10 GLOVER ST - BUILDING INSPECTION (2) CK 4 o 1' IS -7
RECEIVED VICES.
The Commonwealth of Massachusetts
Department of Pub t ' q q 4.1 1
Massachusetts State Building of CNIR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(This Section For Official Use Oni )
OuRding Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block #and Lot#for locations for which a street address is not available)
No.anti Street City/Town Zip Code Name of Budding(if applicable)
0 SECTION 2 PROPOSED WORK
Edition of MA State Code used_ If New Construction check here❑or check all that aPPY
1 in the two rows below
Existing Building❑ Repair r\Iteration Q Addition❑ Demolition Q (Please fill out and submit Appendix 1)
Change of Use ❑ Change of Occupancy ❑ Other Q Specify:
P fY:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No to
Is an Independent Structu rat Engineering Peer Review required? Yes ❑ Noe
Brief Description of Proposed Work: /iz.CTi4Cr (/ i C .Pe. 2 S
SECTION 3:COMPLETE THIS SECTION 11:EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CNIR 34) Q
Existing Use Group(s): Proposed Use Group(s �Y�o GT/ �C ym•C,.
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)it Area Per Floor(sq.ft.)
Tonal Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a licable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A-1 Q A-5❑ B: Business ❑
Fo Facto F-1❑ F2❑ E: Educational ❑
Huard H=l❑ H-2❑ H-3 ❑ H-4❑ H-5❑
1: Institutional 1-1❑ I-2❑ 1-3❑ 14❑ M: Mercantile Q R: Residential R-1❑ R-2❑ R-3�" R-0❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
IA13 IS IIA ❑ t16 ❑ IIIA ❑ IIIB ❑ IV VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone Q Indicate municipal Q A trench will not be Licensed Disposal Site Cl
Private❑ or indentify Zone: or on site system❑ rexluired Q or trench or specify:
` permit is unclosed❑
Railroad right-of-way: Ilazards to Air Navigation: �I,\1 li.n n i'„n,inisi m It a urn•,I'nki_s:
Not Applicable Q Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes Q No ❑
SECTIONS:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Cnmp(s): type of Construction: Occupant Load per Floor
Does the building contain an Sprinkler System?: Special Stipulations:
e
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property,Owner- )
S��P,i i D/�
Name(Print) No.and Street City/Town Zip
Pro arty Owner Clo tad Inf rmation^UA Oils O DSClP
e 2?t--77Y-oasS��F y J
Title Telephone No.(business) Telephone No. (cell) a-mail address
If applicable,the property owner hereby-authorizes /f
None Street Address - City/Town State Zip
to act on the property owner's behalf,in ad matters relative to work authorized by this buflding permit application.
SECTION 10.CONSTRUCTION CONTROL(Please fill out Appendix 2)
If buildingis less than 35,000 cu.It.of enclosed space and or not tinder Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
�,aI77Ghd�ln msa. ��(�� �0�� O�1rFrfS`6 is4'�°s F 7-/S
Name(Regtss�rant) a phone No. ,y/ a-mait address Registration Number
Ciiz s/t S? �.t7iLiip V/
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
/f�,
Comp y Name /r
Name of Person Responsi fur Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Telephone No. cell e-mail address
SECTION 11:4V0RKthS'COhIPFN5A I ION INSURANCE AFFIDAVI I M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from 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 issuance of the building permit.
Is a signed Affidavit submitted with this application? Yq02F No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Budding $ Oa Building Permit Fee-Total Construction Cost x_(Insert here
2. Electrical $ appropriate municipal factor)=$
3. Plumbing S
4, %lechanical (HVAC) - $ Note:Minimum fee=5 (contact municipality)
5. Mechanical Other $ Enclose check payable to
6.Total Cost 3 / s'ljp (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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�tme:md accurate to the best of my knowledge and understanding.
