7 HOWARD ST - BUILDING INSPECTION (3) it SSS 5 ct--- to ,
The Commonwealth of Massachusetts CITY OF
W
Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMR Revised OF
1011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fmnily Dwelling
This Section For Official Use Onl
Building Permit Number: D pplied:
Buihlin801ticial(Print Name). .. Sigttaturo•: '. Date
SECTION 1:SITE INFORttilAT10N:
1.1 Prope A ST 1.2 Assesso MParcel Numbersyw 7tpc2 alM 1.la 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(sy tt) Frontage(It) -
1.3 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided 'Required Provided. Requited Provided
1.6 Water apply:(M.G.L o.J0,§54) 1.7 Flood Zone Information, 1.8 Sewage DJsposal System:
Zone: _ Outside Flood Z Munici �/On site dis sal system ❑
Public Private❑. Check if es po y
SECTION 2: PROPERTY OWNERSHIPk
2.1 Ownert of Record: (Mrs- (j1S23
F�ewAW ST- FJ61K& A&- *Ifi t�onvu3<
three(Print) Cily,State,ZIP r
P.O. 13'd zoo �i J SK on.uve lC. r�G.ANetE: o n�--
No,and Street Telephone Email Address
SECTION 3: DESCRIPTI N OF PROPOSED WORK°(check all that apply)
New Constmction❑ Eiiisting Building Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) O Addition ❑
Demolition ❑ Accessary Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work=: !
Ohlu+ 1 yt/S A/ Ut I liY r tClhr��
Q/ /Y1.CG 4 h r&--- I'1 S t.,14 r
•, cC rn r '
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itta n Estimated Costs: Official Use Only
Labor and Materials
I. Building S Q U t OO 0 1. Building Permit Fee:S Indicate how fee is determined:
❑Standard Cily/Town Application Fee
2.Electrical S 60r 0 c) ❑Total Project Cost'(Item 6)x multiplier s
3. Plumbing S 60f�� 1 QtherFees: S
d.Mcchanical (HVAC) S (qs her List:
5.Mechanical (Fire
Suppression) S ZU �� "total All Fces:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S SOS ❑Paid in Full 13 Outstanding Balance Due:
�J -p — A='1�'t lire,Later YG,rn • 1+�PnJ>= p
r
j
SECTION 5: CONSTRUCTION SERVICES r� .
5.1 Construction Supervisor License(CSL) S—07 9 gST 3--�-'�
StrOwvvoS(�� License Number ExpiratlionDate
Name of CSL Holder p List CSL Type(see below) y
PU' (3�ye Description
TYPc. � P .
No.:md Street -
G I C Z'3 U Unrestricted Ouildin tip-to 33,000 cu. It.
(�gryutr$ / R Restricted )&2Famil Dvvellin
Cityfrown,State,ZIP M masonry
RC Rootin Covcrin
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
f IIC Company Name or HIC Registrant Name -
No.acid Street - Email address
City/Town, State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFUDAVIT(M.G.L.c 151 g 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 Isivance f the building permit.
Signed Affidavit Attached? Yes.......... No...........
13 SECTION 7a:OWNER AUTHORIZATION.TO BE.COMPLETED.P.
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERbIIT'
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in alpl,matters relative to work authorized by this building permit application.
Print Owncr's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
contained in this application is rue a d accurnte to the best of my knowledge and understanding.
Print vt s r Authonzcd 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
___Inot registered in the Home Improvement Contractor(HIC)Program),will no have access to the arbitration
— -- — — - --
program or guaranty fund under b1.G.L.c. 142A.Other Important infortnanon on the HIC Progrem can a oun ar—
www mass.cov;oca information on the Construction Supervisor License can be found at wavay.masssov/Jos .
2. When substantial work is planned,provide the information below:
'rolal floor area(sq. ft.) 6 26 b N (including garage, finished basement/attics,d cks or porch)
Gross living area(sq. 11.) SR 6c> Habitable room count L
Number of fireplaces Number of bedrooms I
Number of bathrooms I Z Number of half/baths l
Type of heating system ✓A' Number of decks/porches 2—
'rype of cooling system N'VA'C— - Enclosed Open
.l. "Total Project Square Footage'may be substituted lour"Total Project Cost"
I' The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Wrkers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Le ibl
Name (Business/Organization/Individual): �.KO ft-Aw `\L �Ci cy/ti t�✓'�
Address: r-0, ror ZOG`f 1 p
City/State/Zip: D4nvte^T t Mk- Ul4 Z3 Phone#: $og^`J6z-3 �►(`/
Are you an employer?Check the appropriate box:
[5A<cv_
pe of project(required):
L❑I a employer with employees(full and/or part-time).• 'Construction
2. am a sole proprietor or partnership and have no employees working for me in emodelingany capacity.[No workers'comp.insurance required.]3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t ❑Demolition4.❑I am a homeowner and will be hiring contractors to conduct all work on m roe 1 will ❑Building additionY P P rtensure that all contractors either have workers'compensation insurance or are sole E]Electrical repairs or additions
proprietors with no employees.
