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52 GALLOWS HILL RD - BUILDING INSPECTION c K 1 210 (all - The Commonwealth pf Massachusetts tt Board of flu:ilding'Jegulatloiis and,Standards 111SPE�TIQfiIA SE i� Massachusetts State Autldirig"Cede,780 CMR ' SA hM 1ll1155 $Ep l R�tLvA2011 lf GO One- Permit Application To Cpttstruct, Repair Renovate Or NpMGTISA q One-or 7tiup-17aipily: hvelling V This.Shictim For Official Use:Ohl . 177 ldingBui pplied Building DftSelpl(Pont t!]pme) 7, ,Signature tD SECTION ; 9 T INFORMATION ( 1.1 P gPerty '{IdrelBi 1,1 Acsessprs Map&Parfol M m, borq l.la Is this m aeca to street?yes_ no Mqp Number Parcel NiggbeN 1.3 Zoning Wormattogi : 1.4 Prppe fty Atglegelqqs, Zoning District Proposed Use l 1, pt Area(sq tt) f mptagg - 1.5 Building Seth cks(ft) FrpptYard"'` Sine Yards `.RBatYiuq.._ Required 'Provided ReNireQ Provided '- jtegnired r; ProyidaA 1.6 Water SpPP ly (M O.h c.40,§54) 1.7 Fippd zgge jur6priAtiopi La sewage plr�tgaall Systeml " ` Zone; +_ • -QutsidoTlood Zone? Public G PI'Ivate(7 ; Cluck i£. esO Municipal F]Dii site dlspnsal system A p' d SECTION 11 'P QP RTY OWNERS IPi ; s 2.1 Ownerl pf Records Name(Pont) '' .. Clty,State ZIP - �a No.and Street `t - Telephone„ �Tsll Address Np , SgG'"t'jON 3:DESCRIP'j'IQN AV.pit(QPOSEA WORKI 00 .oil that,g. . lYl i^ . New Constr4copn O Existing Building❑ Oivpei`Occu led ❑ 1 Aepairs(s) ❑ J'AlteratIcii(4� Addldon ❑ Demolition i7 Accessory Bldg. ❑ Numbcr'of IJnits_ Other-Q $poolfy ` Brief 1)escription of Pjppused:Work2: 1�� d 1�►5o a 2 ��_ T y SECTIOri At e$ T gp CONST(tUCTIRN CQ9TF Estimated Costs,. + Item `y (Ifflcia��Iqe Qnjy Labor and Materials 1.Building $ .:�,o 91c;,6 ` l Building Permit Fee $ ' .` jrtdlcate ltpw fee is detemined: 2.Electrical $ �O a o P 6tggdqrd City/ tiwn Applicatipili oe �i ptgl Project Cyst'(Item 6);jp4 1plief X, 3.Plumbing.. $ . ®OLD:. x OthPc.'Feds i$ „r;p k" .r%t r u ' 1 r,.. is «:,,� +" • 4.Mechgnicgl (I-IVAP) $ x 5.Mec�anlcgl (Fire $ Sure4io0, Total=AII,Fees.$ . ,e ao heck No _check Amount r E Cash Amount b.TQH Prolaft Ct16t: s ''� � P Paid in Full, ❑ Outs tiding jjalWiop ua. W — —5 ✓ N i OL 1So x tra ti 3ECTI4I .t NC, .uCT;AN 6 .. Om 5.1 Cpostroe#op Spporvrsor Wcense(FU " �1 AI 30 O +� , „ icense Naptber _ $xPirnHon ate�� Name of CS4'!�Icier - _ Fist CS(.T pa(see below) 12 No.and Sheet,.• j ^TYpo y ;?Y Pam iipn' -l3imestrictod MuildloRs up to 35,000 cu. 9.) estriated 1&2 Finiffy Pwol Ing. City/Town,State,Zii' " Irt asoa RC RoOrta Goverm WS Window Si SF. 1.4 lianaes" I insulation ... Telephone t - - Email address :'- Domolillon - 5.2 Registered Notpe'{titPro�ement Coptractt (}i}C) ' 4 t�zot- iz 2c� ReglStration Natglt�t pxptratip,Date my Napte r IIIC}tegtotrant Nam p p: No.andand � �Pa'�2At�2. Email 1dd(oss Ci own, ZIF1ale hone . C., AN 4i� I}KI IYS>.Co � � TIPN iN6>�7RANCir,AB'FIpAV}} (FUG L.18 d 4: �Y! '4 S. Workers Cotri ensallott i(!sgrdn8e affidavit n)ust ho,Wmpletcd and sabtilltted tvi€h till'gpplicatiip Paquro tp provide this affidavit wIh resNlt Itt the denial of the Issuitrjpo pf the 6gjlding pdrinit t ' :+ Signed Affidavll AttgehEd? yes ...... No. .,. q f.