24 GLENDALE ST - BUILDING INSPECTION The Commonwealth of Mass NAL SERVICES CITY OF
Board of Building Regulations am,
rtan ar s SALEM
/ Massachusetts State Building Code, 780 CMR 3 A 102 Revised Alur 2011
Building Permit Application To Construct, Repair, a e r Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date ppiedr
l Building Otticiul(Print Name) Signature
SECTION 1:SITE INFORNIATION'
I.I Property Address: c�q GIe� a LQ S� 1.2 Assessors blap&Parcel Number
1.I a Is this an accepted street?yes no Map Number Parcel Number
}`f 1 1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(It)
LS Building Setbacks(ft)
Front Yard Side Yards Rear Yuri
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 yesE3
SECTION2: PROPERTYONNERS11I10'
2.1 Owner'¢ Record:,;,,
Sha109 1 rc> ✓A
I�tme(Print) City,Slate,ZIP
� y > �wdai�
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED\VORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) kJ Alterntion(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief De cription of Prop( V k=:
t15F4I1 CLMaha' Wr� ba41S
Qa 7 r
SECTION a:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. building $ -7 I. Building Permit Fee:li Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing S 2`?ether Fees: S
d. `Icchanical (HVAC) S List:
5. Mechanical (Fire S 'total All Fees:S
Suppression)
—7 Check No._Check Amount: Cash Amount:
6.'rotal Project Cost: S , ❑Paid in Full ❑Outstanding Balance Due:
yn n, ✓>�D
r
SECTION 5: CONSTRUCTION SERVICES
5.1{'�Construction Supervisor License(CSL) D /g P q q a p /P
PDC Z 0I 11`{• - License Number Expiration Date
Name of CSL Holder List CSL Type(see below)
l7 � �,alerS L n
No. ;aid Sueet Type' Description .
�'1 a ( q 7U U Unrestricted(Buildingsa to 35,000 cu. It.
�c f� l ! R Restricted I&2 FamilyDwelling
Citylrown,Stale,"LIP M 'laso
RC Raclin Covering
WS Window and Sidin
'I SF Solid Fuel Burning Appliances
Ybi �q9 � �� I Insulation
Tcle hone Email address D Demolition
5.2 Registered HomeImprovement Contractor(HIC)
1 'o 'e— L�ex1)�- HIC Registration Number Expiration Dale
III Company pp(( e
ame or HIC Re tram Nam
��$ 17oS+di, ��
No t Street Email address
$��rP tJS b�r� �i W �/6' 49" ay
City/Town,Statc Z P Tel e hone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L c.151.§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 .......... No...........❑
SECTION 7u:OWNER AUTHORIZATION,TO BE COMPLETED WHEN!.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
I,as Owner of the subject property,hereby authorize n' e .6z
t9 act on my behalf,in all matters relative to work authorized by this building permif application.
SE ( � Uh +_ r_ 0— 0? 3 �5
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained m this° plication is true and accurate to the best of mYknowledge and understanding.
Print Owner's or Authorizcd rent's ante(Elecunic Signatu e) 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. 1 d2A.Other important information on the HIC Program can be found at
w+v+v ntass.eov'oca Information on the Construction Supervisor License can be found at www.mass.eo+;'dns _
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) .(including garage, finished basementlattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
fypeofcoolingsystem Enclosed Open
3. "Total Project Square Footage"may be substituted for"'rut l Project Cost"
CITY OF SALEM, MASSAaivam
ro Bua DING DEFAR7MENT
120 WAsmNGToN STREET,3'DFiooR
I L(978)745-9595
FAX AX(978)740.9846
MAYOR THmw STYIERRE
DIRECTOR OF PUBLICPROFERTY/BUILDING oobwsSIONER
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# 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:
jl�or�h Sh�r� CC Mj4q
(name of hauler)
The debris will be disposed of in:6 u2. -b em h-Q v-42
(name of facility)
�, P 30 dew
(address of facility)
K IJA
Signat re of applicant
� - a3- l�
Date
The Comnsonwealth of Massachuselts
Depaphnent of Fndustrial Accidents
Office of Investigations
Ulf 600 Washington Street
Boston,MA 02111
www.mass gov/dia
Workers'Compensation Insurance Affidavit: Builders/Contractors/Elects icians/Plumbers
Applicant Information Please Print Leslibly
Name(Business/Organizeflou/Individual): Nome- h£.a Ale were, �Pi/1//GPis
Address: Rob
City/State/Zip: S v . o/SyS Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ®I am a general contractor and 1 6. ❑Now construction
employees(full and/or part time).* have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t ?• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised thew 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers'
13.[VO
comp.insurance required.] dter ] CI Y vt1d t
•My 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 him outside contractors inset submit a mw affidnvit indicating such.
