41 FEDERAL ST - BUILDING INSPECTION (2) 1 The C•onunomve:dth of Massachusetts CITY
l Board of Building Regulations and Standards OF SALEM
J I Massachusetts State Building Code, 730 CMR, 7 edition Revised Jarmdm•
IIJn/ Building Permit Application fo Cons ruct, Repair, Renovate Or Demolish a I• =uux
One.or Two- amity Dwelling
This See on For Official Use Onl
Building Permit No her: Date Applied:
Signature:
Buildin ommissione I •t of 1uildings Date
S TION I:SITE INFORNIATION
1.1 Propert Address: ,�S 1.2 Assessors Map& Parcel Numbers
Ma Number Parcel Number
I.I a Is this an accepted street:'yes G'' no
P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use [.at Area(sq 11) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
ReyuireJ Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,11 54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
�(P;rint) �
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow !ILNomei ^ Address for Service:
ZZZL
Signature 'telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check al that apply) Lr.
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
G-
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item (Labor and Materials
I. Building S I. Building Permit Fee:S Indicate now Ice is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (11VAC) S List:
5. Mechanical (Fire S Total All Fees: S talance
Su ression Cash Amount:Check No. Check Amount:fi.Total Project Cost: S GG d(1 ❑ Paid in Full ❑Outstanding Due:
4-D 06a�
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /
O Jv I.icensr Number Hspiratiun Dute
Name'tt C:S Ilulder //�)" ,��
q ` ' 1.im CSL-fs pe(see below)
.0 O /AJ G Ad/ /l.f�C7i , ._
:\ddrcs n �i/� ., T FORceirdential
Description
T v' .� trictrd u w 15,000 C'a Ft.
Signalur ted IDk2 Famil Uwrllin
KI
Ile
ntial Roolin C'uvrrin
fdcphone ntial Window and Sidin
`771 ntial Solid Fuel Oumin n liance Installation
Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC y Name or I IIC Registrant Name Registration Number
Address
Expiration Date
Signature "relephune
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
Workers Compensation Insurance affidavit must a completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu ce of the building permit.
Signed Affidavit Attached? Yes.......... " No...........O
SECTION 7a:OWNER AUTHORIZATION TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1• - - ✓L� r� .. ��zA as Owner of the subject property hereby
authorize J17 to act on my behalf, in all matters
relative to work tthorized by this building permit application.
aa
St •tore of Ow eri A T Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I• -� %��" ,as Owner or Authorized Agent hereby declare
that the s tmeiits and information on the foregoing oin a li„ g g pp cation are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signatureof Owe ur Authorized Agent'
Si red under the airs and •nulties of r'u
NOTES:
1. An Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(not registered in the Hume Improvement Contractor(HIC)Program), will jol have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and 1 IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sy. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area, . Ft.) Ilabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half7baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for"Total Project Cost"
�i
b CITY OF S U E.NI, I L-kSS.A CHUSET rs
• BI.;ILDLYG DEPARTMENT
130 W.ksmGTON STREET, 3' FLOOR
TEL (978) 745-959S
FAX(978) 740-9846
KIJBERI.SY DRISCOIL
THo
MAYOR .+us ST.PII:aRs
DIRECTOR OF PCBLIC PROPERTY/BUMIZI iG 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 I 11.5
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
111, S 150A.
The debris will be transported by:
lak�na o�} by �-ctx�C
(name ofhauler)
The debris will be disposed of in :
(name of facility) `
(address of facility)
sig/ Lure of permit applicant
�Z ��z
date
.lcbnvl(da
CITY OF SALEM
n
it PUBLIC PROPRERTY
DEPARTMENT
.nliG n:FY:Ix Is(Yn l
\I N I ut 12C WA\HI.N6I U^S ax ELT• SAE P.M. MAMMA It it I I13197C
1'LL:Will.71 -9i95 9 Fix. 97N-71��)S46
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
liPnlicant Information Please Print Leeibly
Vtllne lllucuKnf grNanlratioNlnJlvlduull: �CXt�___ _��}"ice r�j rR�— L (Cj!Sf--N cot)-4( Y Or)
Address: 5+
Ciry,Sr:ire,%ip: lflcx 01223 11honeil: c( 75- -(40(o -i2-7 )
\re you an eayil ?Check the appropriate box: 'Type of project(required):
II.❑ 1 an mpluyur with 4. ❑ I am a-mural contractor and 1 h. E3 new construction
• pluyres(full indlur port-tinia).e have hired the sub-contractors
2 I :on a sole pmprictor or partner- listed on the anachcd sheet. 7• ❑ Remodeling
ship and have no employees These sub-contractors have S. Demolition
working for me in any capacity. workers'comp. insurance. 9, C3 Building addition
I no workers'comp. insurance S. ❑ We are a corporation and its
required.)
otlicers have excrciscd their IO.Q Electrical repairs or additions
3.El ant a homeowner doing ail work right of exemption per NIGL I I C] Plumbing repairs or additions
myself.Lao workers'comp. c. 152,§1(4),and we have no 12.E] Rouf rupairs
insurance required.] y anpioyces.Lao workers'
comp. insurance required.] 13.❑Other
•Any apphcani fliat checks boa ill mull Ass,till wl the sccriun W,uw]lowing their wwkavi conipunuaiutt policy inatrmalimn
'I lomcownun wha udimil this affidavit indicting Illy are doing all work and then him outside"unicion must.uhmis a new a/ridavil inJi,,eina itch.
