11 CHURCH ST - BUILDING INSPECTION (31) The Commonwealth of Massachusetts M
Department of Public Safety 20 b DEC _2 A 0 Z
Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Only)
Building Permit Number: Date Applied: Building Official:
n SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
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,,,,
1 No.and Street City/Town Zip Code Name of Building(if applicable)
(co SECTION 2.PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building 1K Repair❑ 1 Alteration e 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy q Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes No ❑/
Is an Independent Structural Engineering:
Work Peer -1G Review required? "i Yes ❑ No LY
Brief Description of Proposed : I �- 6 ,� &,[Aew- ulp i2.
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY-
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑
F. Facto F-1 ❑ F2❑ H., Hierc Hazard H-1❑ H-2[IH-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ I-2❑ 1-3❑ I-4❑ M: Mantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA IB ❑ IIA ❑ 1I813 1 IIIAO TUB 1 IV ❑ VA VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood one Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public SK Check if outside Flood Zone❑ Indicate municipal A trench w!i!_Lnot be Licensed Disposal Site
required—or trench or specify:6 Mello
Private❑ or indentify Zone: or on site system❑ permit is enclosed❑ Q .
AA
Railroad right-of-way: Hazards to Air Navigation: MA Historic Commission Review Process:
Not Applicable❑ Is Structure witltin airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?:.. Special Stipulations:
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SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
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ame(Print) No.and Street City/Town Zip
Property Owner Contact Information:
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Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby authorizes
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e VStreet Address City/Town State Zip
to act on the property owner's behalf,in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
building is less than 35,000 cu.ft.of enclosed s ace and/or not under Construction Control then check here O and skip Sectior110.1
10.1 Registered Professional Responsible for Construction Control
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Name(Re.' tr Telephone No. a-mat ad' s Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
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Company—�e
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e n
N7ame of Person Responsible for Construction ^_ License No. and Type if Ap licable
Street Address City/Town /� State Zip
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Telephone No. (business) Telephone No. cell a-mail address
SECTION 11:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§25C(6))
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the isss ante of the building permit.
Is a signed Affidavit submitted with this application? Yes®' No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor 7
and Materials) Total Construction Cost(from Item 6)=$ 7� 377.4D
1.Building $ "'t Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ �- S . appropriate municipal factor)_$
3.Plumbing $ c { -f ^
4.Mechanical (HVAC) $ /- Note:Minimum fee=$ (contact municipality)
5.Mechanical Other $ Enclose check payable to
6.Total Cost ' , co (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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 accurat o ,pest m knowledge and understanding.
`Ptlleeas�t iind si n e P Title Telephone No. Date
Street Address City/Town State /J Zip
Municipal Inspector to fill out this section upon application approval: ll,'2w
Name Date
Appendix 1
For the demolition of structures the building permit applicant shall attest that utility and other
service connections are properly addressed to ensure for public safety.
Please fill in the information below and submit this appendix with the building permit
application. The building permit applicant attests under the pains and penalties of perjury that
the following is true and accurate.
Property Location (Please indicate Block# and Lot # for locations for which a street address is not
available) �`1/ /�> ( ��
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No. and Street City/Town Zip Name of Building(if applicable)
For the above described property the following action was taken: /
Water Shut Off? Yes 0"'No ❑ Provider notified and Release obtained? Yes H No ❑
Gas Shut Off? Yes ❑ No 5/ Provider notified and Release obtained? Yes ❑ No ❑
Electricity Shut Off? Yes ❑ No 0'� Provider notified and Release obtained? Yes ❑ No ❑
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Yes ❑ No ❑ Provider notified and Release obtained? Yes ❑ No ❑
Other (if applicable)
Appendix 2
Construction Documents are required for structures that must comply with 780 CMR 107. The
checklist below is a compilation of the documents that may be required for this.The applicant
shall fill out the checklist and provide the contact information of the registered professionals
responsible for the documents. This appendix is to be submitted with the building permit
application.
Checklist for Construction Documents*
Mark'Y'where applicable
No. Item Submitted Incomplete Not Re wired
1 Architectural
2 Foundation X
3 Structural
4 Fire Suppression
5 Fire Alarm(may require repeaters)
6 HVAC �!
7 Electrical X
8 Plumbing include local connections
9 Gas Natural,Propane,Medical or other
10 Surveyed Site Plan(Utilities,Wetland,etc.
11 S ecifications t/
12 Structural Peer Review X
13 Structural Tests&Inspections Program
14 Fire Protection Narrative Report X
15 Existing Building Survey/Investigation .r
16 Energy Conservation Report i(
17 Architectural Access Review 521 CMR X,
18 Workers Compensation Insurance
19 Hazardous Material Mitigation Documentation X
20 Other(Specify)
21 Other(Specify) l
22 Other(Specify)
*Areas of Design or Construction for which plans are not complete at the time of application submittal must be identified herein.Work
so identified must not be commenced until this application has been amended and the proposed construction document amendment
has been approved by the authority having jurisdiction.Work started prior to approval may be subjected to triple the original permit
fee.