tContmctms that check this box must attached an additional sheatshowing the name of the submmmenors and their wotttess'comp.policy i mention.
I am an employer that Is providing workers'compemadon bauranceformy employees Below is thepoRey and job site
hnformadom /a/ / �^
Insurance Company Name: `e4AJ /r"//44 �X Irg� 5 ✓0
Policy#or Self-ins.Lic.#: uW/�C O 1 i / 3 y ( � Expiration Date: 3 /
Job site Address: 0 / 6 [en dale cJ 7 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 Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby under the pahu and p-mahha ofpedxry that the beforneadoa prod/above h true and correm
%gnature: C�-h ✓ Date:
Phone#:
OB9clai use a*. Do not write in thk area,to be coagrleted by dly or town of trial
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#
1At Massachusetts.Department of Public Safety
�f Board of Building Regulations and Standards
Construction Supervisor Specialty
License:CS81.099M
�/� 1�r�Mq/��\\\mil
AVB�BKtpll POp��,lA/0
LXN�VSale10 OlY1a
�i.�...11 dtfs• re`� \` Expiration
Commissioner 0?/Ot1=16
r� 4
C���e ���a62-r�lz�azc�re�c�,��� c�C���zs.��rc�cc��f�J• ,-.
Of. ice of Consumer Affairs and Business Regulation
,< 10 Park Plaza - Suite 5170
>, Boston, Massachusetts 02116
Home Iflnprovera ; ;Contractor Registration
Registration: 126893
Type: Supplement Card
THD AT HOME SERVICES, !NC. Expiration: 8/3/2016
MARK NIADNA ----- -.—..._�._ ---- -- -- - ..
2690 CUMBERLAND PARKWAY SUITE=3.00 :`a:', --- --- ----- - --_•_ .
ATLANTA, GA 30339
Update Address and return card.Mark reason for change.
scn t .; zotn.osm
Address fJ Renewal (] Employment [7j Lost Card
r':%�r•*1 Ile,It umcvr1/1 /1rr.:jne,1mj,/Ll
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
!)a, before the expiration date. if found return to:
OME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation
Registra00fic 726893 Type: 10 Park Plaza-Suite5170
Expiration; gi3/201.6—,. Supplement Card Boston,MA 02116
THD AT HOME SERV1t:ES:;INC1
.. THE HOME DEPOT;AT,t:{OME,SERVICES
MARK NIADNA
2690 CUMBERLAND PARKWAY S
Xff-'AM,GA 30339
Undersecretary Rpt valid withou signature
j
p
Branch Name:hanno NttM&South little: / Sold.Famished need Installed by
THD At•H,' v rare Services,Inc.
Branch Number:JI and JJ 9UE&ustvn 7 a The floor!DIPIN AI-Home Services
mpike,Unit I,Shrewsbury,MA 01545
Federal ID a 75-2 'full Free E77.903-376E
t�,� CT IJc n IIIC05h5522:MA Him,improvement Gums wtu 191 at Con,
Reg.0 12tisv3
Installation Address: d` 1 Ct"�..('. ts5 S''t" ES'�•(�"m ...td ( ,7 O
City Stale Zip
Purchuser(s):
Work Phone: Home Phone- Cell Phone:
� Ck S CA [ I [ ] I I
[ I [ l [ 1
Home Address;
(If different from Instillation Address) City State Zip
❑E•tnail Address Qo receive project communications and Home Depot updates):
1 DO NOT wish to receive any marketing entails GOm The Hane Depot
Proied Informallon: Undersigned I"Costumer'").the owners of the property located at[he nfnvc insmllativn address,agrees to buy.
