9-11 FOREST AVENUE - BPA 15-689 }
The Commonwealth of Massachusetts
Board of Building Regulations and Stan CITY OF
EI VED SALEM
Massachusetts State Building Cogni A; SERVICES Revised Mar2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwel
� This Section For Official Use Only
6/0� -Build ing Permit Number: " - - Date plied:.
S Building Official(Print Name) Signature - DNe
111n SECTION 1:SITE INFORMATION
1.11Property Address: 1.2 Assessors Map&Parcel Numbers
/�
t� 1.1a Is this an accepted street?yes `' no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
F1.6'Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.S SewageDisposal System:
Zone: Outside Flood Zone?ic L9, Private❑ Check if yes❑ Municipal @'7'On site disposal system ❑
SECTION 2: 'PROPERTY OWNERSIRP'
2.1 O nert of R ord: \\
_cater t�.�e c5 �ew. N'�I /A O\cl-f O
Name(Print) City,State,ZIP 1
cj FaccS� p,Je.. et'1$-'I'il-3"f fib C<'4". oc,�\ey�9u+w•`•Co
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building GY Owner-Occupied M- Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
Foca.S}
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ l� 00 0 .O o 1. Building Permit Fee:$ indicate how fee is determined:
2.Electrical $ ❑Stindard City/Town Application Fee
Total Project Cost'(Item 6)Txjmultiplier - x r�
3.Plumbing $ 2. Other Fees: $
4.Mechanical (BVAC) $ List:
5.Mechanical (Fire $ ..
Su ression Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ kO 100 3 . t)O ❑Paid in Full ❑Outstanding Balance Due:
W"
/ lr \
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
Lis 070836
rG�l Co6,4;-
/y � ( (y License Number Expirati ate
Name 3'"l C He
1� � List CSL Type(see below) �d S
No.and Street Tye Description
L- Unrestricted(Buildings up to 35,000 cu.ft.
V Ltd R Restricted 1&2 Family Dwelling
Cityffown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
l �`.� SF Solid Fuel Burning Appliances
C _� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
egisr it on Dale
HIC Co�mpanna Nafne'}`11C�Regi ant Name
� ) S I
No.at St17 Email address
c 9k# m� • �(T o2 7<0 5�e2 61R 3
City/Town, State,ZIP Telephone
SECTION G:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152.§ 25C(6))
Workers Compensation Insurance affidavit must be ompleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issu of the building permit.
Signed Affidavit Attached? Yes ..........6 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'/ 'Rto eo1QJ
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signatur Date
SECTION 7b: OWNERr 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.
Rt�.ys0.va �tDS1"Ci C+v�:�G JW.a�c.J.�S Z l3`Z-�tS
Print Owner's or Authorized Agent's Nam lectronic 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.eov,'oca Information on the Construction Supervisor License can be found at wwvr.mass.ttov/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"
QTY OF SALEM) MASSACHUSE M
SK z Bua DING DEPARTA ENr
� ' r 120 WASIRNGTON STREET,3' FLooR
TEL(978)745-9595
FAx(978)740-9846
KIIvlBERI.EYDRISO�LL
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUIIAING CObAHSSIONER
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 111.5 Debris,
and the provisions of MGL c40, 5 54; Building Permit ff 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:
(name of facility)
(address of facility)
• v�
Signature of applicant
Date
The Commonwealth of Massachusetts
Department oflndustrialAccidents
Wrkers'Compensation
I Congress Street,Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERNDTTING AUTHORITY.
Applicant information �yPleasePrint Leeibly
Name (Business/Organization/bidividual): �j�� ^/ ( A e C�7 5�I[��—�
Address: a tJ4t 4(,� A- ( yJLt►
eicyistateizip: 6M - OW 2 Phone M 1> 601 3
Are yo an employer?Check the appropriate box: Type of project(required):
1. I am a employer with _employees(full and/or part-time).* 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in $, �emc deling
any capacity.[No workers'comp.insurance required.]
9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]I
10 ❑Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole I1.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5,❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.t
6.❑We are a cmporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tConnactms 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. ffthe sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: CO&Vcy MunlAL
Policy#or Self-ins.Lic.#: 315 —313<C 3 V 5 �0 3U Expiration Date: A/
Job Site Address: 11 —"1 fi;ta-&57 AV — City/State/Zip:
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 criminal violation punishable by a fine up to$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 copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under tthe/paaiinns and penalties ofperjury that the information provided above is true and correct.
Signature: <I �---- 4 Date'
Phone#: 74 I a G/ q 3
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)name(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 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 fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please 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 perri t/icense 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 permit to bum 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-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
SITE CONDOMINIUM PLAN
SALEM , MASS.
SCALE I IV FEB. 271981
CARTER B TOWERS EN.GI EERING CORP. a
SWAM'PSCOTT., MASS.
