24 HATHORNE ST - BUILDING INSPECTION ' I fie Commonwealth of Massachusells
Board of Building Regulations and Standards CITY OF
'r J9 Massachusetts State Building Code, 780 C'MR SALEM
L:,•• Ka ri rrd I Lv'll//
Building Permit Application To Construct, Repair, Renovate Or Deneolish a
(fie-or 7'uv-Famill 011 ellin,t;
this Section For Official Use Dill
Building Permit Number: Dot Applied:
`4,T<.r�
Building OBicial(print Niune) Signature Dmc
SECTION 1:SITE INFORNIAT
1.1yPrlipe tZ^ddr" 1.2 Assessors.Map Sat Parcel Number
I.1a Is this an acce led street?yes no Mnp Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District 1'ropnsed Use Lot Area(sq 11) Frontage(11) j
1.5 Building Setbacks(R)
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 Zone Information: 1.8 Sewage Disposal System:
Public� Private❑ Zane: _ Outside Flood%a ie? Muniei al On site dis 1
Check il' es P Wsal s stem ❑
SECTION 2: PROPERTV OWNERSHIP'
2.1 Ownerl of Record:
Fanu W;l/'am e �Cl�m /na 0/970
N;une(Pru l)/ City.State ZIP
4/ i�/lorne S'f o7-4poll--0 03
Nu.anJ Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner•Occupied Repairs(-) Alterat(on(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of.Units_ Other ❑ .Specify:
Brief Description of Pr oposedWork':_ c4a ,' 6 a
o /1 r
SECTION J: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labur;rod.Materials) Official Use Only
I. Building S 0. I. Building Permit Fee: S Indicate how fee is determined:
'. Flectrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6).x multiplier _:.__.x
i. Plumbing S , Other Fees: S
J. Mcchanic,d ill\ W) S List:
\Icch:mical i fire - — - - -- - -
Cu+rressionI S Total .\II Fees: S — -
o. Total Project Cn.cC S /, 00 Chcck No. _('heck Amount: _ C,ish \mount:
�V�� . O P,iid in Full ❑Oulst:coding IluLmce Due:
SE("I'ION S: CONS'I-RUCTION SERVI(TS
S.I C'unstruction Supervisor Livrnsr(C'Sl.) zq3.0ir /
'7If-�QnP � (`t V er l iccuse,,\'uuthcr rvpir;ainu (late
Namc ol'l'Sl. Holder
I isl(-.St. f.%pc(sec helms)
Description
No, and SireN
�� U Ivnet cstcJ IOuildin's ti lu lS,l)tln eu, It
� e q._.Q��U ----'--.. . R R 4estricted I&I I anlil M%ellin
l'il\i loan.Stine.Lll' \I Mason
RC Ittitifing C'tnarin
\\'S \\'indo%% ;wd Sitting
SF Solid Fuel Ihlming Appliances
ZZ 1-3:)rt✓!r g,,g;I, corv� I Insulation
'felt hunt Finail address D Demolition
5.2 Registered Ilume Improvement Contractor(HIC)
Itic Registration Number Fvpiruliun UJIL'
I IIC Cautpan) Name or I IIC Itegistrunl Nanle
No. and Street Ernuil address
City/Town.State,ZIP Tcle hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 152.1 25C(6))
Workers Compensation Insurance affldavit 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 ..........If No...........❑
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 I trPr
to act on my behalf,in all matters relative to work authorized by this building permit application.
�lOne, (.(.)ONAl✓15 �V/7//,<
Print Uancr's Nmne(Electronic Signature) Date
SECTION 7b:OWNER( 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.
