or withdrawn. You may be represented by an attorney. Please also be informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports, orders, and other documentary information in the possession of this Board, and that any adverse party has the right to be present at the hearing. Sincerely, in Larry Ramdin Health Agent Cc: Michael Lutrzykowski, Assistant Building Inspector Salem Police Department Salem Fire Department Posted on the property 2/26/14 • �itp Df AfEm, :fliam�aLbU�Ett5 PLANS MUST BE FILED AND APPROVED BY TBE INSPECTOR PRIOR TO A PERMIT BEING GRANTEDc� Building Permit Applkatioo For 1'OCO wag JO� VJ�1 �V1�f� '(Circle whicltam Vplia) Root:Reroof, [nail S• C Deck.Shad,Pod 5 F1ZeM—M,q Addition, Alteration, FWANion Only, Wracking Od ar. 1 fJ 1 PLEASE FU L OUT LEGD3LY& COMPLETELY TO AVOID DELAYS IN PROCRSMG To the Lttpapor of Bui)diogs: ' The W*NipW bmaby applies for a penwt to build according to the Following apoci icatlow Ow ft"Nww sp(Z C fltL Ho Contractor. Street Q*014D pLLCity 1� Street ,'hone( — Ambisact: city of Saba Shut City state U c# B>p# Smto Phone ( ) hero Easmpt Forma no Strrreatre (please atde) Single Family, MuUi Family�Otha Edimated Cast of job S �W , WIN bo WWg m irm to law!,—_-�tq Asbsstosim ao Deaaiptlaa of work 1 done: / n r Dmwioga submitted: no Mall Peralt to. 41 1e ER THE PENALTY OF PUFURY` (D . CONSTRUCTION TO BWOmXUT D yyrmiN SIX(6)MONTIiS OR PERMIT ISSUED DATE Dapmtmant use only: Parrs 0 zo R'0tT_ Permit fee S , oarkltTS: fl 'D of ZQ ri OX on �..... C 0 O 0 _9 • Q - ipKlt�u7!. rt. W . ,.a.•1t• Illy "UJ '.,Ill: IV ^� .., _,,•� . ,.�"1�•�f�IIJM.:,•,>r, V�',r>µ�i:1. 'ftX,#4it�iR11►ft:•(ii�f?'PF1ri7'r.11" 1 �i��'isi,;d: 'u••:\^.athViY.�;sT�1rH„tf?;' �tikli�ili�t '�.Nd►;+.k�;q�,:tn►rVtr`,+ 'l .t:�+,<;. �,rtMc•�.Vtf.!nil,NptNNws' ).rn. ••••f}ft ;:cst�ls�t9s}, 111 i ivft':n+M.....:.Maf rd:e .t t t t 1�Mti vM4tiM4�0:. ?aft utU ;`fit. 1�::-+.: ._t.,,:• . ',IIOK•. ,t 5:1� ,+ " vw'. >,1-1!, .. . r Olvtfj.jnnn+.•1, }l ri.e•,r11! Vlr laMnf.eC: %i�i - y..11V!L`b((fSl ' �,' r.�p: _ �.v , • '. .,P:1 U`: "� :11'1':p+'./hf1Oq� '+Cfa'7'I'll't l �? ft. .;l{;.'. 'd 1,•f(! 'Ptfo`. t :U tA'I1�.(i i.i@ . .�k4 i;.'�yi,fS(. .• ?If4(. •ry.:.EYM .. ;'•D;:::.,lq« y::r 'q'n%1'i lfttte:'.v;e.111t j_ • 1,r.'•iif; ' .• .;y:yp ! yil;,'y:e.'Y. ,v.K.a. .�,1 . b f k1:r;°' \P".:fr,{' pM.G;' �iAYI S:la•: i x,. •,.�•Y:"pf,U4.• y1!i�ltaalrl.eM»r ?.:,. e + 4 *IYI'ttw0Y F :iy1�l �16►f'` Y. F7T'r6n' .ne , :.tClS3►ti�►:(i$�ilt�:�r�d'iftf,I.i?)` ►! �•:'q� fr (Y �'I•r : ?+ ! FS ('. '1 \ ,i . • J • • M4r1 13 — 1 q _ c( Z,1 �1 The Commonwealth of Massachusetts Board of Building Regulations and Stand ar RECEIVED CITY OF V' ! Massachusetts State Building Code, 780 CMRSPECTIONAL S RVICE51 FM r Revised Mar 2011 Building Pennit Application To Construct, Repair, Renovate�e pctno b a 33 One-or Two-Family Dwelling ((UU��VV PPIIAATT LLUU This Section For Official Use Only Building Permit Number: Date Appli Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Proppety Address: 1.2 Assessors Map& Parcel Numbers I.la Is this an accepted street?y no Map Number Parcel Number 1.3 Zo mg Information: 1.4 Proper' Dimensions: oing District PmposerK .e 7V' Lol Area(sy fl) Frontage(fl) 1.5 Building Setbacks(ft) Front Yard Side Y:vds Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.I,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Fluo lone? Ivt Public Private El — Check if yes unicipalOn site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: eJ ' I 7see,' lr Ala cA fi�oo �iA p/g6GL Name(1' un) V City,State,ZIP 61 Nu.and Street l'elcphone hmai Add .s SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units / Other ❑ Specit'y:jeco�/%2 W Brief Descriplion of Proposed Work': As�/ CHtitD/GYr iwi PsQlo.? , '�o a.