12 GARDNER ST - BUILDING INSPECTION =� The Commonwealth of ItMassachusetts
Department of Public Safety
\lass,tchunrlts SLUo Building Code(78U C\IR)
1itiIding Verrnit Application forAity Building other than a One-or Two-Fa fit ily Dwelling
(I'hiv Section put Official Use Oulu)
Building l'ennit Number- _________- Dale Applied: Building Official:
SECIION 1: LOG\PION(I' •ase indicate Itlock N and Lot if for locations fur which a street address is not available)
No. •old Street Cily /fown Zip Code Name of Building(if applicable)
SFC'1'ION 2: PROPOSED WORK
Fdown of MA 51,ne Code used _ If Nvw Construction check here❑or check all that apply in the hvu nnvs l+clew _-
FaislingBuilding❑ Repair :\Iter,u ion ❑ Adtilion❑ Demolition`❑ (Please fill out,uul submit \ppen(ji.x l)
Change of LNe - ❑ Change of Occupancy ❑ Other ❑
Arc building plans and/or<onst to,Iion dr WU nlcn is being supplied,IS part of this permit application? YeS ❑ No ❑
Is all hnlependent Structural Engincerin 4l,�"��eer�R�e�v_iew required? Ycv ❑ No ❑
l)rit Ucscri 'on of Propus• W rrk: Q'CIQ + < C n
-- - ` Gtcr n w
n PUP
SECTION 3:COMPLETE 1`11IS SECFION IF EXISTING BUILDING UNDERGOING RENOVATION, ADDI'f ION,OR
CHANGE IN USE OR OCCUPANCY
Chcck hero if an F.xisti ng Building Investigation and Evaluation is enclosed (See 780 CNIR 14) ❑
Existing USc Groups): _ Proposed Use Group(.v):____—
SECTION 4:BUILDING IIEIGIIT AND AREA
Existing Proposed
No.of Items/Stories(include basement levels)h Area Per Floor(sq. ft.)
Tuf.tl .\rea(sq. ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A; Assernbly A-1 ❑ A-'-❑ Niglnclub ❑ A-1 ❑ :\-I ❑ A-5❑ B: Business ❑ G Educational ❑
F: Facto F-1 ❑ 1:2❑ H: Ili h Hazard H-1 ❑ H-2❑ H-\ ❑ 11-4❑ 11-5❑
I: Institutional 1-1 ❑ 1-2❑ 1-1❑ 1-4❑ ,\I: \lercantile❑ R: Residential R-10 R-2❑ IW❑ It-4❑
S. Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe blow:
Special Usc
SECHON 6:CONSTRUCTION IYPF- (Check as applicable)
IA ❑ IB ❑ II.% m IIBO I11,\ ❑ IIIB ❑ IV ❑ V.\ ❑ VB ❑
SEC'r1ON 7: SITE INFUIt�I.\LION(refer to 78B C\IR I1LD htr details on each item)
Water supply: Flood Zone information: Sewage Disposal: Trench Permit: Debris Removal:
I'u hlic❑ Chrrk it outeiJo Road /_one❑ InJicate mm�icil+,Il ❑ .\ trench will not be Lin•nsoJ Disposal tine Cl
I'ric.Ilc❑ or indenlity Lmo' or on sec ce sh•IIt ❑ n•yuirrd ❑nr Inauh or sprrily:
no it is enclosed ❑
Railroad right-ot-way: Ilazards it, Atf.Nav igatiun:
N,n \pphcable❑ Is ctrur tore o Illtin aupoyt appro,ich area.' Is thou rev i, i anlplrlyd.' .