1;7
('rimD\\ncr'sae:\whorireJ,\gent'sName(h. vvilnlcSlgnature) Date
NOTES:
70%�ncrr whu obtains a building permit to do his.her own work,oran owner who hiresan unregistered contractor
tered in the Home Improvement Contractor(HIC) Program),will no have access to the arbitration
ur guaranty fund under I.G.L.c. 14'_A.Other important information on the HIC Program can be lbund at
•s n � A Information on the Construction Supervisor License can be found atbstantial\vork is planned, provide the information below:
ea t sq. n.l . __-._I including garage, finished bascmcnCmtics.decks ur porch t
Gross living area(sq. 11.) ---. Habitable room count __. ... -
\umherol'lircplaces .... Numberofbcdruums
\umhcrol'hathmoms — \'umbentl'holFhaths
I)pc of Beating s);lem . . . . _ \tunhcr of decks, porches .
i
I\lie ofeoolnlgit5ctil I`Ilclosed
I. "fold Project Square Foolagc-nla.% he \uhsl itutcd litr"rutal Project Cost-
CITY OF SM.EM. Ati sS:iCHL'SETTS
BUILDLNG DEPARTmE.NT
120 WASHLNGTON STREET, 3-FLOOR
ra. ,• T EL (978) 745-9595
F.Lr(978) 740-9846
KI\Ii3ERL.EY DRISCOII.
MUY01 T3IOMAs STTIF-RRH
DIRECTOR OF PUBLIC PROPERTY/BUMMING CO\LMISSIONER
Workers' Cmnpensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
%jiMleant Worm"rtion ` Please Print Legibly,
V;tlna 1llucilxss Organiration individual): /O/1G 14)/ 111'a M S
Address:4Z f1,11ioMt S' k-
CitylStatc/Zip: eGlltm_ real 01071) Phoned & -7 ,Pe2/- 0903
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6• ❑New construction
einployees(full and/or part-time).• have hired the sub-contractors �/
2.❑ I am a sole proprietor or partner- listed on the attached sheet I 7• Go kemadeling
ship and have no employees These sub-contrsctors have V. CJ Demolition _
working for mein any capacity, workers'camp.insurance. 9. El Building addition
(No workers:camp, insurance 5. ❑ We are a corporation and its
�cquircd.) officers have exercised their I0.0 Electrical repairs or additions
).LYJ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(No workers'cump. C. 152,$1(4),and we have no 12.0 Roof repairs
insurance required.) t employees.(No workers' 15.0 Other
camp. insurance required.)
•,any appliasnt der 0oviss but rl must also rill uul the wuliwe below showing their wwken'compenutlun putisy inlbrmation.
'I bvneuwnurs who uiltmit this aMAnvil indicating they an doing all work Intl than hire outside cantnctam most aahrnit a new afl)davit indicting ruck
:(%mimitin thol chak ibis box mtst wtachod an edditiorwl.hest showing the nwne of the mbeanlrxtan and thalr wurio n'comp.pulley infornution.
l urn(in employer that la providing ivorkrri'compensatun insurance jar my einplayeex Masotti rbr Polley end Job site
information.
Insurance Company
Policy 4 or Self•ins. Lie. 4: Expiration Date:
Job Site Address: CityiStatwzip:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
h5dlure to secure coverage as required under Section 25A ot'NIGL c. 152 can lead to the imposilian of criminal penalties of a
fine tip to S1,500,00 and/or arse-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a line
of up to S'_50.00 i day against the violator. Ile advised that a copy of ihis statement may b: iurwardcd to the Office of
lirvc•stigatiuns of the DIA I'or insurance covaragc verification.
1,10 hereby cerfijy fard�,jw/hepain/t undddiynn�alde.s u/perjury floe the in/urnratlar pro Piled above is true and cornea
I'hrute 1:
Of is ivl n.se wdy. On ,at write in dri.v area,to be completed by city or town n/firiaL
I
City or 1'nwn: Ncrmit/1.Icense 4
jhsuiog Atalvirily (circle one):
L L'uard of ilcallh 2. )luildim„Dcpart(Ile'it I.Cityi rolvn Clerk 4. F"lectrieai Inspectur 5. Phimbing Inspector
6. Other —_-
Contact l'crsont_ _ Phone rh.
Information and Instructfl®n3 .
Massachuscus General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of anuther under any contract of hire,
cypress or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in ajoint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or an the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings In the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the Insurance coverage required."