��/l /�� 7i�A/ C,z�lQen.�.9��1 .�/,•�r/f�.�Tr,G�G� �G �eA� ju O L s- (LAB n/t�✓ SF"CT N 4: ESTIbIATF.D CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and iNlalerials) I. Building $ e 0 el 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ fl 0 i ❑ Standard City/town Application Fee ❑Total Project Cost' (Item 6)x multiplier x 3. Plumbing 00 2. Other Fees: $ 4. iNlechanical (I IVAC) $ List: S. Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: C,. "Total Project Cost $ 64y 0 0 6 ❑ Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 ConstructiuTSupervisor License(CSL) �S T,Q icenu:Number Lxpiration Date Name of CM,Holder �/ List CSL"type(see below) ,A:�2 S�C�' lit1+✓G Ile Description No.and Street rype U Unrestricted(Buildings s u el ing cu. ft. ^I R Restricted I&2 Family Dwelling City/gown,State,W M Masonry RC Roof-in Covering WS Window and Siding SF Solid Fuel Burning Appliances 97o'g? �G97 fOP e� faSc@�m19a JO c/ CbY� I Insulation Tele hone E ail dr s D Demolition 5.2 Registered Home Improvement C � ntractor(HIC) .7 . G.7' HIC R gistratiunNumber Expiration Date HIC Co pany N,m-or HIC i�gistrant Name 9d 1LP� 6 i_✓�__ ae o� A A&I Gee , ,.and Street / T E I a ess 7Cf367'City/Town,Stgfo,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 Issuagete of the building permit. Signed Affidavit Attached? Yes ..........td No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWN ERt OR AUTHORIZED AGENT DECLAILVTION 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 nowledge and understanding. Print O ner's, Aulhoriz Q Agent's Name et is Signature) Dale 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 fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.1ndSs.uov/dps 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 halt%baths "Type of heating system_ _ Number of decks/porches Type of cooling system Enclosed Open 3. -rotal Project Square Footage"may be substituted for"Total Project Cost" CITY OF SM.EM, %L-1SSACHUSETTS y 11!!tt BUILDING DEPARTMEINT 120 WASHLNGTON STREET, 3"M FLOOR T EL (978) 745-9595 F.Aa(978) 7.10-98.36 KiNIBERt EY DRISCOLL L1YOR THo&w ST.PIE.4RH DIRECTOR OF PUBLIC PROPERTY/Bun.DI>IG ccimmis5(ONER Workers' C(nnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Legibly V;Iltic(Business Organ 1731iOW Individual): 0 -Y A'(C 7A r Address: �✓C_ 2 �� t�L' , City/State/Zip: V D ,0 -fy94`11hone N: Z 79> - 9F-5�'.76 97 Arc you an employer?Check the appropriate box: Type of project(required): I.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑Ncw construction 2.Xnlployees(full and/or part-time).• have hired the subcontractors I ran a sole proprietor or partner. listed on the attached sheet. t 7. A Remodeling ship and have no employees These sub-contractors have S. .❑demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition (No worker!comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 ran a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself.(No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t employees. (No workers' I3.❑ Other comp. insurance required.) -Any uppl,vaan der chucks box et must alsu Fill out the saclien below flowing their woden'cumpensadun policy in;i mason. 