>. TiAN 78:qwN) >;TJ It}y TI N TO BI GPMpF+T .A W K' '6 AGENT O 'C PL S IF 1V Q I,as Owner of cite subject property,hereby autfigrI p'r` to act op myrbaltalf,fq all jriatters relative Io wor ✓} *Orizori by tht�F buUdtng petmlt gppitcation vs Print Owner eNwrne(}?Ioctmnic Signature) date - ::' OWNgR' A ARZEA A(; T n G P +4 .; By enteI'llring R'}'ttamo below,I hereby attest under the pains apd penalties Perjury that 41 of thg 1ltfpjjl�rmatiotl contained m;f ills app�jcatlbit isfrue apd acc4afe jtYriiC'�bet'of my t p edge al 4 undpret&rldigg, i d .j Fnq• A Print Owner's 'gr Autljgrized Agent's Name(] leotmnio Signptare) {31tta v 'h.�'.;"'r'i^ �r7,r•ivp.',�yri" 'N* : `'.v Ct�NOTES: 1. M Owner who obtains a building permittp p ls/ItOr ovyn work,or an owner whb hires an Npre&istered Obntractor not regi4cNO 1�thel-)ome'Improvetnehr;Colltractor Clil!✓)Progratb) will pot have access to the at'bltiatioli_�, , proorarq'd}gparapty,furld under M G I o. 142A Qtlt0 important in OR on the 41CprQ iapr cap be found at `- W .mbss:sov/oCe-{pformation on 1(te Cot44tt11trtl64 Supervtsti'r r:iceusc obt(be tbdnd.ai w%K mds9:a'oWdos"'" 2. When"slttigtan 41 work Is planned,provide thQ info talion below; •„> -r Total floor aivi(sq+ft).:a -' " (tpciutltAg$ara$e,finished baeemoni%att(es,decks or porch] Gross iivuig arba(s9:fl;) Flabitabtd rooms,cnurlt Number of$eepigces .,. Npfl6er pf 6agrgppl9 Numberofha oolnµ f$llmhernfhalf/IiathF Type A3fjteatjrig 4 s(otp Nurltlier of decks/porphos p r Type 3. : "Total Pto)ect S Nate Footage that'bP PbsiWtgd for"Total Projeprptiil " fi - The Commonwealth of Massachusetts Department ofIndustrfalAccidents I Congress Street,Suite 100 Boston,lrfA 02114-2017 www massgov/dia VIVorkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers. TO BE 1711"WITH THE PERMTT7ING AUTHORITY. Aimliesuat Information Please Print lA 'bl Naive(Business/Otgamretioln/llndividual): / Address: t6— City/State/Zip: L/J Phone M �� 2 oC) Are you an employer?Check the appropriate boa: Type of project(required): 1.01 am a employer with employees(full and/or part-time),• 7. 0 New construction 2- I am at sole pmpriemr or partnership and have no employees working for me in 8. Ig Remodeling 'rC®y capacity.[No workers'comp.insurance required] 3. I a a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. Demolition 0m 10 0 Building addition 4.01 am a homeowner and will be hiring contractors to conduct all work on my property. I will easme that all contractors either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions proprietors with no employees. 12.0 Plumbing repairs of additions 5. am a general contractor and I have hired the subsonhactors listed on the attached sheet 07bese sub-contractors have employees and have workers'comp.msswance l - 13.0 Roof repairs 6.0 We are a corporation and its officers have exercised their right of exemption per MGL c. 14.0 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 mfoimation. .. t Homeowners who sulimit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. lContractors that check this box must attached an additional sheet showing the rune of the sub-contractors;and state whether or not those entities have employees /f the sub-contixtors have employees,they must provide their workers'-comp.policy number. I am an employer that is providing worlrers'compensation insurance for my employees. Below is the policy and job-site information. Insurance Company Name: 2KXJL'E7 Policy#or Self-ins.Lic.