❑
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 12. Plumbing repairs or additions
These sub-contractors have employees and have workers'comp.insurance.t 13.❑Roof repairs
6.❑we are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer,that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.M Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy 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 th e pns and.J�n�aIn of perjury that the information provided above is true and correct.
Si ature: l 1 IQ4 2A, zaib
Date:
Phone#: SO�'�jb Z 3gl
Official use only. Do not write in this area,to he completed by city or town official
City or Town: Permit/License#
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#:
� 4
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 or 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-contractor(s)name(s),address(es)and phone number(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 sign 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 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 file for future 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 bum leaves etc.)said person is NOT required to complete this affidavit.
e
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax # 617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALEA AWSACHUSE M
Bu mDmDEPAx7mmr
120 WAStm4GwNS7REET,32PRom
AL(978)745.9593,
FAX(978)740-9846
RIMRFRiF]�D1i18�j j, ,
MAYOR 7)AS ST.PlERRE
DmEcrca of mzucPItaPBm/stnDm oOH nwffONER
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 c40, S 54; Building Permit d 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 156A.
The debris will be transported by:t
Ntw h� lGh�l :O /OCX L�hBT�
(name of hauler)
The debris will be disposed of in:
(name of facility)
01-11oi.le--Ac -oi � M74—
(address of facility)
ignature of applicant
Date
Unofficial Property Record Card Page 1 of 1
Unofficial Property Record Card - Salem, MA
General Property Data
Parcel ID 35-0180-0 Account Number
Prior Parcel ID --
Property Owner ROMAN CATH ARCH OF BOSTON Property Location 26 30 ST PETER STREET
Property Use Church/Syn
Mailing Address 28 ST PETER STREET Most Recent Sale Date
Legal Reference
City SALEM Grantor
Mailing State MA Zip 01970 Sale Price 0
ParcelZoning Land Area 1.700 acres
Current Property Assessment
Card 1 Value Building 1 294,900 Xtre Features
Value Value 0 Land Value 180,600 Total Value 1,475,500
Total Parcel Building 3436600 Xtra Features 19,600 Land Value 180,600 Total Value 3,636,800
, ,
Value Value Value
Building Description
Building Style School Foundation Type Brick/Stone Flooring Type Lino/Vinyl
#of Living Units 1 Frame Type Wood Basement Floor Lino/Vinyl
Year Built 1950 Roof Structure Flat Heating Type Forced H/W
Building Grade Average(+) Roof Cover Membrane Heating Fuel Oil
Building Condition Average Siding Brick Veneer Air Conditioning 0
Finished Area(SF)4824 Interior Walls Plaster #of Bsmt Garages 0
Number Rooms 0 #of Bedrooms 0 #of Full Baths 0
#of 314 Baths 0 #of 1/2 Baths 0 #of Other Fixtures 12
Legal Description
Narrative Description of Property
This property contains 1.700 acres of land mainly classified as Church/Syn with a(n)School style building,built about 1950,having
Brick Veneer exterior and Membrane roof cover,with 1 unit(s),0 room(s),0 bedroom(s),0 bath(s),0 half bath(s).
Property Images
�1
Disclaimer:This information is believed to be correct but is subject to change and is not warranteed.
http://salem.patriotproperties.com/RecordCard.asp 3/3/2016
00
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION ��w4v C-7- DATE FGt; ZU 7,
ASSESSOR DATE OC 7 �C4
93 Washington t.
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CITY CLERK C 'DATE
93 Washington St.
PUBLIC SERVICES�u��eeMyDATE
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d ui 120 Washington St. Q� �lO+v� .$ St ei SexvV oed (tg
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` WATER a DATE �c�Fm,� tad be��re „�xt,�y
` t 120 Washington St.
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)(CROSS CONNECTION DATE
W =
o Jefferson A
c PLANNIN \" — DATE �! 15` �
120 Washington St.
CONSERVATION DATE
120 Washington S
ELECTRICAL DATE
48 Lafayette
FIRE PREVENT[O DATE o? l
29 Fort Avenue
HEALTH DATE riz-t Ili
120 Washington St.
BUILDING INSPECTOR AT lb
120 Washington St.
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