49 HATHORNE ST - BUILDING INSPECTION (2) BL tblq 2-3�,
The Commonwealth of Massachusetts
A 'Ak Board of Building Regulations and S. CITY OF
ED SALE
Massachusetts StateBuildinAIWE; C Revised Mrrt20!/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or 7ivo-Farnily LUNI;UN
This Section For Official Use Only
Building Permit Number: Date A lied:
/
Building OtBcial(Print None) Signature IUate
SECTION I:SITE INFORMATION
1.1P ro�'I ertyAJJr ,s: 1.2 Assessors Map& Parcel Numbers
�
I.1 a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(tl)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L,c.40,§54) 1.7 Flood 'Lone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Lone?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recm•�da i �n
Lk" �,��'f-Cr(,e �TI r27T 4l rJ G^ G(� M P • a (1 XJ
Name(Print) City,State,LIP
�7� 5+�-4e t��► _ 5,2a
No.and Street 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that applyt—
SECTION New Construction ❑ Existing Building' Owner-Occupied ❑ Repairs(s) Alteration(s)
Demolition ❑ Accessory Bldg. ❑ Numberof Units_ Other ❑ Specity:
Brief Description of Proposed \York': ...4: ESTIMATED CONSraucTiON COSTS
local Estimated Costs: Official Use Only
Labor,mJ Materials)
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑'total Project Cost'(Item 6)x multiplier_ x _
3. Plumbing $ 2. Other Fees: $
4. Mechanical ( $ List: 4�
t
5. Mechanical (fiFirere -_
Suppression) $ Total All Fees: $_
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ,. b Balance Due:
❑ Paid in Pull ❑Outstanding
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)Jai c �-g cj r
1 J Cdn'�eP�rr\ /��7;01;��'�e=^�rr License Number Expiration Date
Name of CSL Holder ejJa • +•iG�r"t yr �J •+
List CSL Typc(sec below)
No.and Street ('' 1 hi u+ "v rava Type Description
li Unrestricted(Buildings to 35,000 cu. 1'1.)
Ciwn,State,ZIP R Restricted 1&,2 Family Dwelling
M Masonry
RC Roofing Covering
WS Window.md Siding
SF Solid Fuel Burning Appliamces
I Insulation
Telephone Email address D Demolition
.5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
I IIC Company Name or I IlC Registrant Name
No.and Street
Email address
city/Town,State,ZIP Telephone
SECTION 6:WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 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 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
conNed in this application is true and accurate to the best of my knowledge and understanding.
wncr's or Authorized Agent's Name(Electronic 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
(not registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under YLG.L.c. 1 d2A.Other important information on the HIC Program can be found at
www.nmss.!-,ov/oca Information on the Construction Supervisor License can be found at www.ntass.eov/dps
2. When substantial work is planned, provide the information below:
Total Floor area(sq. It.)_ (including garage, finished basement/attics,decks or porch)
Gross living-area(sq. It.) 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"rotal Project Cast"
r
�hT
CITY OF S:U ENf, ti -ISSACHUSETI'S
t OLILDLNG DEPAR'M&NT
I A WASHLYGTON STREET Y`FLOOR
-` TEL (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9844
tLt�YO:t THoscts Sr.PtERRt3
D(.2ECTOR OF PUBLIC PROPERTY/BCILDLNG CONWISSIONER
Construction Debris Disposal Arf1davit
(required for all demolition and renovation work)
In accordance with the sixth edition of the state Building Code, 780 CMR section 1 l 1.5
Debris, and die provisions of NIGL c 40, S 54;
Building permit It this work shall be is issued with the condition that the debris resulting from
l 11, S ISOA. disposed of in a properly licensed waste disposal facility as defined by b(GL c
The debris will be transported by:
o-�+-
(namcorhauler)
The debris will be disposed of in ;
(narne of tacdity)
----�(address of latility)
signature of permit applicant '—
C TY OF SIU.E,NI, AiSSACHUSEZTS
4
BUILDING DEPAR'i.\lE\T
120 \X/.iSHLYGTON STREET, 3u FLOOR
TEL (978) 745-9595
N-x(978) 740-9846
iCf\lB ERL 8Y D R1SCO LL
AAYOR Ti-hmw ST.PIERM
DIRECTOR OF PUBLIC PROPERTY/BL•ILDING COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electrlcians/Plumbers
%liplicant Informatinn Please Print ( e ft
Name (Rosiness,Org,tniration,'Individual):
Address:
City/State/Zip: Phone #:
Are you an employer!Check the appropriate box: 1
I.❑ I am a employer with 4, ❑ I am a general contractor and I Type of project(required):
employees(full and/or pan-time).' have hired the sub-contractors 6• ❑New construction
2.❑ I am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working Por me in any capacity. workers'comp. insurance. II ❑ Building addition
(No workers'comp. insurance 5. ❑ We are a corporation mid its
required.] officers have exercised their 10.❑ Electrical repairs or additions
7.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(No workers' cutup. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' 13.0 Other
comp.insurance required.)