,,r L.,mvnt fa llu J,l rm lasrJ❑ lrs❑ „r No❑ 1 \rs❑ Ni. Cl
SI:CI ION 8:CON II:N'I'OF CFIt I'11IC•All!of:OC-CUI':\N('Y
LI dan o of lode: . C.,•Grou pUl, ft l„ „1 C,,wslrm non l+rI up.mt 1 ,.iJ per l hmr —
lt,ms the l,iiilJinl1,rnl.un.w �pritlkh r Sr stem'' � ,rri.Il'IlI,ulmiom-
t � C
_SR IION`): IIRUPYR'IY OWNFRAUI_11ORIZA 1 ION____
--- -+ --- -- —
w pl \ddr sss It Il�'�rrI.I�pl•it Oontr
City/Town /iIt
N.unc (Print) No. and Street )'/
Property Owner Cuutael Infonna l ion:
I ide —.__- -- - -_— relophone No. (business) Telephone No. (cell) a-mail address
If applicable, the property owner hereby JU11101"l/Cs
._-- Name ---- Street Address - -City/Town Slate Zip
to act on the property owner's behalf, in •
all matters relative to work authorized b this built in x•nnit application
SECTION 10:CONS'1'RUC LION CONTROL(Please fill out Appendix 2)
If building Is less 111,11113,0W Cult.of enclosed S,a[e algl or nut tinder ConstnlRion Control then check here D and.rki 1 Section 111.I
10.1 Registered Professional Responsible for Construction Control
630 � �fQv oars ,lam _ 16
Name(Registrant) -relephone No. e-mail address Registration Number
tit reef Address Cily/Town State Zip Discipline � xp13vm Date
10.2 General Contractor
Company N.0
�
iQGecJ-�/�?i S —
Name of Person Respuossinibll'e pfor Construction License No. and Type if Applicable
V W LLOL-:) ���M /,M _ 0I,-i-l0
tilrect Address City/Tow State Zip
-* G�o aria , -----
TAT ,hone Nu. business Tele phone No, cell e-mail address
SECT•ION11: m S I 1t�)urn.-:�.II'I" 1\'an;.)\'-I .\II111""1 M.G.L.c.152. 25C6
A lYurkcrs'Compensation Insurance Affidavit frtnn 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 Lssuance of the building permit.
Is a signed Affidavit submitted with this application? Yes O No O
SECTION 12.CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs: (Labor U00.
Item Total Construction Cost(from Item 6) -5_-r
old Materials)a
1. Building Building Permit Fee-Total Construction Cost x—(Insert here
'. Elcctricol S appropriate municipal factor) 5
1. Plumbing; b contact numiri .slily
Note: .\linlnnun fee-5__( I )
1. \Ivihaniiel (IIV:\C) 5
i. \Iceh,1111CA (other) b 1?nclose check payable to
I,. fugal Cost 5 (Contact municipality)and write check nun.ber here
SECTION 11:SIGNA TUBE OF BUILDING PERMIT APPLICAN'r
iiv enterint; my name below. I hercbv attest under the pain.s.uld penalties Of perjury That all of the information iot'Llo yd in this
application is Inlc and accurate to the hest Of Illy know ledge and understanding.
Elul a � - - ---- � /'
- -
I'Ir, print ai �.ig;u I'm _..____._•:5 . - __._. I itle I Icphent•Nn. Uaty
r I'oteny.fyg, Stat
t C�\�law
,twlicip.il Inspector to fill out this section upon application approval: _._ y�
Name I Is,tleit,
CCI-Y UN S:UIM) NWSACH[:SE'ITS
13L'ILDING DEPART\tE.NT
120 %VASHLNGTON STREET, 3ta FLOOR
\.�. TEL� 978) 745-9595 Fxx(973) 7.10-9844
K1\I31ERt EY DR1SCOLL
�L1YOR TrIOhL\S ST.PIIeRRB
DIRECTOR OP PLSLIC PROPERTY/SUMOFNG COWMSSIONER
Workers' Compensation Insurance Affidavit: (3uiiders/Contructorv/E(ectriclans/Plumbers
4nollcont Information Please Print Le2ibil
N;I Inc Inuiitic.aorgantntiomImlividual)'
Address: (1W W11.1,A0L D
CilyiStatc/Zip: Phone M: 2a )--
,1re y in employer?Check the appropriate boat Type of prnJect(required):
I. I am a er with employer I 4. 0 I am a general contractor and 1
D Y 6. ❑Now construction
employees(fbll and/or part-time)."' have hired the sub-contractors
2.O Ian a sale proprietor or Partner- listed cot the attached shoot l 7• ❑ Remodeling
.hip and have no employees These subcontractors have 8. ❑ Demolition
working for me in uny capacity. workers'camp.insurance. 9. 0 Building addition
(No workers:comp.insurance 3. 0 We are a corporation and its
required.) ofncers have exercised their 10.❑ Electrical repairs or additions
S.❑ I an a homeowner doing all work right of exemption per MOIL I I.0 Plumbing repairs or udditlons
myself. (\o worked sump. c. 152,j 1(4),and we have no 12.0 Roof repairs
insurance required.)t cmpluyees. (No workers' 13.❑Other sump.insurance required.)