-('omracttur that chuck this box mass anahod an additional nluvn showing the nano of tho sub-contracton and their Wuhan'comp,pdicy inte madun.
/um un ruyduyrr abut Ls praridinp rvurkers'ruonprnrntinn in.rurancc/br my unp/uyees. Below is the policy and job site
infororutiva
Insurance Company Natne: _. _
Policy a or Sulf--ins. Lic.Hr: j l Expiration Date:
Job Situ Address:e- it /"P...d `� I Ctly,State/Zip:
.\each n copy of llte workers' compensation policy declaration page(showing the policy nuniber and expiration date).
Failure to ssocurc coverage as required under Sectiun 25A ul'JIGL c. 152 can lead to the imposition of criminal penalties of a
tine up m SI.5110.00 and/or one-year imprimmincnt, as well as civil penullics in the Toren of a STOP WORK ORDER and a fine
of tip to i250.00 it Jay aguinst file violator. Ilc advised thut a copy of this si utcment may be Iurwardcd to the 0111cc of
Imrsngaouns ui'thc OL\ for insurance covcra,e tcrilicatiun.
/da hereby crrtijy under the/i Iins,nod prat i ti, u//perjury that the iafunnullon provided above is true trod correct.
<Icaaulre: —��/1 Grp D,,c• - /)Arl)l
o(jicial use only. no toot twits,in Chit area,tube citmplefed by city or town a/jicial
i
City or Town: _ Permit/License d_ I
Issuing;Auiltorily (circle one):
I. hoard -jr Ilcaith 2. Ihiildin:,. Ucpartmcul .1. Cilyi o%%ii Clerk 4. Electrical luspcctor 5, Plumbing; Inspector 1
b. Other
C.,mict Pursuit: __ .. Phone Y:
4
a '
Information and Instructions
,.I:us.tchusetts Gcneral Laws chapter 152 acquires all employers to provide workers' compensation liar their cntployces.
Pmr.suant to(ills],atute,an emplurer is defined as"...every person in the service of another under any cummct of hire,
express or implied, oral or written."
An employer a defined as"an individual,partnership,association,corporation or tither legal entity, or any two or more
rt the torceoing engaged in a Joint enterprise, and deluding the legal representatives of a deceased employer,or the
receiver or trustee of.ut individual, pumership,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."
.%tGL chapter 152. 4, 25C(6)also states char "every state or local licensing agency shag withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
:applicant olio has not produced acceptable evidence of compliance with the insurance coverage required."
additionally, %IGL chapter 152, §25C(7)states"Neither the commonwealth not 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)name($), address(es)and phone nunmber(s)along with their certiffcatc(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
:\ccidents for confirmation of insurance coverage. Also be sure to sign and date the ufndavit. The affidavit should
he 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 u 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 he sure that the affidavit is complete ;and printed legibly. The Department has provided a space at the bottom
of time affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
lal:ase be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple penmidlicensc 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 lucatiuns in (city or
town)."A copy of the uftidavit that has been officially stamped or marked by tilt city or town inay 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
t i.e. it dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
I he 011icc tit luve Sri gations would hike to thank you in advance fur your cooperation and should you havc:any questions,
picase du not hesitate to give us a call.
The D:paruncnt's address, telephone and fax number:
The Cornmonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigation
600 Washington Street
Boston, MA 02111
Tel. N 617-727-4900 ext 406 or 1-817-MASSAFE
Fax 0 617-727-7749
Ra,.iscd i-1_6-05 www.mass.gov/dia
41 FEDERAL STREET 641-11
GI s# _` , 4023 u, COMMONWEALTH OF MASSACHUSETTS
Map .g 26 CITY OF SALEM
Block s " a ;�
Lot ;„ = 0414 zjs
Category REPAIR/REPLACE
Permit# 't'h�. 64111 : „_.'`,,:r... BUILDING PERMIT
Project# 4 IS 2011-001003 r,`
Est Cost .' $8,500 00 I
Fee Chaiged "`'' $104.00
BalanceDue: $.00 , 43j �, ', PERMISSIONIS HEREBY GRANTED TO:
r
Gonst. Class:' .` qff. ` Contractor: License: Expires
Use Group ' �:iI4� t 4N�"t. Richard Cross/Cross Construction CONSTRUCTIO SUPERVISOR- 101822
to Size sq.ft): 4079.8296 ;- c'
' , Owner: FEDERAL STREET TRUST,MELLO EDWARD-MELLO PHYLLIS M
Zoning: B511.1
Units Gained i��I I Applicant: Richard Cross/Cross Construction
Units Lost: „; ,:: a. i' . ;AT. 41 FEDERAL STREET
Dig Safe#:Yi
ISSUED ON: 10-Mar-2011 AMENDED ON: EXPIRES ON: 10-Aug-2011
TO PERFORM THE FOLLOWING WORK:
REMOVE EXISTING SLATE ROOF AND INSTALL NEW ASPHALT ROOF AND REPLACE FASCIA BOARDS jbh
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
Underground: Underground: Underground: Excavation:
Service: Meter: Footings:
Rough: Rough: Rough: Foundation:
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# Smoke:
Treasury:
Water: Alarm: Assessor
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
Fee Type: Receipt No: Date Paid: Check No: Amount:
BUILDING PEC-2011-001116 10-Mar-11 4999 $104.00
GeoTMS(9)2011 Des Lauriers Municipal Solutions,Inc.