6 HILLSIDE AVE - BUILDING INSPECTION (2) 50-7
The Commonwealth of Massachusetts
Board of Building Regulations and Standards SILTY OF
EM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: I Date Appl' d:` 1 L- a>t>-
Building Official(Print Name) Si - Date
SECTION 1:SITE INFORMATION
1.1-Prop Address��� 1.2 Assessors Map&Parcel Numbers
H
L l a Is this an accepted street?yes—Z no Map Number Parcel Number
1.3 Zoning Information: t.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 Sewagee/Dy�iosal System:
Public Private❑ Zone: _ Outside Flood_Z}�+�fe? Municipal fd On site disposal system ❑
Check if yeses"
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow r of Record: / n
CLjs./cs f / s `
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building 21 Owner-Occupied UKT Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_,[ Other ❑ Specify:pe fy:
Brief
/De/scriptionnof Proposed Work 2: �n �n4C e o �� /ceryv/f Co r e oas
n0 t/e 4 �.-co�rl - / -�c- �fic SL,o�v¢f ��cf ✓hni�
SECTION 4 ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $
750,oo ❑Total Project Cost'(Item 6)x multiplier - x
3.Plumbing $ 3 5 OC2 o v 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ /47500,00 ❑paid in Full ❑Outstanding Balance Due:
C6A-LI1_,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
®o 4V//7 License Number Expiration Date
Name of CSL Holder /
y // !L ®�d,p 1 List CSL Type(see below) (/
No.and Street T Description
/ id' /ram/l d3��� Unrestricted(Buildings u to 35,000 cu.ft.
L R Restricted 1&2 Family Dwelling
o State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
911V-'/1>3- W63 //ILGcnOwncn/�o/�Glr�a•% I I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
1W �j G�d� /osoat 7/6/�
HIC Registration Number Expiration Date
HIC Comp y NNg or HIC Registrant Name
No.and Street lJ
Email address
/* t'J'30/�
Cr 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 f the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRAC�TTOO/R APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize ///ra�hG� ej® ✓/�
to act on my behalf,in all matters relative to work authorized by this building permit application.
aAllra i -, /2--
Print Owner's Name(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.
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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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"maybe substituted for"Total Project Cost"
CITY OF S., .F.M, 1f'Lxss.ACHUSETTS
BUILDING DEPART%MNT
L130 WASHINGTON STREET, 3w FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KimBERL.EY DRISCOLL
MAYOR THonus ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMaSSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transportedby:
„�'a,S�ih7�5>crr
(name of hauler)
The debris will
be disposed of in
i�a�JOw�s'c o�" �o5�h
(name of facility)
Ila ��s h S-), 61err//-/
(address of facility)
signature of permit applicant
date
dcbris ffdm
t Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supcn-isnr
License: CS-081670
O'HCHAELF000DWIN;r b,
7HOLTRD 4; f,=3
Epping NH 0304Y ?
xoiration
Commissioner 08/08/2015
I Cons mee„Affai m&Busoe�$iRr<rJ�.�c/rule/� License or registration valid for individul use only
Office of Consumer ARairs&Business Regulation g y -
^�PH
,HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
eglstra0on 105029 Type: Office of Consumer Affairs and Business Regulation
x Ira[ion: 7/t6/2014. Individual 10 Park Plaza-Suite 5170
P
Boston,MA 02116
MIF.GOODWIN JR
i
.Michael Goodwin Jr.�`
7 HOLT,RD. -
EPPING,NH 03042 Undersecretary I Not valid without signature -
The Conitnonwealth of Massachusetts
Department of Industrial Accidents
Office ofInvestigations
600 Washington Street
Boston,MA 02111
tvwminass gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/Organization/Individual):_
Address: 7 o/f
City/State/Zip: i�41 /../ 673o 5,.tPhone.#:
Are you an employer?Check the appropriate box: Typa of (required):.
1.(� I am a employer with.3 4. ❑ I am a general contractor and I project
employees(full and/or part-time).* have hired the sub-contractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed on the-attached sheet. 7. RRemodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. employees and have workers' y Building addition
[No workers'comp.insurance comp.insurance.
required.] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their I LEI Plumbing repairs or additions
myself.[No workers'comp. right of exemption per MGL
insurance required.]t c. 152, §1(4),and we have no 12.❑Roof repairs
employees. [No workers' 13.❑Other
1-11 comp.insurance required.]
