414 JEFFERSON AVE - BUILDING INSPECTION The Comnnmwerdth of Massachusetts CITY
Board of Building Regulations a J Standards OF SALEM
r, �1 Massachusetts State Building Cude, 0 C'MR, 7 edition Renard Jwtuun•
I _ Building Permit Application T'o Construct, epair, Renovate Or Demolish a 1. =uux
On -ur Two-Fumi Dwelling
Th Section F r Official Use Only
Building Permit Number: Date Applied: tI
Signature:
Iluilding Cum issioner/Inspector i its Date
SE TI N 1:SITE INFORMATION
I.I Pro,�f rt ddress: 1.2 Assessors Map& Parcel Numbers
I.la Is this an accepted street?yes y no Map Number Parcel Number
_
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District 1'raposed Use I at Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yazd Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.an,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check il' es❑
SECTION 2: PROPERTY OWNERSHIP'
41� 2.1 OwnerlofRec�d: �2ou31� 1.41� (7-PI�TP2S0r'
Nome I) (,, Address I'or Service:
AV
. ignaturc "relephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 111 Owner-Occupied lif Repairs(s) ar Alteration(s) ❑ Addition ❑
Demolition Erl Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of proposed Work': O r1zS lj
1 - 2lyI - I - �u?Z -
!/ IS fa4ti NLvlprL T
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item I Labor and Materials
I. Building S I. Building Permit Fee: S Indicate now lee is Determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Pmjcs:t Cosl1(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (IIVAC) S List: J
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No._Check Amount: Cash Amount:_
v 6. Total Project Cost: S �, ab 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
/, 5.1 /L'iicensed Construction
nSupervlsor(CSL) QXJM�onryOnly
�[/eNtqf� 01A21 licpiraliun UamName UIS .JIOJseeWow)
Addrc sstricteJ a to35,OU0(' Ftictedtiignutygre n Onl
` �g 6-3 1 RC I Residential Roofing Covering
lelephone I WS I Residential Window and Siding
SF I Residential Solid Fuel flaming Appliance Installation
1) 1 Residential Demolition
5.2 Regi. grad H e Ins ove nt Csracor(onttHIC)
�tPi
I IIC Company np u�! Regisl an Nm>le. Registration Number
((kJ I �a AJJnss S - �- 2a//
n
PJri%yl/1 ( " 976 2 N 2 Expiration Date
Signature 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 .......... O No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
v /
1. S Ina, P� l J a)u/a , as Owner of the subject property hereby
authorize pertnlIS • ( /dQ e ebl erZS) to act on my behalf, in all matters
relaliv to work a orized by this building permit application.
i4l
Si atureot'Own r Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, /•Je.v..i '�' ` 1102/<k ( & 1-X27//e?f/,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Ot-pdoal tS 011qel%r.
Print Name
�/// / Zd7/
Signatureof Owneror Authorized Agent
(Signed under the pains andpenalties ofperjury)
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 flame Improvement Contractor(1-11C)Program), will Lfgof have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basememlattics,decks or parch)
Gross living area(Sq. Ft.) Ifabitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hal0baths
Typc of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage'*may he substituted tiff"Total Project Cost"
71 REMOVE OLD BATHROOM WINDOW AND
INSTALL NEW SMALLER WINDOW.
8] REPAIR SEWER PIPE IN BASEMENT [ 4'AREA]
PLEASE MAKE PAYABLE TO DENNIS CLARKE
WE PftOAOSE HEREBY TO FURNISH MATERIAL AND
LABOR COMPLETE IN ACCORDANCE WITH ABOVE
SPECIFICATION FOR THE SUM $14185.00 WITH $8,000.00
DOWN $4000.00WHEN PLUMBING AND SHEET ROCK $
1000.00 WHEN TILE WORK HAS BEEN COMPLETED
$685.00 WHEN SEWER PIPE IN BASEMENT REPAIRED
$500.00 WORK HAS BEEN COMPLETED.
