11 GARDNER ST - BUILDING INSPECTION (2) \ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
I a l o
Massachusetts State Building Revised Mar Code, 780 CNIR SdMar
O\IW\ 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This section ForOfficial Use-0nly
Building Permit Number Date Ap beds;
Building Official(Print Name) 'Signature
SECTION 1: SITE INFORtNIATION
1.1 Property A dress: 1.2 Assessors Map& Parcel Numbers
i t Gof�.�>, Sf
1.1 a 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(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 Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[]
SECTION2:;PROPERTY'OWNERSHIP�'
2.1 Ownert of Record:
K o„ � r. �o��d 1, I ( G d,�,rJ._ 5 �.
Name(Print) ' City,State,ZIP
a l 93 4' a y 3
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) k Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':_ C, t_ ! [r [Jto_t - Y'a a L d� t
s
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
[tern Labor and Official Use Only,
M aterials
1. Building 1 Building Permit Fee £ Indicate how fee is determined:,
❑ Standard City/Town Application Fee
3. Electrical S
❑Total Project CosC,(Item.6)x multiplier x
3. Plumbing S 2 Other Fees: $ x�
4. %.lechanical (lIVAC) S List �/� y
5. Mechanical (Fire
Su> ressiai) Total All Fees: S
Check No. Check AnnOnnt: Cash Amount'.
6 Total Project Cost: S OG 6 - ❑ Paid in Full__O Outstanding Balance Due_
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No. and Street — Type _' Description
U Unrestricted Buildin's up to 35,000 cu. ft.
__ R Restricted 15e2 Famii Dwelling
City/Town, State, ZIP -M Masonr
RC Roofing Coverin
\VS Window and Siding
SF Solid Fuel Burning e\ppliances
I Insulation
rcle hone Email address D Demolition
5.2 Registered Horne Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IIIC Company Name or 1-IIC Registrant Name
No. and Street Email address
City/Town, State, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. t52. § 25C(6))
Workers Compensation Insurance affidavit mast 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 .........�M' No ...........
13
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 Owner's 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 kriawledge and understanding.
A,\jor
Prim[Owner's or Authorized Agent's Name(Electronic Sig t6 tre) 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.mas. ov%uca Information on the Construction Supervisor License can be found at wwwanass.,zov'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,lecks/ porches--- --
1'vpeofcoolingSy,tent F..nclosed_ _ .---_--_Upon--- —
3 - Total Project Squm-c Foofa_e" way beubtituted for-''Ibt.d Project Cost' ------- -------------
CITY OF SALEM, -A-1SSACHUSETTS
BI:tLD4\G DEPAR-MENT
3 N• 130\'4.1SHLNGTON STREET, 3PD FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KIJII3ERLEY DRISCOLL
NLkYOR THo.%w ST.PiERRa
DIRECTOR OF PLBLIC PROPERTY/BCILDNG CO.NaIISSIONER
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 c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a property licensed waste disposal facility as defined by MGL c
l It, S 150A.
The debris will be transported by:
(name of Hauler)
The debris will be disposed of in
--- (name of Facility)
—_(address of facility)
signature of permit applicant
— ! d — 12
date
y Z
NOTICE NOTICE
TO TO
UV
EMPLOYEESEMPLOYEES
'The Commonwealth of Massachusetts
DEPARTMENT OF INDUSTRIAL ACCIDENTS
600 Washington Street, Boston, Massachusetts 02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you
notice that I(we) have provided for payment to our injured employees under the above mentioned
chapter by insuring with:
ASSOCIATED EMPLOYERS INSURANCE COMPANY
NAME OF INSURANCE COMPANY
54 THIRD AVENUE P.O. BOX 4070 BURLINGTON MA 01803-0970
ADDRESS OF INSURANCE COMPANY
WCC 5006255012012 04/20/2012 - 04/20/2013
POLICY NUMBER EFFECTIVE DATES
24 Federal Street 4th Floor
Boston Insurance Brokerage Inc Boston MA 02110 (617) 556-7000
NAME OF INSURANCE AGENT ADDRESS PHONE
Ebersole Construction LLC 87 Flint Street Salem, MA 01970
EMPLOYER ADDRESS
02/22/2012
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish
adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act.
A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.
The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary
and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that
the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL FACILITY
NAME OF HOSPITAL ADDRESS
TO RE POSTED BY EMPLOYER
H't �Eit4PRCt CMENTCOYTW.CTOR
s _ Registration(�t4F 495 Type: k4
Expiration:
4/7ri 073 Ltd LiabilityCpq;
EB SOLE CON$T U SION L l�j
ei
ANDRE -EBERSOLE`
87 FLINT ST
- SALEM, MA 01970
_ Undersecretary.
*= Nlassachusclts- Department of Public SJell
Board of Building Regul:uions and St:mdards
Construction Supervisor License
License: CS 86492 • g
ANDRE L EBERSOLE
87 FLINT ST
SALEM, MA 61970
Expiration: 4/22t2013
('onm�isvioner'' - Trp: 13316