28 GARDNER ST - BUILDING INSPECTION (2) -- ----
�� The Commonwealth of MaSSaCIttISCltS
Board of Building Regulations ;de Standards8 CNISALCl M
'i•�'c, Massachusetts State Building Cole, 730 C'bIR SALEhI
Revived.I lur 21111
Building Permit Application To Construct, Repair, Renovate Or Demolish a
TUrtr- or Tow-Fumilt•Dwellh p
�a Fhis Section For Official Use Onl
Building Permit Number. Date applied: _
MW_ Lv
Building Olticial(Print Mune) Signal a Date
SECTION 1:SITE INFOR ION
L I PrCo_perty AJdress: � Assessors M Z Assessors & Parcel Numbers
J
1.1 a Is this an accented street?yes no_ M1tup Number Purcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Toning District 17wposed tJxc Lot Area(sq Il) Frontage(R)
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood one Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
ph_': Municipal ❑ On site disposal system ❑
SECTION2: PROPERTVOWNERSHIP'
2.1 Ownerl of Record:
Gr. k (wZ-00 SS /e/In M/I o � 7b
Name(Print] City.State,LIP .
No.and Street -relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check Il that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑
Demolition G11Accessory Bldg. ❑ Number of Units_Repairs(s)Other ❑ SFerations) ❑ Addition ❑
AIAlttEeci :
BriefDescriPdonofProposed Work': , ,:Lsr fFl.`,�r) Cv:�TP S 3a ,•,�,. ro•r
�sy.,r(, hew -n J S r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S (iJU 1. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
J. Plumbing S ❑TOW Project Cost'(Item 6)x multiplier _-- x
CDC) ?. Other Fees: S
1. \krhanicul III\':\C'1 S ( List:,-- __` 6
;. .Mechanical (Fire ---/��{{{���� -..
.tiu��nuionl S 'Fund :\Il Fees: S ___ - ----- -
o. Total Project Oust S(�//�j �yZ Check No. ---('heck amounC - (',uh:\mount: -
avri ❑Paid in Full 0 Outstanding Balance Due: _
SECTION 5: CONSTRUC'TION SERVICES
5.1 Construction Supen isor License(C'SL) ��U
— --'-- ----
\\ .�, Licenx Nunthcr P brut to D;nc
Nwne ul'C'SI. I Ioldcr
List(.St.1)pe!sec below!—_.—______
Description
No id Street _
��� / �(c y r U l Inrestrieted I lluildin�s a to)5,0110 cu. Il.l
•ram; ��� ( I R Restricted IR2 Family Dttclhll
Curl foam,Slatc.LlP %I %fason
RC R(totling Covering
W'S Window wtd Siding
SF Solid Fuel !turning Appliances
6 C 7)qO '-7_7! ' I Insulation
'Talc hone Entail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) !' rct 6U
IIIC Registration Numlwr li.pirati ut Uate
IIIC C'ontpan) Name or I IIC Registrant Name
No. and Street Email address
City/Town.State,ZIP 'rcic hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.9 25C(6))
Workers Compensation Insurance affidavit must 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 .......... O No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property, hereby authorize JGSU✓\ \J Z P�
to act on my behalf,in all matters relative to work authorized by this building per ' application.
Frt -Z
Print Owner's Name(Electronic Signature) ale
SECTION 7b:OWNERI 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.
Print Owner's or:\uthorireJ Agent's N;une 1 P.lcctrunic.Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his.her own work,or an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program).will LL)i 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
wttw MA" �;,,t ,�,P ubforntation on the Construction Supervisor License can be found at i%k% t% dtl,
2. \\'hen substantial work is planned, pros it the information below:
Total flour area(sq. R.) _ I including garage. finished basentcnL'attics,decks or porch)
GrOSS living area Isy. It.I ___ Habitable room count
Number of fireplaces __.. - ..._ Number of bedrooms
.N'tunher of bathrooms Number of Ball'haths
I\pe of heating sN stem _ .. _ . _- _ _ Number of decks porches
I s pc of autlutg sN stem _ - Fmclowd _.Open . .