-.soy spptiuns hd cha:ks but At most atw,col out the watioa below ahawing their waken'eompenntiun pulley inllnrnaiion.
'I Lvneuwnen whu.uhmil this antdavil indicating they an doing all wart and then hire outside tontnttan mut submit a raw onldavil indicating.ueh,
t'•imnwmn that chaslt this box mot aaachd in.dduiumd.hat showing llanwna orlM,ub.uniruWn and ihairwurkui comp.polity lnfamut
lain Below!s du po/!cy and Job site
in/urn'atlen.
In,urmcc Company
Policy a or Self•ios. Lic. H: Expiration Date: I'I
Job Site Adtkuss: Gtylstute/Zip:
.\rich a copy of the workers'compensation pulley declaration page(showing the policy number and explradoe data).
F.tiluru to wcuru cuvenge as required under.Section 21.E of,fGL c. 152 can lead to the imposition orcriminal penalties of a
tire up to il,500.00 and/or one-year itriprisnnmcn4 is well as civil penalties in ilia forth of is STOP WORK ORDER and a line
of up w 5_'S0.110 day against the violamr. Ile advixcd that a copy of(his atatcincm may be furwarded to Ilia Ofticd of
Invc,ligatiuns of the 01A for ioiuravmc cdvcragc vcriticatiun.
/du leer ."Il y and rho palest enuiller"Ipeijury tbut rile hifunnudmt provided abuva it rrur atad c✓rreet
Data:
Uf/icivl r,er.u,ly. O✓nnf rvritl in tidv:area, to bet campleted by city ur to sa,n/fhiu!
City le 7otvn .. _ i'crmitil.lccmae i
te,uin; Attllwrily (circle nnc)o
1. Iloard oil'Ifeillh t. Iluildim" Department 1. ('ilyi fours Clerk 1. I•:Icerrie.11 (n,pcctor i. I'Innlbint: lutpeetnr
G. Oilicr
L
CITY QE S.UzN[, AUSACHUSETTS
8L'tLDCIG DEP.1ATtE`T
110 TUHNGTON STXW# 1'O Fta04
•. T1L 197� 74S-9S9!
KIMBPRI Y DIILSCOLL P.IX(71� 110784d
MAYO1t Ik0.1W ST.1?1EIlttJ<
Mumma OP PCBLlC PROPIATY/3t;MnLYG CO.%OIt3lrONEX
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 Cj%AR section 1 I I.J
Debris, and the provisions of MGL a 40, S 34;
Building Permit At is issued with the condition that the debris resulting
this work shell be
III, 3 IJOA. disposed of in a prope from fly licemed waste disposal facility as defined by,%,IGL o
The debris
will be transported by:
(name ul'houler)
The debris will be disposed of in :
t,ddrrfr arr,,,t„y)
tn re or;7"mit ipplicint
.!jig
BEAU VAI S
B-LjI Ems'
F9ni5h Carpentry & Remodeling
781-630-2--3.52
l0 rZgT AvevN
Sni3_�.L �'i E"119"10
Date 5 / 17/ 12
TO:Tenets at 12 Gardner st.
Salem Ma.01970 Estimate
Rebuild rear decks
support both upper levels from ground up
• Remove existing post, railings ,decking and framing on all three decks
• Install four new concrete footings
• Install new 4x4 p.t. post
s Frame three new decks with 2x8 pt framing and attach to house with 5" lag bolts
Build new steps
• Install new 5/4" x S /,' pt decking
Install new pt 2x4 railings with balusters to mass building codes,(42" high is to code for 2ntl and 3" floor
•
railing height).
• Repair third floor door to gain access to new deck
Remove all debris from site
Total cost....................14,000.00
Payment to be made as follows, 7,000.00 due at signing of contract,4,000.00 when framing is completed,
with balance of 3,000.00 due upon completion
'�X
Respectfully mitted by /� (�
Daniel B uvais------------- --- - ------- - ---- Homeowner
�T