0 WILLIAM 9 SYLVIrA MOYN4hH.A',N_;...
i m
n; N
w
y rr
do
{ g 2
ae
`✓� rim ,;mow-,�,a °' -
N
CONIC. 1. O
GARAGE 7 J
DRIVEWAY COMMON
AREA N'
y (CRUSHED STONE) k
a za z
W,
, �GONC WAlK ., t
I� t
t
iM PO GH I
o DWE LING p
Y1 zV2 STY.
WOID
� z
ca
c ,
a t
m
b UMT 9 UNIT I !
�i N0. 9 N0. 11 W �.
F
�, A • C r IQ@"W""y jd VHOWS iif KOPERP,vIM,IPi
d ): T4AT ARR Wf L(N88,Y8 '$,k YG iWP k,NS A?dG TI(P t@,.G f96
4Tpt' �'�i
�. hrAn Atv'7i WxRYM1&i t✓S h' �,fltY.F Of P(nuc OR PRAIATO
PORCH STREET!69 WAVS StRgArJ`RSTARUSM'n AND THAT NET NEW 1
PORCH. ❑ri b FOR p3Vtii#N Wp EXLrT,Nfl UV N+CdMT p@ FOR N6%d[CAYS 1
ARS Sb*VM." a
{
JiMG1�n:D tam s-uavrYens
I
1 crortify tl Tt tins plan fully and accU- I
P'tely ICIPIC6S tl,e location and dimensions
FOR REGISTRY OF DEEDS USE ONLY of Tile buildings a6 bunt inJ sully IiStb
s P« " FOREST AVE.
b snits pittainad thc,Dl,
PLAN, 8LldKI6P'LANU f
£$SE%ftF615iAv OF OETRS.S0,Disr. `j�
SAUM,
wiss.
wtti f��ctSFCr �s' e�
x x iq rAXTJjIStrAI;fJA CC 19
g
r rSro YJ pDT namxrY W rta %B
r,T,5 rt R,rT ATr mrs OF TIE TEE,
t.. V'.'kA'r:Tki cll M(+95)S Dr 7AD D'ltd't114-
D Y
Reybkrafp<edr t � � �Mw:n.,
' m SCALE I' =,LO nA�'„ iui , >.Y�',R1CU;G$ 'k111�Yfw�'t5yp
0 10 20 3g 40P 50
,r.
fascia
18-16'and 2-10'2x65 pressure treated '"$226
4'-101/16"
2-12'and 1-16'2x12s pressure treated "$77
O -- ......___"— _ �R- --- — �u 4-8'x10'tapered fiberglass columns $1023
_ Jli Milli 11 _ 246'1'x12'cellular PVC fascia "$95
it III II! li!it III .—_ -- — -- $ - $'
2-12'and 3-10'VIM"cellular PVC fascia
7.4'x10"sonotubes
I i Ii1 Ii1 lil Ii1 j! it I! I! I I! !
I !i:,E',
�l'-� 0eckmg $vso
j IIII ili lilt ii j! %! !j! !
I l I I I II jl II jl III I 1-16'4"x6"pressure treated
i! I!! ZnII! i! lil II
1 sheet%"pressure treated plywood ^$28
pressure treated 2x65 t!I III Ili III Ili ll jj I! II II I
it III Id lL II, 'II jl jl I! III! I Hanger hardware,nails etc. '"$500
jilii IIII Ili lili II ! ! !
,i III lj i1 Ili I! I! I! jl jl Railing `$800
i, II. i, li, it p it it I
!6__-_ _I,I___ I- _ -lL __ I,I�!�;:!tls: 3 Lattice panels '"$100
N —_= lid- i�---1IIF ——li--- --- IF—— I. I .
Concrete
li! Ill I! !
710"x4'sonotubes j! llj Ili Ili 'li it jl I! II !i -$5033
II Ij l jl it jl,
j i l!!I ii IIII ii it it i! it i! ! ,ttIff6 Il 111 illl 111 (IIII II III IIi1i -- IIII.. - .. ..
I. ! ! III
It 'I
tapered fiberglass t III III! I! !I ICI !I !'I II !I'I it '!I n
i' 'I. Il I. III
load bearing columns
5'-g5/16" ll! ill
't 111 i! I
--------------------- ----------
ra 1%2" ii II !i III !i 11i°
0
12'-7"
li
I.
it 'll it II 'll 11.
.I i! Il 'Il Il it Il
• ICI i,, i i, it
9 Forest Ave.
Front porch deck rebuild it ii' !' !i !'I 1 'i
�
6'-0'.
7/3/2015
Richard Lobsitz
9—11 Forest Avenue Condominiums
11 Forest Avenue
Salem MA 01970
The City of Salem
Inspectional Services
120 Washington Street
Salem MA 01970
To whom it may concern,
We the undersigned Trustees of the 9—11 Forest Avenue Condominiums are aware of and
approve the planned rebuilding of the deck and supporting structure of the front porch at 9
Forest Avenue and the ordinary repairs needed on the other porches on the property. We are
also aware of the need of a building permit to be applied for by the contractor, Rich Cole.
Sincerely,
Richard Lobsitz
Trustee
j. '� SSAJL
Craig Schoelles
Trustee
9-11 Forest Avenue Condominiums
3
fi.
l