Please pruitjnd sign name // Title Telephone No. Date
Street Idress City/Town State Zip p
Municipal Inspector to fill out this section upon application approval: 13
Name Date
CITY OF SA\L.EM NL-1SS:ICHLSETTS
4
l [3L'(IDNG DEPAR'I1lE.\iT
120 WASHLIJGTON STREET, 3"s FLOOR
TEL (978) 745-9595
F.kX(978) 740-9846
KI\tBERLEY DRISCOLL
"',1 LAYOR THollw ST.PMRA151
DIRECTOR OF PUBLIC PROPERTY/BUILDING COJL\IISS(O.NER
Workers' Compensation insurance Aflidavit: Builders/Contractors/Electricians/Plumbers
Anplicant lnformatinn // Plca se Prtnt Le tP hlv
VBInC (nusincysyOrganiraatti/o vIndividu:d):./Sg1/L�'+r-o/per, p.: /��
Add reSS: . �/ .LOiY ,�.S/�— e—
City/Statc/Zip:a/VLre rf/ //O, O/9.? Phone #: ,7�p- 77%- 0 ) S�
Are you on employer:' Check the appropriate box: F
project(required):
I.❑ 1 am a employer with 4. ❑ I am a general contractor and Iw construction
employees(full and/or part-time).• have hired the subcontractors
2.P 4aln a sole proprietor or partner- listed on the attached sheet. 1 modeling
ship and have no employees These sub-contractors have molition
working ter me in any capacity. workers'comp. insurance. ilding addition)No worker•'comp; insurance 5. ❑ We are a corporation mid itsrequired.) officers have exercised their ctrical repairs or.additions
3.❑ 1 am a homeowner doing all work right of exemption per Ill I I.Q Plumbing repairs or additions
myself. [No workers'comp. c. 152,§1(4),and we have no 12.Q Roof repairs
insurance required.) t employees. (\'o workers' BEOther I CZ
curnp.insurance required.)
'Any opplicmti than uhcukabut f I must Aw rill out the section boluw ahowioa their warkmr'cumpenwttun policy inWnnallun.
'I lumuuwnvn tvhu submit this alYidavit indicating they im doing at work and then hire u,l$iJ,cantmcrM mot suhmit a now a fr. aviI indicaling such.'
('unrwtun Out check this box most unachal in addilurul Awl shu wing Ile none or the ab.onlncton and their worker'camp.put icy inrutmation,
1 ant an eurpluyer that n providing Ivorkers'compensarlun iururance for my employees. Below 1s that policy mid fob Nile
infiuurafinrs. � r /�
Insurance Company Name: J".-i� '/•�/%.� (�j
Policy 4 or Self-inst. Lic. tl///y/�d 761 cPC.Z/Fd/.ZQ/z ExpirationDotE: l G%�
Jub Sift tWdress: ZO U/'LO 0 Piz
Atlach a copy of the workers'compensation.poilcy�declaratlon page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of.%IGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a tine
OFup m S2S0.00 a day against the violator. Ile advised that a copy of this statement may be furwardcd to the Office of
Investigwiutis ol'the i)IA for insurance coverage veriticatiun.
/do hereby c•nIVJ of 111e uinr mid penalde.S�that the iafurnmflun provided nbovu iN true and correct
�liylllrC. Data:
/
Phone '!' y7d
Oj/icial use only. Do not rvtite in this area, td be cumpleted by city uriovn njjfchil
i
City to•fawn: __- PermI0.1cenie#
Issuing Authority (circle one): ---
1. Board of Ilaaith Z. ❑uildlog Dcpartnicut I.Cilylfuwu L'ierk I. Electrical lospectur 5. Plnntbing Inspector
6.0(her
Cunlact Perion: ,
t hone:l:
a
QTY OF SALEM, MASSACFNSETTS
BUILDING DEPARTMENT120 WASHINGTONSTREET,3" FLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR TrIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNIISSIONER
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:
(name of hauler)
The debris will be disposed of in:
Ia2T'la Ve /,tiZol/ sr�y
e
(name of facility)
Saq.4tyl,nitG�/®�Q
(address of facility)
Signature of applicant
Date
HIC # 126356
®ID �O101rp �rrilacC�, �lnc.