*My applicant that checks box Rl must also fill out the section below showing their workers'compensation fotrm policy infim. _
t Homeowners who subndt this affidavit indicating they we doing all works and then hire outside contractors must submit a new affidavit indicating rs such.
tContracto that check this box must attached an additional sheet showing the name of the sub< ha oneturs and state whether or not those eatitiea have -
emploYees. If the sub-cantn etors have employees,they must lumide their workers'comp.polio number.
I am an employer that is providing workers compensation hisurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.LichM 6P/S/ 7S$C �
1 Expiration Date: ,�✓r�/�/
Job Site Address: ��/����a City/State/Zip:_,��/Oj� .
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 certify under doe pains and penalties ofperjury that the information provided above Is true and correct.
Signature:/% �//r� Date
Phone#: —
OjJlcial use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/Licease#
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#•
130 Centre St. Estimate
Box C-1 ® ® ® l?
Danvers, Ma. 01923 978-423-8463
Chuck & Debbie Benvie 11/4/2013
6 Hillside Ave.
Salem, Ma.
Project Description Total
This estimate is for the following work. 0.00
Hi Chuck& Deb,
Here are the two estimates for the kitchen and the 2nd floor bathroom. If you
have any questions please do not hesitate to give me a call.
2nd floor bathroom
Scope of work;
We will apply for the proper building permits.
The existing fixtures will be disconnected and removed.
We will take up the flooring down to the subfloor.
The existing shower will be taken out and a fiberglass unit installed.
We will patch the walls around the shower unit so that it's ready for paint.
We will install Durock tile underlayment on the floor followed by tiles and
grout.
The new vanity and mirror will be installed.
We will install new wood baseboard.
The bathroom will be primed and painted.
The plumber will relocate and replace the shower valve and head, install a new
Total
Signature
mfgoodwincompany@gmail.com
Page 1
Mass.CSL #081670 Mass. HIC #105029
130 Centre St. Estimate
Box C-1
Danvers, Ma. 01923 ® � ® 978-423-8463
Chuck & Debbie Benvie 11/4/2013
6 Hillside Ave.
Salem, Ma.
Project Description Total
floor drain for the shower, install a new toilet, sink and faucet.
The electrician will replace the ceiling fan with a new fan/light unit and
separate the switches. A new GFI receptacle and vanity light will be installed.
All rubbish will be removed from premises.
Homeowners will provide all the bathroom fixtures, tiles, grout and accessories.
Permit fees are additional and will be billed separately.
Work is based upon leaving the sink and toilet in the same location.
Total estimate: $ 9200.00
Kitchen;
Disconnect the kitchen sink and dishwasher and remove the countertops.
Move all the appliances into the other room.
Take up the kitchen floor down to the subfloor, working around the cabinets.
Install Durock tile underlayment on the floor and then tile and grout the floor.
Re-install the appliances and hook up the new sink, faucet and garbage disposal
once the granite is installed.
Homeowner to supply the new plumbing fixtures, tiles and grout.
Countertop to be template and installed by others.
Total
Signature
mfgoodwincompany@gmail.com
Page 2
Mass.CSL #081670 Mass. HIC #105029
e,I
130 Centre St. I ' Estimate
Box C-1 ® ®
Danvers, Ma. 01923 979-423-8463
Chuck & Debbie Benvie 11/4/2013
6 Hillside Ave.
Salem, Ma.
Project Description Total
No painting is included.
Permit fees are additional
The work will begin the week of January 1 st.
Total estimate: $6300.00
Total of both projects: $15,500.00
Payment Schedule;
A deposit of$ 5200.00 upon starting.
A payment of$6000.00 upon completion of all tile work.
Balance of$ 4300.00 upon completion.
Acceptance of Proposal;
Contractor: Date:
Homeowner: CA,4 &a v;oei Date: 11-3o-►3
This proposal may be withdrawn by either party within 48 hours of signing
Total
Signature
mfgoodwincompany@gmail.com
Page 3
Mass.CSL #081670 Mass. HIC #105029
130 Centre St. 1 Estimate
Box C-1
Danvers, Ma. 01923 978-423-8463
Y
f..
Chuck & Debbie Benvie 11/4/2013
6 Hillside Ave.
Salem, Ma.
Project Description Total
Total $0.00
Signature
mfgoodwincompany@gmail.com
Page 4
Mass.CSL #081670 Mass. HIC #105029