'I lummtwt er1 who submit this slB(lavit indicating they m doing all work and then hire outride cunimctam mml auhmil anew of,arit indicating such. ;(."moturs thus check this box most anachal an addiliorwl,heal shuwing lho mmne of the subeanlncton and their workers'comp.policy information. I ant can employer that is providing)iorkers'cowpearsodatl insurance for my eurployees. Beloly is the polfcy mrd fob site irrforrnntion. Insurance Company Pal icy q or Sclf-iim Lie, H: Expiration Date: )cab Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failuro to secure coverage as required under Section 25,A ot',viGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500,00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S2i0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Inve;ligatiuns al'Ihe MA for insurance coverage verification. /do hereby certify larder the point mrd pen !ties ojperjury that the bljunnotlml provide)above is true and c•orrret Of/ic•icl use only. Do not write in this area,to be completed by city or town official Cirynr'fown: PermiVlAccnxeli Issuing Authority (circle one): -- I. Board of ticahh 2. Building Departulent. I.Cityffuan Clerk J. Electrical inspector 5. Plumbing Inspecror 6. Other C:onfact !'anon:_ Phone It:__.__ CITY OF S:u E1I, 1SS:ICHUSETTS t BuIMLNG DEP.Itt't ONT 130 \U.1SHLYGTON ST:iEfiT, 1'4 FLOOR TEL (973) 745--9595 F.LX(97a) 740-99 4S 1UJtHEItL.EY DRISCOLL A-kyo;4 Dto.%us ST.PM&M DfucTOEt OF PGBLIG pttCpERTY/3t:UMLN(;COJLNUSSIONER Construction Debris Disposal AFt3davit (required for all demolition and renovation work) In uecordance with the sixth edition Of the State Building Code, 730 CrVfR section 111.5 Debris, mid the provisions of NIGL c.40, S 54; Building Permit hi 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 &ICL c 1 11, S 150A. The debris will be transported by: y (name urhauly) The debris will be disposed of in (nano of t]•ility) —' address of facility) 1119" :y re rp"I 'ta" alit _— The Commonwealth of Massachusetts _ Board of Building Regulations and Standards CITY OFSALEM 4 / J Massachusetts State Building Code,780 CMR Revised Mar 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Da Applied: .ter cr-J ) Ij Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers I.1a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Pro erty Dimensions: mood Se %oning 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 D' posal System: Public I$ / lone: _ Outside Flood L '? " Private❑ Check if ycs Municipal On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: / �sr-�Q rP, GAmwJo�✓ f�.�ooy. /yj�4 �/�T6� Name(Print City,State,ZIP JZO No.and Street 'telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition el Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': Guir� t. i,!JTco.Q/CFI ?�P✓r�Al%inA�. j2cMBL.Tn,.ZT� .P�^:Q�o0o .lit..r-.9//��Q �'__.p��SL_rs��G�,.c�Dpµ9 S SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials I. Building $ I. 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 S 2. Other Fees: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire $Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ ❑ Paid in Full ❑Outstanding Balance Due: �c�aCr�o� �3oop SECTION 5: CONSTRUCTION SERVICES r r 5.1 Construction Supervisor License(CSL) R• 6A4. A/ License Number Expiration Date Name of CSL Holder ,p List CSL Type(see below) �O �2/SLi9.v� I�.O!✓P Type Description No.and Street A A Q/�� U Unrestricted(Buildings up to 35,000 cu.ft.) R Restricted 1&2 Family Dwelling City town,StJ,ZIP M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances Z8_Y��S27Trti« gg,.�o,�- �Ov� I Insulation Telephone d esr/Ja D Demolition 5..22 Registered Home Improvement/Contractor(HIC) 0 ,� > >a3 �• ��,•Q y w/O/Y HIC Registration Number Expiration Date HIC C pan Name or H[ egistrant Name � G��YA.�o D/Zi�e foe � las�.o�'�inm•tlo✓, ao.� No.