P f 13 SEWALL STREET
PEABODY, MA 01960
r''+.,,, „r•° OFFICE: 978-922-6120
SPECIFICATION SHEET _
/ Home Phone: . t +
Owners Name . . . . . . . . . . . . . . . Work Phone: . . . . . . . .
�J
. . . . . . . . . . . . . . F. . . . . . . . .�[s.,.e,•�. ll.-.�-'. . CiN . . . . . State A . . . Zip . . . . . . . . .
Job Address . . . . . f. . . . . . . . . . . . . . . . . . . . . . . . . . . . "�/4. . . . . . . . . . . . . . . . .
SIDING
1.Siding 7vpe (/ . . .Ll �L!st?. .� . . . . . . . . . . . . . . . . fdth ./
`Y. . ./ . . . . Color. . . . . . . . . . . . . . . .
2.Area to be done. Main House . . . . . . Breezewasy D� . . . . . Garage —*' ? c: . . . . Additions . f�''. . . . . . . .
Dormers .': ?`4. . . Other . a. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
3.Insulations??. .3��. . f c �?}?. . . .�./. . . . . . . . . . . . . . . . . . . . . . . . ./.,.�. . . . . . . . . .
s 4. Trim cover Wr O No Color!!t! . . . . . . . . . Trim to be done: Soffits . . . . Fascia..may. .-J. . . . . . . .
. . . .
Rakes . Ceilings .G n i . . . . . . . . . . . .
. . . . . . . . . .
5. V65ndo and Door Frames .( a . .!��'. . . . �!Lv�: l� �fL• ?4g./.7%Z �&
6.Gutters and spouts ❑ Yes U'o Use heavy gauge seamless . . . . . . . . . . . . . . . . . . . . . ./. . . . . . . . Color . . . . . . . . . . . . . . . .
7.Shutters O Yes RWo . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
8. w ndows and Doors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
ROOFING
MaterialType . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . C or. . . . . . . . . . . . . . . . . . . . . . .
Areas to be done . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Remove existing shingles ❑ Yes ❑No 15 Its.felt. . . . . . . . . . . . . . . . . . . . . . . Metal Edg'ig . . . . . . . . . . . . . . . . . . . . . . . . .
Chimney acid veri etc. . . . . . . . . . . . . . . . . . . . . . . . . . . . . .p
NOTES
. . . . aF: .`."Y. . . . . . . . . . . . ?+?L .. . . . . . . .. .. . . . . . . . . . I . . . . . . . . . . . . .
. .
. . . . . . . . . . . . . . . . . . I . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . : . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . ,fry-iP . . . �i �i. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
O C �. . .o?0p.'' . .Deposit
Material and labor to cost$. . �. .7.. . ...
payable as follows: S. . . . . . . . . .1st os talhrtent
DO NOT SIGN THIS DOCUMENT IF THERE ARE ANY BLANK SPACES. $. . .�. . . . . . .2nd Installment
a�Balanee on completion
Contractor will do all suid work in a good workmanship manner. You mar cancel this agreement if it has been c onsmnnhated br a part thereto at a place
other than an address of the seller, which map be his main offie a or branch thereof.provided you notify the.seller in writing at his main office or branch
by ordinan,mail posted, by telegram sent or by delivery, not later than midnight of the third business dip'fallowing the.signing of this ugreemem.
IN VYITNESS HEREOF, the parties have hereunto signed their names this. . . . . ,.../. ..f(y/ . . . . .m ot'T-e-Z
20.1.Acre net• S'i,nee �[ ff��i a. . . . . . . .
®ID ¢Colonp urlbuz, Xur, her
S'igned. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
OwnerPer. S: . . . . '/fit. !l° . . . . . . . . . . . . . . . . . . . . . . .
Representative Authorized Rep
Shike.s. lubm disputes, indemeni heather ornnterial supplier delays resulting in work stoppage are beyond the,rneml the rornpmis.