'Any upplicva 1141 checks bus el must also nII out the rucliun below showing their warkeri compensation policy inliu otion.
'11nmSnw'N"wha sul ntil this aOkLnvi1 indicating Ihay am doing all work and then hire outsida cuatm .v ctm midi hmil a new afrlduvil indicating suetL
:('umrauturs thus check this box mail attachul an addiliumlahwi showing the mane of the ab.:emncWn and Iheir workers'comp.pultcy inromation,
I um can employer that is providing)vorkers'coniprorxatlon insurance for my employees. Below is the policy and job.silo
irrfornralion.
Insurunce Company Vame: —_'--_-_--
Polity it or Self-inn. Lic. d: Expiration Date:
lub Site Address: City/Slate/Zip:
Atlach a copy of the workers, compensation policy declaration pogo(shawing the policy number and expiration date).
h'ailuru to secure coverage as required under Section 25A of SIGL c. 152 can lead to the imposition of criminal penalties of a
line up to S I.500.00 und/ur one-year ilnprisomncnt,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against the violamr. Ile advised that a copy or this statement may he funvarded to the 011ice of
Inreetigatiuns of(he DIA for insurance coverage verification.
Ida hereby certify raider the pains rnrd penalties of perjury that the hrforwathor provided ubove i.s true sad correct
1i_�'tldlum Date:
Phone,t
Ft)II
only. Do nor write in this area,to be completed by city or rerun ;jjit'iuL
lvn: _... -- Permit/l.ieensep . ..----
thurily (circle one):
'Ilcallh 2. 13uildlnq I)eparlineut 1.Citylfntvn Clerk I. Electrical Impector S. Plumbing luspcclor
rson:_. Phone
Commonwealth of Massachusetts
yt A °3
' A ` City of Salem
I
aI k 'Je 120 Washington St,3rd Floor Salem,MA 01970(978)745-9595 x5641
MIA!'p0
Return card to Building Division for Certificate of Occupancy '
Permit No. B-14-815 IN a
FEE PAID: $236.00 PERMIT TO BUILD
DATE ISSUED: 4/25/2014
This certifies that BATES KATHERINE
has permission to erect, alter, or demolish a building »49 HATHORNE STREET Map/Lot: 250467-0
MKI
„r
as follows: Renovation 786-14 REMODEL2ND FLOOR!UNIT;:NEW KITCHEN, BATH OPEN UP 3 WALLS
(ACCORDING TO PLANS)
r i a ��
Contractor Name: JJC CONTRACTING/JOHN CAMIRE ..w. .:
"
DBA: � i
�J , 2 -
Contractor License No: 95895 �ut1'
} 1t rf.
4/25/2014
Building Official � � Date
Or
C
s y v permit
-� m - .. n ix
This permit shall be deemed abandoned and invalid unless the work authorized by this permit is commenced within six months after issuance.The Building Official
may grant one or more extensions not to exceed six months each upon written requue�st t iy } ! .
All work authorized by this permit shall conform to the approved application and the approved construction documents for which this permit has been granted.
tit 4 @P-m 21,
All construction,alterations and changes of use of any budding and structures shall be in compliance with the locaal zonmg by laws and codes.
This permit shall be displayed in a location clearly visible from access street or road and shall be maintained open for public-inspection for the entire duration of the
work until the completion of the same. ---
The Certificate of Occupancy will not be issued until all applicable signatures by the Building and Fire Officials are provided on this permit.
Wit9ffX Sy^ .' A
HIC#: "Persons contracting with unregistered contractors do not have access to the guaranty fund"(asset forth iii MGL c.142A).
;1 Nil
Restrictions: � `° � �,�, �
ss� �
Building plans are to be available on site.
All Permit Cards are the property of the PROPERTY OWNER.