and THD At•Homc Sttvices, Inc,(•The llotne Depot")agrees tv furnish,deliver and arrange for the insmllatiun(" nstallathai')of
all materials described on the below and on the referenced Spec Sheet(s),all of which are incorporated into This Contract by this
reference,along with any applicable Smre Supplement and Payment Summary attached hereto and any Change Orders(collectively,
"Contract"):
Job Y: a,-, .,ma Products:
Sort Sheet s)Y: Pro art Amount
n Roofing LJSiding U Windows J Insulation ^ $ S511
1 UO ❑Gutters I Covers ❑Entry Doors ❑ Ll
Roofing Siding Windows insulation
❑Gutters/Covers ❑Entry Doors ❑ $
Rvofmg w4lueng u Winsovs U Insulation
❑Gutters 1 Covers❑Entry Doors❑ $
Roofing Siding Windows Inwiarian
❑Gutters I Covers ❑Entry Do" ❑ $
MWmum25%Depadt Of Contmcl Amaua dm upmeaeaaioa of this ca tm-L ��ICI
y Maine l'urehusets may no/dep®t more than ottere CummclAmoutd. Total(:onlreet Amount $ .�
Customer agrees that. immediately upon completion of the work for each Product,Customer will execute a Completion Certificate
- (one for each Product as defined by an individual Spec Sheet)and pay any balance due. As applicable, each Customer under this
Contract agrees to bejointly and severally obligated and liable hereunder.
The Home Depot reserves the right to issue a Change Order or terminate this Contract or any individual Produces)included herein.at
its discretion,if The Home Depot or its authorized service provider determines that it cannot perform its obligations due to a structural
problem with the home.environmental hazards such as mold,asbestos or lead paint.other safety concerns,pricing errors or because
work required to complete thejob wits not included in the Contract.
Payment Summary: The Payment Summary >t-1[�5� 1 (0 , included as part of this Contract. sets forth the total
Contract amount and payments required fur the deposits and final payments by Product Ins applicable).
NOTICE T)CUSTOMER
You are entitled to a completely filled-in copy of the Contract at the time you sign. Do not.sign a Completion Certificate(note:
there is one Completion Certificate for each listed Product as defined by Individual Spec Sheets)before work on that Product
is complete.
In the event of lermination of this Contract,Customer agrees to pay The Home Depot the costs or materials,labor,expenses
and services provided by The [ionic Depot or Authorized Service Provider through the date of termination,plus any other
amounts set forth in this Agreement or allowed under applicable law. TLIE HOME REPO"('MAY WITHHOLD AMOUNTS
OWED TO THE HOME DEPOT FROM THE. UFpOSIT PAYMENT OR OTHER PAYMENTS MADE, WITHOUT
LIMITING THE HOME DEPOT'S(yl'HER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
MeAceeolance and AufhuCIMLIOn: Customer agrees and understands that this Agreement is the entire agreement between Customer
The Home Ucpol with regard to the Products and Installation services and supersedes all prim discussions and agreements,either
Oral Or ,wriuen,relating to said Products and Installation,This Agreement cannot be assigned or amended except by a writing signed
1 by Customer and The Home Dejeol.Customer acknowledges mid agrees that Customer has read,unders1, ids,volumarlly accepts the
terms of and has received a copy of this Agreement.
Accepted by: s b t d
°��� �� _
Custon is Signature Date S: 's .on mh:ml' Sig08rn
❑ Date�-tX Telephone No. ; 1 ^ G /
j Customer's Signature Ume Sales Consultant License NO.
CANCELLATION: CUSTOMER MAY CANCEL THIS ^ WxappliwNe)
AGREEMENT WITHOUT T PENALTYNNOTICE
TO
ME 1 U ^„Q � /
BY DELIVERING WRITTEN NOTICE TO THE HOME a 1 (` YI' J\
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT ATTACHED HERETO /.gyp GC ,
CONTAINS A FORM TO USE. IF ONE IS
SPECIFICALLY PRESCRIBED BY LAW IN
CUSTOMER'S STATE.
N(rl'ICR:ADDITIONAL TERMS AND CONDITIONS ARK STATED ON THE REVERSE SIDE AND ARE PART OF THIS CONTRACT
02.03-15 White-french Fie Yauow-Cualomer