Additionully. MGL chapter 152,ty'25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)nume(s),address(es)and phone number(s)along with their certiBcate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
he returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the munber listed below. Self-insured companies should enter their
self-insurance license number an the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Of7ce of investigations has to contact you regarding the applicant
Please be sure to till in the pormit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary) and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on rile for future permits or licenses. A now affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves ctc.)said person is NOT required to complete this affidavit.
The Ofiice of Investigations would like to thank you in advance for your cooperation and should you have any questions,
please do not hesitate to give us a call.
The Departments address, telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Otlice of Investigations
600 Washington Street
Boston, MA 021 l 1
Tel. #617-727-4900 ext 406 or 1-877-NIASSAFE
;acv:;ed 5-26-05
Fax#617-727-7749
www.mass.gov/dia
CITY OF S,V-&N[, �tiL�ss.1CH�'SETTS
9LLLDLNG DEPARTlE\T
120 W.ksjjL,VGTON STREET, jw FtOOA
rM (978) 745-959S
KIJLHERLBY 01MOLL FAX(978) 740-9846
,bUY01! 7}(Oxcu ST.PMX"
DIRELTO A OF PC BUC PIIOPEATY/8C Q.DL%jG CcNNIS$IO.V EA
Construction Debris Disposal Atlfidavit
(required for all demolition and renovation work)
In ucordance with the sixth edition of the State Building Cade, 780 CMR section t l I.S
Debris, and the provisions of MOL a 40, S 34;
Building Permit AI i
S I SOA. disposed s issued with the condition that the debris resulting from
this work shall be of in a properly licensed waste disposal facility as defined by NIGL c
111,
The debris will be transported by:
FZ Tic r✓nc_ I
r rlri/
(eame of hauler)
The debris wi II be disposed of in
*or
ru+lity)
�n Rc i I ro�1 4a. n
c v�
(�ddmr or ra.d+ty)
+ yna Nre arperm+t applicant
L ' d" 1Z
CITY OF S.UYENf
PUBLIC PROPERTY
DEPARTMENT
Vw►ae i�pv�ou�cnoNl++asr•s�u+aM.a�owssrnotf'0 \
L�
HOMEOWNER LICENSS EXE.rIMON
Please Fria
Daa -7
Job Loeadaa 0-// MCAY< Drnw 4}.
Home Owner Address Q I H44hnrnG S+.
Home Owner Telephone _ 6 /7 - Da y - n903
Present Mailing AddreN _,�?4'
The current exemption of Homeowners"was extended to include owoar-occupied
dwellings of two Units or less and to allow such homeownee to engage an individual for
hire who does not possess a lieasa4 provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Paaon(s) who own@ a parcel Of land on which hdsM reddest or intatds to reside.on
which them iA or is intended to be,a one or two family dwelling, attached or detached
strucnues accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"honteowner'shall submit to the Building Omcial,on a form acceptable to the Building
Official, that he✓she be responsible for all such work performed under the Building
Permit
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she undentands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
'mill comply with said procedures and requirements.
HOMEOWNERS SIGNATL7Z
APPROVAL OF BUILDING INSPECTOR
See other side for state code
LN Insurance Corporation
Liberty Roston,Massachusetts
7�� + 7 LibertyGuard6� Deluxe �(n
1Vlutual Homeowners Policy Declaration Libertyly7utual Group
N NIED INSURED AND !MAIL,ING ADDRESS: SALES REP: R GLNH1.1
STEPIIEN MCDONALD 38 POND Sl-
FIONA A 1NILLIANIS FRANKLIN NIA 0203E
24 HA I IIORNG ST
SALEM NIA 01970-3062 -
INSURED RESIDENCE PRE TISES: SERVICE: %8-541-2171/877-665-7123
SAME AS MAIL ADDRL:SS CLAIMS: 800-?CLAIMS(500-2?5=2467)
- WEBSITE: libcrtymutual.com
Your Policy Number: I135-218-308349-401 3
Policy Period: 09/15/1 1 to 09/15/12 12:01 AM Standard Time at the Insured,Residence Premises
Reason for"Phis Notice: This Declaration EAlective: 09/15/1 1
Renewal I lomeowner Policy Summary, made part of your LibertyGuardrk)Deluxe I lomeowners Policy
Premium Summary
Base Policy Coverages and Limits S 2,262.00
Additional Coverages S 153.00
Discounts S (837.00)
Total Annual Premium S 1,578.00
Premium Detail
Rase Policy Coverages and Limits Deductible Limits Premium
Section I
Coverage A -Dwelling with Expanded Replacement Cost S 353,600
Coverage B - Other Structures on Residence Premises S 35,360
Coverage C - Personal Property with Replacement Cost S 265,200
Coverage D- Loss of Use of Residence Premises Actual Loss Sustained
Section I Deductible
Losses covered under Section I are subject to a deductible or: S 500
Losses as a result of Windstorm or Ilail are subject to a deductible o1'2`A,:
Section II
Coverage E-Personal Liability(each occurrence) S 300,000 .