t. ''fot;d Project Square Footage"mas he substituted for"11nal Project Cost"
1
CITY OF SALEM
PUBLIC PROPRERTY
t° DEPARTMENT
ilu6 MI I Y InIV 191
\I il, YI
11C \Vn it U.S.A.l U.\i1,ith I' • $,\I ,r.ln V I n�ri7�
fr.l. �)�:lS'et�+S •1',.r 97s•7sG,IxM
1Yurken' CumpenJation Insurunca U(lduvit: lJuilders/ContractursiElectr(cianwelumbers
� 1 Illc4n In urinuflo
PI ' .e I e 'hl
V,l1T1C I h11VIK',Y I)r�yl1/11111N InJIYulaall: I• i��\ 'v`� t
CL • Jy^1�Jdres.v: D I�CSSUI f�L 4_6 /Cily,.Sr:ua7ip' >" 1 c r� Lte✓I 1/�117 D/ r% 1
y � hunt ik
I \ cnyiloysr7 Chvck Iho apprnyrlura box:
1 un 4 clnplu)er with 4. ❑ I ;un 4 general coulraelor and 1 1)M"fpru)vet(required):
v pluycvs(ru11 mJ/ur ptsewinre).• huva hind the.suh•cuntravwrs rl. O New cunxtruclion
I Im 4 sub jampric"n or partnur• lisnd on rho anachcd.,heus 1 �• ❑Remodeling
Alip;uul have no mnpluyvvs These sub-contractors have
u"rking thr Iriv In ally c4paClly, workers'camp, Insuronee• g' O Demalirion
I No workers'cutup, insurance 1. O We are s cooperation and its 4' ❑Ouildind adddiun
required) "rlleen have vsvrc(.rcd their 10•O Electrical repairs or additions
!.O ! and 4 h"meuwnur Juing 411,nark right of asemption per AIML 11.E plumbing repuits or addition
myself, (N'o ivinrkcrs'cunlp• c. !3J, I l4).and we have rm
in.urancy required.) r cmployvcs, (No,vorken' 12.❑Ruul'npuin
eolnls in.urancunyuind.) 13'0Unler
• nr.,,iphcae Ulan cAcb tNs eI map.dw till uw IM
'Ir,Invrlvnrn„M,Ibmil this allWfvlt iWlIwAin I •IICIIva ln:hrr llwwlne ltyy wwYws'cW,Ifl,yyl„n la4ivy laliamaliulY
T,mlrwll"lhfr thccY InI a 1wr of Jw^I all wurY real IM's him wistisdf watermelon T s Dfa Intlp Inxhee,In Idallitayl.Mp Jluwina Iha Iunl*W IM taa•ceN/ wl.wlwW 4 nfw undsve indlfaelnx ash,
ipalx an*IhfII aaAfm'cony,prlKy Inhemsntl�
io�/new mr vtnpl*yer that If prvv!✓/nr IvurAers'rurnparmNon ln.furnner/w roy ernpluyeea 9i/awls rA*Pe/ley un✓/u1.,il�
urnruHma
In.,ur4ncc C'umpany Nairro: .
Policy Is ur 3vlr•ins. Cic.H:
ERpirattan D,Ir*:�_
)Ole Site Addivi.v:
.trt4cb a cu C1tyISlaterTlp:
Vy of Ih* werken'eumpentall"n pullc) J904ratlun pugo fshowlnp rA�policy number and vsplrarlue dote),
Palluro w,ccura cwerago as required uuJer Sculien?Jr\ul'S(OC c. I!2 c44 lead to the imposition orctirnin4l penalties ofa
up nl SI 5110.001ndlur une•year nnpri.vn"Inume, Is IYcll.1.q civil pcnallwa in'hot lurm ofa STOP WORK ORDER and a fine
.fi up In i!!0 00,4 Jay Igmn.s Ili* V;.Almr Ile sdvl.icd thus 4 campy urlha.Iutumwtl rrtuy be 16nv4rduJ to
the O111Cv wt
Ini„Ily,n,�ta ul':ha UTA :or nnnr u'ca eu.cr44e i alli.4hun.
/.la/I,•r.•Ay ;
i.rri/yIrnde/drlryninr,.. p n..h",
per/"ry rhyr r/re "�'Y//IIY/I00//NYI✓t✓yOer'e;'s tried''tied carlerR
r)//lriul one ml/y, pu am wit*lot th;l 4rt•u, to A*ruuly/ctr✓by my u/tolvAn
//h iu(
rityur I'nnn:
Punnir/Lleenie
I,.viny .\ulhnrily (circle anul:
I 1111vr o(11v.Jlb !. IhuLhn•j Ilk
L. Ihhar p.lrnnenl I. Cil).'I'uIf"Clerk t. Ckvirrical hl,pccrut ;. clumping In,yeelar
._ �� I�hpI1Q 1•
Information and Instructions,oGuthc,rcnlyluyee+.
eve e fcrv,ce ut another und Cr•lily Cumnct of hire.
hu.>eus General Luws Chayter 132 ,cyuues.+Il clnpluyars to provide wuriteri wu,pensa l
I•urnu.u,t to[III*>latuta, Inreeyloree 1+dctined as rY Vlion In the
:.press ter Imp6cJ, urai or wrlltan." orauun ter tither legal enttry.or my Iwo or inure
�n uYQf,of(he
rinQluyer I+JctincJ L"an Individual. purtrianhip,.Issoclilwa.Cory
t the Illoye 14 engagcJ In a iwnt enterprise and Includinll the legal represenutcmelu a^t.aly. m sl)ces.ed I Nowcvcr he
ant of the
eumver ter bullet ui'.m individual, pstmenhlp, assoemuua or other legal fes,j P Y g '
+ r+onO w Jo nain,enunce.cunsuuclion or repair work in such dwelling house
uwnar,)f a dwelling{house having{not mere Char three apace°nu and who resides hermn,ter the occupant
Jwvihng bouts.>f another who employ. {><
or on ,he grounds ter building{a employ"
^art he«ro shall not because of such employment be deemed to be Jn elnpluyer.'
