6 HAYES RD - BUILDING INSPECTION 1
The Commonwealth of Massachusetts
�w Board of Building Regulations and StandardsF, "C CITY OF
yMassachusetts State Building Code, 780 CMR.:F L' iz ) ovi qA�LEM '
,.u.3. Revisea Mar 2011
Building Permit Application To Construct, Repair, Renovate
One- aA , 2g
One- or Two-Family Dwelling 3
This Section For Official Use Only
�\ Building Permit Number: Date plied:
`i v
(� Building Official(Print Name) Signature Date
SECTION 1: SITE-INFORMATION
1.1 gopeny Address 1.2 Assessors Map & Parcel Numbers
vmw
l.I a Is this an a cepted street?yes no Map'N.umber Parcel Number
1.3 Zoning Information. 1..4 Property Dimensions. ,
Zoning District Proposed Use Lot Area(sq ft) ` Frontage(R)
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 Zone Information: 1.8 Sewage Disposal System:
Public ❑ Private❑ Zone: _ Outside Flood Zone? Municipal.❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
' 22..1 Qwnertofl.ttrc — \
�/avt°L < .7eLK.K t�� ����?W MA• V\RnC)
Name(Print) r� City,State,ZIP
ko \�AHe 7
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building s,
_. L Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ El Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (FIVAC) $ List: O3 ��� � ��
5. Mechanical (Fire
Suppression) $ Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due:
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) O d /
� 6 t>
License um er Expir tion Date
Name of CSL Holder
^^,,//[� C 1T List CSL Type(see below)
No.and Street Type Description
W U Unrestricted(Buildings u to 35,000 cu.ft.
o.A.�L rJ !' Y`T V U R Restricted 1&2 Family Dwelling
City/I'own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
f SF Solid Fuel Burning Appliances
I Insoli
ulation
Telephone Email ddress T D Demtion 1.
5.2 Registered Home Improvement Contractorff-
C Registration Number Ex ati n Date
Compan NU or HIC Registrant Name
le St
No and Sqeet .
0 Ru l A 1� J�1��� � Email add ss
J t-`F� V
City/Town, State,ZIP ele hone
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.
SignedAffidavit 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 D"' , :S , 1\\ ( r..4.�
�[ to act on my behalf,in all matters rreela�tive to work authorized by this building permit a placation.
Print Owner's Name(Electra4c Signature) Date
SECTION 7b: OWNEW 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 Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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. 142A. Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can 6e found at www.mass.eov/dps
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
The Commonwealth ofMassaehusetts
Deparbnent oflndusirklAccidener
I Congress Scree;Suite 100
Boston,MA 02114-20I7
WWW.massgov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FII,ED WITH THE PERMITTING AMHORITY.
Annlicant Information Please Print Legibly
Name(Busizim/ rggamratiion/fndividuan: 11.� *1 --�
Address: d""O��xb L-5+u n
City/Sti te/Zip�1) r�r 1 ()Phone#:
Are you so employers Click the appropriate beer:
I.❑Ism a employer with Type of project(required):
eoTkYas(fdl eaNmpmt-time).r
I am a sok pmpsiems or partnership and have eo employces working forme in 7. ❑New construction
any wpaeiry.[No workes'comy.matrance required) 8. ❑Remodeling
3.❑I am a homeowner doing all work myselt(No workers'comp.insursooe required.)1 9. ❑Demolition
4.❑I am a humeownerand will be hiring conhactms tn conduct as work on my properly. I will 10❑Building addition
coursers
that all eDummlws eitherhave worke 'emepemspou msumnce us are sole 11. Electrical poopti�with oo�o➢eer ❑ repairs or additions
5. I sm a 12.❑Plumbing repairs or additions
❑These stub-wntrapers hawand I have hired thevubs workers'
ore p,in on the attached sheet.
employees and have workes'comp.msmunoel 13.❑Roof repairs
6.❑We are a emporatim and its offices have exercised thearight of exemption WMGL a 14.❑Other N
15Z§1(4),and we have no employees.[No workers'coop,insurance required)
'Any applicant that checks box#1 must also an out the sermon below showing their wmkes'aompeomtlon policy mfmncation.
s Homeowners who subunit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicates such
lCnatraUM that check this box must attacl ed an additions]shoe showing the ounce ofthe sub-mnhaoms and serer whether m not those modes have
employees. Ifthe subKmtreckni have employees,they must provide then workers•comp.polwyeus
I am an eaeployer that is providing workers'compensation lnsurancefor my employees. Below irlhe and'ob rile
information. parley J
insurance Company Name: C ( ,r� i,"
Policy#or Self-ins.Lic.#:_ S`jV y 1,p^(` y64 V41 Z —�(—I 6 Expiratioa Date: 6 I
Job Site Address: R�) sty/hemp ��
Attach a copy of the worken' ompensation poBcy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under thepains andpenaltdes ofperjury that the information provided above !ru and conece
Si
IM te-
phone#:
FO=tber
only. Do not write in this area,to be completed by city or town ofjiehll
Town: Permit/License#
ority(circle one):
ealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
on• Phone#:
Information and Instructions
Massachusetts 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 another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two ar more
of the foregoing engaged in a joint 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 on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL 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."
Additionally,MGL chapter 152,§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 fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and if
necessary,supply sub-contractors)name(s),address(es)and phone menber(s)along with their certificate(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 saga and date the affidavit. The affidavit should
be 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 number listed below. Self-insured companies should enter their
self-insurance license number on 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 Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permittlicense 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 file for fume permits or licenses. A new 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 bun leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02 1 14-20 1 7
Tel.#617-727-4900 ext. 7406 or 1-877-NIASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/cba
A contract for services to be performed at the Doyle residence at
6 Hayes Road in Salem Massachusetts
repair of termite damage
the replacement of section of main carrying beam in basement that has
been damaged by termite activity.
The beam to be replaced from its where it bears on the southwest concrete
wall to where it bears on top of the lalley column
the new section to be made of LVL lumber, to be integrated with the existing
beam above the existing lalley column
the abutting sill on top of the southwest wall to be replaced as much as the
damage requires ( anticipated 6 feet ) with a piece of pressure treated wood
of like dimension as the existing
any other necessary work ( hvac and/or electrical) to be coordinated with
but contracted outside the scope of this proposal
Expected cost including labor, materials, permit & trash disposal; $ 1550.00
Thankyou — }
Daniel J. O'Leary III Carpentry date far
HIC 159516 CSL 083589 LR 002449 617- 50-1751
C17YOF SALEA MASSAQMEM
Buu>xGDxPArrr
120 WiiMOMSMET,30Aloaa
1t3L(q78)745-9595.
gA ynxrcrrn� Fex 740-98�6
AUYadt ?YaIWASST.P=
DBMCWaCFPUUIIb /BUMDMa3WMMONMt
Construction Debris Disposa/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 coo,S 54; Building Permit#1 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 ill,S lWA.
The debris will be transported by.
ame of h ler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signatur of applicant
G �
ate
�-\ Office of Consumer Affairs&Business Regulation '
i HOMEIMPROVEMENTCONTRACTOR
Registration "'N59516 T
. Expiration "¢t8 DBA yce.
i 'DANIEL J.OLEARNI'.1= - 2
DANIEL O'LEARY � 1 a
202 OAK ST '
WAKEPIELD, MA 01880Undersecretary
Massachusetts
t
Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-083589
Construction Supervisor
DANIEL J OLEARY� %.
202 OAK ST
WAKEFlELD MA;0788,0a
n Expiration:
Commission8r 09/06/2018