#: :�J c-7 O - 00,�-V V w —O 2_ Expiration Date: 2 (o Job Site Address: 9-1- C A-0,-)S 1�1 U 2� City/State/Zip: AZ'I- Attach a copy of the workers'compensation policy declaration page(showing the policy number and- exp onhira 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 cer! ry that the information provided above is true and correct Si dip sand penalties o perju Signature: ate: r 1 r Y- PhoneM L t7C�2 OffleW use only. Do not write in this area,to be completed by city or town official City or Town: Permlt/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 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 dqg 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. #617-7274900 ext. 7406 or 1-877-MASSAFE Fax# 617-727-7749 Revised 02-23-15 www.mass.gov/dia i 52:Gaibws�3mRD Salem,;MA TGRESS:Windnw EXn . aar#z # 5.0+ SQFIF , ® existing Stairs Up kr— BAlliPMM LAUNDRY :replace 4>windows SMOKE 264" Ceding Heighyty=�\81" Rough � _ )cony.ig W joist/ BEDROOM ` a Mechanical Room LIVING ROOM; i HeMiril Panel rt h Y Y 52 GaEnws WRD.= Salem;MA �•• - - '1=liRESS'lilrindOw EXIT#2 5.9+ SQFT 1 ®• existing Stairs Up BATHROOM LAUNDRY fey' 'f •�, , replace-4 WfBlOWS —\ 4 A r ! q?X SMOKE 26C SCeJling'Height y�81" Rough - `(conaete- joist) — BEDROOM Mechanical Room ' i ' ,.. .-- LMNG ROt3Nl i•. .-^'> ieahcw Pam, W a s ► r . - - 492" 521Galms tM RD SMOIWCO Salem,-MA \4 EGRESS Window EXIT#2 \ EXIT 5.0+ SQFI A :' I existing Stairs Up a 1 , BATHROOM LAUNDRY j 1 s jj replace 4 windows —� r rgv A SMOKE I 264" Ceiling Heigttt= 87r' Rough (rancrete to Jam) i 1— BEDROOM r— Mechanical Room I — LIVING ROOM f 4 i i Office of Consumer Affairs&Business Regulation License or registration valid for individul use only ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: k'Vjepiration gistration 162014 - Type: Office of Consumer Affairs and Business Regulation 12/261201,6 Individual 10 Park Plaza-Suite5170 - ,,(— 3 . iBoston,MA 02116 .. JONATHAN SANTILLO y` . JONATHAN SANTILLO 15 LOWELL AVENUE MALDEN,MA 02148 � Undersecretary Not valid without signature I Massachusetts Department of Public Safety Kv4 . N Board of Building Regulations and`$tandards,a rt Construction:Supervisors: License CS 102547 JONATHANSANXI 15 LOWg11 AV& 7 f . Malden MA 02148 -w�-� jrio' Expiration ', c Commissioner 01130120171 I � CITY OF SALEA MASSAaiUSEM BuIIDiNG DEPARTheNP 120 WABHINGTON STREET,3O Flom 7kL(978)745-9595. KRaERLEYDRISODLL FAX(978)740.9846 MAYOR TrRCMBS STYMME DIRECTOR OFPUBucPROPERTY/BI mDmomaasgomR 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, S 54; Building Permit g 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) a re o applicant 9T� 1 / lam Date Details Page 1 of-I na iSfPian,4VeGsiio of he dxecusv--Oi:ice of PubL SaPefy and Sc- -.ty(EOPSS) Mass.Gow home S'tete Agencies ePnsmeeDn etails c InTf ormTsO# ull am . MA THANAN SANTILLO ender:er Name: ddress: ddress 2: City: Malden tate: MA ipcode: 02148 o nt : U 'ted tates icense No: S- 0 54 License Type: Construction Supervisor Profession: Building Licenses Date of Last Renewal: 1/6/2015 Issue Date: Expiration Date: 1/30/2017 License Status: Active Today's Date: 9/14/2015 Secondary License: Doing Business As: atus Chan e: Lic se Renew I o rere uisite Information No Discipline Information ocumen um Close Window ©2011 Commonwealth of Massachusetts Site_Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=lMicense_id=291469& 9/14/2015