Coverage F- Medical Payments to others(each person) S 1,000
Total Base Policy Coverages and limits 5 2,262
Additional Coverages Deductible Limits Premium
Credit Card,Fund Transfer, Forgery(110 04 53 04 91) S 1,000 S o
Home Protector Plus(FMH0-2144) S 136
Mold Buyback (I'M1-I0-2405 02/03) S 10,000/50,000E 1 o
Coverage E increased limit S 17
Total Additional Coverages s 153
Yelping People Live Safer,Alore Secure Lives Paec I
Your Policy Number: 1-135-218-368349-401 3 - - This Declaration Effective: 09/15/1 t
(Continued from Previous Page)
Discounts
Group Savings Plus.to(5%discount included in base policy premium)
Waters Corporation
Preferred Risk Rating Plan Discount;
Insurance to Value Credit S (136)
Inflation Protection Credit S (68)
New or Renovated Hone Credit S (45)
Protective Device Credit: - - S (136)
Smoke/Heat Alarm-All Floors, EXtinguishers and Dead Bolt Locks
Multiple Policy Discount S (452)
Total Discounts s (837)
Special Messages and Massachusetts Provisions
Your Homeowners policy does not provide coverage for damage caused by flood,even if the flood is caused by storm
surge. Liberty Mutual can help you obtain this coverage through the Federal Emergency Management Agency(FEMA) if
your community is one of the 18,000 conununities which participate in the National Flood Insurance Program.
Base Policy and Amendments Included in Your Policy
LibertyGuard:f0 Deluxe Homeowners(1I0 00 03 04 91)
Special Provisions(110 01 20 10 94) No Sccll/Limit I-Daycare(110 04 96 04 91)
Amendmt Pol Definitions(FML10-2934 7/04) Amendatory NonRenewal(110 05 23 07 97)
Amendatory-Collapse(FMHO 1089) 1lomcowner Amendatory End(FM110-2510 5103)
Protective Devices(FIO 04 16 04 91) Inflation Protection (FMHO-2836),
Wind/Hail Deductible(HO 03 12 10 93)
Mortgage Information
Mortgagee L
WELLS FARGO 13ANK NA#708
ISAOA
LOAN NO.0216618181
PO BOX 23030
JACKSONVILLE FL 32241-3030
FNll-10 3047 12 06 Countersigned 08/1 t/11
7t'""i�.���;a,�7 �l/•�,,�,�l�.uy ��et�kn���i�►tmS
AU I'HORIZEDREPRESENTATIVE
Helping People Live Safer,More Secure Lives fir€e 2
.' iYfav�ic4uscttw eSi.p.ecnnent of Pufrlec �Je'i.�..
i Bu erel of Builtlutl; Rv',ul do unel$t uular.is
Consttu0ionSupervisor;License ,
. i°9e's . 103018 p...
. License: CS
Ft 1
4estricled to.. r-
ST,EPHEN DRIVER
1.46 NORTH STREET APT 2
SALEM, MA 01970 :
Expiration: 612912o13
�`- TrN:,103018