�d,b�et 6,/ y6o � Em ' a ress City/To tate,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 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 behalf,in all matters relative to work authorized by this building permit application. Print Owners Name(Electronic Signature) Date SECTION 7b: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 wner's or Aulk4rized Agemanny,01ectronic Signae e) Date 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 fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 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" t Ll z� /o CITY OF SALEM, NUkSS.1CHL'SETTS 13i;11-DING DEPARTMENT 120 W."HLNGTON STREET, 3aa FLOOR TFL (978) 745-9595 F.A-x(978) 740-9846 ICIMBERLF-Y DRISCOLL v1AYOR THows ST.PIERRE DIRECTOR OF PU BLIC PROPERTY/BU MDDJG CO\11,IISSION ER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information - Please Print Leeibiy Name (BU.OIcs.wO(gan o3tioru'l ndividual): fOS 5e/� le 64Z� A,,/ Address: City/State/Zip: S C' Phone Are you an employer!Check the appropriate box: Type of project(required): 1.El 1 am a employer with 4• ❑ I am a general contractor and 1 6. ❑New construction _JX11ployees(full and/or part-time).' have hired the subcontractors 2 Ji I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑ Remodeling .hip and have no employees These sub-contractors have 8. �molition working for me in any capacity. workers'comp. insurance. 1). ❑ Building addition [No workers' camp. insurance 5. ❑ We are a corporation and its requited.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions myself. [No workers' sump. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. (No workers' 13.❑ Other cutup. insurance required.) -Any applicant auto checks box al must also rill out the uctwn below showing their workus'compensation policy inlbonation. 'I hwncuwnors who submit this anldavil indicating they arc doing all work and then hire outside contractors mml suhmil a new air-davit indicating such. ;q"mmctors Out check This boa must anachod an additionul xhrmi showing the name of the sub-contractor and their workers'comp.policy information. f ant an employer that is providing workers'contpeusatlon insuruncejor my employees. Below is the policy and job site information. Inwrmcc Company Name: Policy 4 or Self-ins. Lic. H: Expiration Date: Job Site Address: City/Stale/zip: ,Attach a copy of the workers'compensation policy declaration pale(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A ar'vfGL c. 152 can lead to the imposition of criminal penalties of a - Jline up to 51.300.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and line of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of nvestigutions of the DIA For insurance coverage verification. /da hereby certify under the putts and penallies ojperjury Thal the h1fVrma110n provided above is true mrJ cwrreeL. Phone J: 97�•��s= 6I7 OJjiclal use only. Do nor write in this area,to be completed by city or farm ojjle•lul City or'1'nwn: ___._.. . .__ Permit/License p , Issuing Aulhurily(circle one): . 1. Board of Health 2. Building Deparintent 3.City(fuwu Clerk J. F.Iectrieai [uspcdor 5. Plumbing Inspector G.Other Contact Person: _. Phone ts: ] lee nor CITY OF 5iuz f, ;tiL1SS.ICHU5ETTS SUILOLNG, DEP.IRTNIENT 130 WASHLYGTON STREET, 310 FLOOR TEL (973) 745-9595 KIImERLHY DRISCOLL FAX(978) 740-9845 AFL-IYOR TI-imas ST.PtERRs DI.2ECCGR OF PUBLIC PROPERTY/BCiLDLqG CONNISSIONER Construction Debris Disposal Aff7davit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5 Debris, 'uid the provisions of bfGL c 40, S 54; Building Permit 4 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 ,NIGL c l 11, S 150A. The debris will be transported by: y �iPl G Z �/5f'aSA (name oFhaulur) The debris will be disposed of in (name of hell1 sign rewl" mit, licant