Registered Professional Contact Information
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Name(Registrant) Telephone No. e-maif adilress Registration Number
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Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zi Discipline Expiration Date
CITY OF SOU EM, l.'L),SSACHUSETtS
BCUDLNG DEPARTMENT
\ 130 WASHNGTON STREET,3" FLOOR
TFL. (978) 745-9595
F.tx(978) 740-9W
KIN
IBERLEY DRISCOLL
NLAYOR THows ST.Pwmm
DIRECTOR OF PUBLIC PROPERTY/BUUMDJG CO%aflSSIONER
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 It 1.5
Debris, and the provisions of MGL c 40, 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 disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
C��t��l gy �sy5
(farmic of hauler)
The debris will be disposed of in
(. /Ittl<o ��I Co-P
(name of facility)
t :4. C"e I N
address of facility)
/slignarepermit applicant
date
Jc6riulfJu
The Commonwealth of Massachusetts
Department of Public Safety
m Massachusetts State Building Code (780 CMR)
J`Ssyw a�y��cr Building Permit Application to Construct,Repair,Renovate or Demolish any
Building other than a One-or Two-Family Dwelling
Code and Other Requirements for Building Permits
The Department of Public Safety has issued these building permit application forms so that municipalities
across the state can move toward use of a single permit form and consistent permit application process.
The MA State Building Code specifies the requirements of building permits and the applicant is advised to
review and be familiar with these requirements in order to avoid some of the common permit application
problems. Likewise the applicant should be aware that some municipalities require that the owner confirm,
even prior to acceptance of the building permit application, that no outstanding property taxes,water fees,
etc. exist.
Filing Instructions
1.Please contact the city or town where the work will be done to ensure that the city or town will accept
this application form and if any additional information is required, and obtain the correct mailing
address. After doing so, print the application, fill in completely and then submit to the local city or
town where the work will be done.
2.All applications shall be considered complete and will be reviewed if construction documents,
specifications, fee, and other materials that may be required as indicated in the Building Permit
Application are included with the application.
3.Please include a check for the Building Permit fee. The fee may be calculated using the information to
be supplied in section 12 of the Building Permit Application. The check is to be made payable to the
local city or town where the work will be done.
C'.ABINET111" y
DIESIGN
Preliminary Remodel Proposal
November 3, 2016
Agnes Serino
11 Church Street
Salem,NIA 01970
We are pleased to quote you on doing the following work in your home. All work is fully insured and all
trash created by Cabinetry By Design will be removed by Cabinetry By Design.
Kitchen Remodel:
Cabinetry $11,435.00
We will supply and install Yorktowne Cabinetry,door style and color to be selected by homeowner
Installed per plan and design layout. Cost of cabinetry subject to change with alternate color and size
options per home owner.
Counters and Back Splash: $3,100.00
Supply and install level 2 granite countertops. Countertop color to be selected by the homeowner. Cost
estimate subject to change with alternate color selections.
Construction: $26,700.00
Remove existing counters and cabinets. Remove wall adjacent to current stove location. Relocate
electrical for stove and dishwasher connection. Install under cabinet lighting to be selected by
homeowner. Replace general lighting and update all electrical to code as per plan. Plumbing to include
relocation of sink drain and water supply lines. Disconnect existing and reconnect with new homeowner
supplied appliances. Remove existing carpet throughout unit and install new prefinished floating
hardwood flooring.
Proposal continued on next page
CABINETRY :3y DESIGN
56 North Putnam Street - Danvers, MA 01923 - Phone 978-774-0002 - Fax 978-774-7799
DESIGN
(Proposal continued)
Master Bath Remodel: $19,485.00
Remove existing shower surround,vanity,flooring and bathroom fixtures. Install new shower walls,
owner supplied tile and grout,and shower fixtures. Fixture allowance included up to$1981. Install
owner supplied bath fan with heater option. Install owner supplied tile flooring and grout. Supply and
install new vanity and countertops. Install homeowner supplied bathroom accessories. Update plumbing
and electrical as needed to code. Patch walls and ceiling as needed to paint ready. Relocate closet
outside master bath. Install new doors and patch and plaster as needed.