llact
>lGL chapter 132. t)23C(6) also states hat"Ovary 1 or �oecal 11961151116buildingsstruct alie I hat withhold d the Its o rad or
rene>vsl of a Ileense ter P°rrult to operate fabl bavideace of cumpWrru wlrb t�lnsuot u PC""rance
of giubdivrequired."
sions.+hill
prod P not any D
;,yplleuat »ho has not pro i!C 71>ratee 'Neither the eonunonwt hh
\dJitiunaily, %IGL chapter l S_, i_
enter into any contract I'w the performance eao Plaadbu th Ilk e contact g authority"'
u1 wnlPliurice with he inwnnca
requirements of this chapter have been p'
\yyllcsnu I to our situation and.if
er sad phone numb along with their cerlificute(s)of
plea-le fill stir the workers' c�mpalisation affidavit ceinpl°rely,by checking the boats that apply uoe other than the
naccssary,supply sub-contraetor(s)namefeL udJrssal ) with no em goy
workers' compensation liuuronee. If as LLC or LLP does have
inswunce. Limited Liability Companies(LLC)or Limited Liability partnerships(LLP)
ent of
membndustrial
ers or purtners, are not required w carry
en+ployaas,a policy is requited 9e advised that dtte�lee be auto10 ldr and Jute the ui'ildaviL Tile latlidav 1 should
unit of license is being requested, nog the Daporimant of
.\ccidenu for file city or to of insurance coverageir the the law or if you am required to obtain a workers'
be wtumad to rlu city or town You have that the myt4luu ofre regarding
I ndusuiul,\cuiddnta. Should y eni at Iha number listed below. Self-insured camp
ariea should enter their
compensation policy, pleas°call the DaPWM
sclf•in lurance license number tin the a ro Bute line.
('try arrows Officials
you to I'll cut in the leant d ri cc of Investigations has to contact you regarding he applicant.
Please he stirs that the afflduvit is complete ;mJ printed Icglbly, rho Department has provided u space ut thu tto m
(dla sit davit fat y
i'leasa be surd to tilt in the permit/license nwni)dr which will be used as a reference u mitsar, I1 addition,an app
that must submit multiple pannitliCOItL" 3PP'Icallo s"t any given y+uliauuIce�.AcuIJ write Pull lu ueiuns in iwting current
rD
policy 60,01 mation tit necessary) ed or marked by he city Of town Inay be provided to he
tuwnl. .,\ copy of the uffiduvit that has been Wei' sump'
applicant as proof that a valid affidavit is tin file for Hitun pelmiu ter licensees. A new atllduvit must be lilted out each
y e;Ir. Where a hums owner ter citizen is obtaining a license er permit not relmcd to any business or commercial vantun
t i I Jule li A home
a permit to burn leaver dteJ sail persolt is NOT required to complete this altldavit. uasumu,
ri gatiuns wuuld Ilea to chunk you in �Jv;u,cd rut your Coupantion and shuulJ you havd.nY 4
I he l)I li.e .d llWss },
pleaaa Ju not 11411t3rd 10 give us a call.
the u.p.lrnnenrs adds+s, telcphuna °nd rjot number
The COMMOnWealth of Massachusetts
0,!PUVnent of Industrial Accidents
0Mce of lsvatlQadons
500 Washington Street
Boston, MA 02111
f el. M 517.727-4900 ext ;06 ar 1.871-MASSAFE
Fax M S11.727.7749
_j n.ils vww.inam,jov/dis
CITY OF S,Vl&Ni, AkSS.ICHL:SETI'S
SLtLDLNG DEP.1RTTfLNT
I 20 W.I'"L*1GTON SnILMM, Ji°Rccit
TEL (978) 745-9599
KlJ(BERlEY DRMOLL FAX(978) 74Q9846
MAMA T1•tomu ST.Pmus
DIRECTOti OP PLBLIC PROPt3tTY/BLR,DLYG CO-%311SSlON EX
Construction Debris Disposal AYfIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.S
Debris, and the provisions of MOL o 40, S 54;
Building Permit M 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 MOL c
111. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
Gr�it'Rerec� U
�./ (name or racdily)
C11 L
(�ddre» or racrLty) ^!
/uynarureb( crmrt z6plrunt
NlassachusMts- Dcp:utmcnt of Public Safety
UMOL
t Board of Building Re-ulations and Standards
Construction Supervisor License
_ License: CS 98808
JASON DIXEY t -
20 BESSOM ST#5 1
MARBLEHEAD,MA 01945
Expiration: 6/2/2013
(',nnmi�si„nrr TO: 21022
Omce oPL`on�mer ams $u41��§' 7�
_ HOME IMPROVEMENT CONTRACTOR
159609 _ TYPE:Expiration SM5/2012 Individual
E[ )Registration:
NSTR4CT,ION f -=1;
-/ �JA3ON DIXEY
22:I.INCOLN AVE
1'.aRE"EPEAD, MA 01945
Undersecretary