Optional. TileJlooring in shower installed with copper pan $1200.00
Guest Bathroom Remodel: $16,657.00
Remove existing shower surround,vanity and bathroom fixtures. Install new shower/tub walls,tub,
owner supplied the and grout, and shower fixtures. Fixture allowance included up to$1277. Install owner
supplied tile flooring and grout Supply and install new vanity and countertops. Install homeowner
supplied bathroom accessories. Reverse swing entry door if possible. Update plumbing and electrical as
needed to code. Install bead board in guest bathroom. Patch walls and ceiling as needed to paint ready.
Nothing other than stated above is included. No tile,grout,hardware,appliances, or painting in quote.
Quote subject to change based on the selections made by the homeowner.
Total Contract: $77,377.00
Terms: 30%down,30%upon starting, 30%upon delivery of cabinets, 10% upon completion.
er Date
im Phillips,President Date
HIC License #15283
Agnes Serino Remodel Preliminary Proposal 2016
CABINETRY �y RESIGN
56 North Putnam Street - Danvers, MA 01923 - Phone 978-774-0002 - Fax 978-774-7799
i CITY OF S iLE;tit, NL1SS.�CHL'SETTS
BUILDING DEPART iaNT
• 120 WASHINGTON STREET,3'a FLoOR
b T EL (978)745-9595
FA.X(978)740-9846
KINIBERL F-Y DRISCOLL
MAYOR THo.%w ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BU ILDL\G COND(ISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
I_ �,J,�
Name (Busim-soOrganizatioNlndividual):(rlbAr+i eq LC"SI/h
Address: �� �✓� tuTh4vt, 7I• V City/State/Zip:_Aflyer5 /vW 01973 Phone #: 17!b-771U
' CLVZ
Are yyu an employer?Check the appropriate box: Type of project(required):
I. 1 am a employer with 3 4. ❑ 1 am a gcmoral contractor and 1 6. ❑N w conswcdon
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet. ?• Remodeling
ship and have no 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 corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself(No workers'comp. C. 152,9l(4),and we have no 12.0 Roof repairs
insurance required.]t employees.(No workers' I3.❑Other
comp. insurance required.]
•Any applicant that checks box Amutt also fill outthe section below showing then worker'enmpensation policy information.
r Homeowner who submit this affidavit indicating they are doing all work and then hire outside controtor most submit a new affidavit indicating such
:Contractor that check this box most attached an additional shcet showing the name of the aubcontrctar and their worker'comp.policy infomatim.
/am an employer that is providing workers'compensation insurance for my employees. Below is the policy and Jab site
information. 1 /�
Insurance Company NameA h T Amcof A—)5"-7cQ o-
Policy#or Seif-ins. Lie.#: U.,W(3 17Z Nq0 Expiration Date:Job Site Address: I I �!✓�C 1t 54• 6 � ✓70Y City/StawiZip:S41e 14 0070
Anach 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 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 S250.00 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.
/do hereby certf&under thr ins and penalties of perJury that the brformaton provided above is true and correct.
aim re Date: (Z t 1
Phone#: 1 p 72` 77V—a;i02
Official use ady. Do not write in this area,to be completed by city or town official
City or'rown: Permit/License#
Imulag Authority(circle one):
I.Board of Ileallh 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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All dimensions size designations This is an original design and must Designed: 11/3/2016
given are subject to verification on not be released or copied unless Printed: 12/1/2016
job site and adjustment to fit job ^O^O applicable fee has been paid or job
conditions. 1 1 order placed.
II
I ASerino Master Bath _ __ _- __ _ _All Drawing#: 1 I No Scale.II
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Massactfusetts -Department of Public Safety
Board of Building Regulations and Standards
Sune"or
License: CS-084143 t
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TEWKSBURY MR 0JV
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Expiration
Commissioner »
- L/�I>_ ILC»]29)1(}JL2'o(/-�[/Z G�✓L�QISCLC�lG9E�
Office of Consumer Affairs&Business Regulation
HOME IMPROVEMENT CONTRACTOR Registration valid for individual use only
d-_ F, Type: Caporation before the expiration date. If found return to:
ti ===i' tion Expiration Office of Consumer Affairs and Business Regulation
�' €52638 t0i02+2018 10 Park Plaza-Suite 5170
Boston,MA 02116
Cabinetry By Desigr 3ncr
Richard Brown /J
56 North Putn 01
Dam SL - �;�cGG --
Danvers,MA 01923 v
Undersecretary �— Not valid without signature