ACCEPTANCE OF PROPOSAL THE ABOVE PRICES
SPECIFICATIONS AND CONDITION ARE SATISFACTORY
AND ARE HEREBY ACCEPTED. YOU ARE AUTHORIZED TO
DO THE WORK AS SPECIFIED , PAYMENTS BE MADE AS OUTLINED
ABOVE
SIGNAT -- --------SIGNA ------------------
ANK YOU FOR YOUR BUISNESS
CITY OF Sm.E.m, NL-1SS.A aiUSETTS
13LUMLYG DEPARTMEINT
120 W.A.SHLNGTON STREET, 3 °FLOOR
TEL (978) 74S-959S
FAX(978) 740-9846
KIJtBERiEY DRMOLL
MAYOR THO.uAs ST.PIFjtnB
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG COMMISSIONER
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 ofMGL-e 40,S-54;— — - --.- --
Building Permit tl 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 transported by:
C'liaek decAe -
(name of hauler)
The debris will be disposed of in
(name of facility)
t�t�o(1�PlowiJ 010 G(g
T� (address of facility)
signature of permit —
B p mit applicant
`loll
Bate
I.hna IN.w
CITY OF SALEM
'# r PUBLIC PROPRERTY
DEPARTMENT
.iw':X:FY:ININan 1
\Isvixt
1!.'WAafING 1 US S IXEL•T s $AIJ..m,M.tD.tt.l 11 at-I Is J197�
l'r.l.:0111-715Y9395 s 1:VC 979-7Q-7x46
1Vurkers' Cumpensation Insurance At'Adavit: guilders/Contractors/ElectriciansiPlumbers
koviicant Information J [) n Please Print Leeihlv
Vi11TIl;IlluauX;sygrgmlratirnvindl/v�Juull:/ t��QI(P ��fd((�/(f
City,Starc;%ip: P60 y O)VC Phoneil: 978 53L y'S2
1Are flu an cngsloyer.1 Check the appropriate box: 'Type orproject(required):
1.❑ 1 tun a ampluycr with 4. ❑ I:on a general contractor and 1
npiuyccs(full ind/ur part-time)." hove hired the sub-conrracturs f' ❑��^ew cw> tructiun
2. 1 I am a sole proprietor or partner- lisrod on the attached sheet. 7• L!7 rcelnodelina
ship and have no cmpluyucs These sub-contractors have N. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 4 puiWi❑ ng-udditiun- -----
----- -----iNrrwnrkcrs"cump. iuxurance--—5�❑-Wearcacm•po�atinn:intlits -- ---
required.] otYcers have cxarcised their 10.❑Electrical repairs or additions
3.❑ I ant a hmncowncr doing all work right of exemption per tvfGL 1 1.❑ Plumbing repairs or additions
myself.[No workers'sump. C. 152,§1(4),and we have no 12.❑Ruurmpairs
insurrncu reyuired.J t cmployetm[No workers'
comp. insursncereyuind.J 13.❑Otter.
Ant,,,phrami Ilia Oxcks boa 01 mwt:dsu lilt alit liw aeciiafi Wuw dmwine)heir w•wkwi cumpentutiwt pulicy inhuntwittn
I lumauwtwn who stibmit#his affidavit indiutina i1my its doing all vurk and ihcn him wnside cuurneton mm,.ubmd a nsw atndavil irafiulina v#eA.-Cowfmltav that chmit this bass must Jawbod in adi iliutwl.heat,howine#hc nanm firths sulrsfintrsctu s and their wurkun'comp.pdicy inPortnatium
/alit un euydoyer that/r pruviding workers'rornpen.radon insurance for my nnp/uyeer.
ififuanution Behalf!s the Polity and/lib site
Insurance C'unlpany Name:
I'ulicy Mot Sclf-ins. Lie.H: ..._ . .._ EApiral#on Date:
Job Site Addmss' city)state/Zip:
Attach it copy of this workers'cwnpen.ution policy deelarutidn puke(showing the policy number and expiration date).
Failure w secure coverage as required under Section 25A ul'.MGL c. 152 can lead to the imposition of criminal penalties of a
tine up nl S 1500.00 ind/ur une-year imprisonment,Js cruli Jx civil penullics in the f'unn of a STOP WORK ORDER and a fine
ofup at 5250.00 a Jay aguinbl the violator. lie advi.icd that a copy urihis malcinent may be Iurwarded to the(Alice ul'
htv'csugJunns al'the OL\ for mmirarce�iiOefJge 1 CI'IfleJlliln.
/ /a hereby rrrtify mailer Ilia li n. ad prnultiee of pe n that he infurmullon prurided above is true and correct.
a,•:rw�re: Pm/Yln
-- � bah H// / 20//
Ofliciel use only. Dd an,n•rhe in Mir urea, to he cunrp/efed by city or town a/J/ciuj
i
i
City
or 1'nwn: _ Permit/Lleense X_ _ I
Isvuing Authority (circle une);
I. lloard of Ilcalth 2. Iluildio., I)cpartlncnt I. Cilyi funs Clerk 4. Electrical lotpcctor 5. Plumbing inspector
6. olhvr
l'�ntlJcl 1'cnuttt _ . _ Phoned:
I
Informati
on and Instructions
.%Iass.)chuseus General Laws chapter 152 requires all employers to provide workers' compensation llx their employees.
1'ursuarn to this nature,an employee is defined as"...every pa:son in the service of another under any cumn ct of hire.
ckpreas or unplied, oral Jr written."
.fin employer Is defined as"an individual,partnership,ussocanoa,corporation ti other legal entity, or any two r t more
.�1 the (,)regouig engaged In a Joint enterprise, and IncluLfing the legal rep(eeClllanve4 JI]deceased Cn1plUyef,Jf the
..I the of Jf traSlCe UI.ut IIId1VIdUa1, prumenhip,assoclutoo 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
h dweng hose
li
dwelling house of another who employs persons
to shall ndo og construction c
otbecause of such be deemed tube an elmployer."
or on the grounds or building appurtenant
�IGL chapter 152, Q'_SC(6)also states that"every state or IOcal licensing agency shall withhold the Issuance or
renewal of a license or permit to operate a business or to construct buildings fa the commonwealth for any
:tpplleant wlro has not produced acceptable evidence of cumPHance with the insurance coverage required."
kdditionally. IvIGL chapter 152, § nt
25C(71 slates"Neither the commonwcaldt our any of its political subdivisions shall
enter into any contract for the performance ut'public work until acceptable evidence ufcupliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants ply to your
— -- — Pheasc ftlVout-the-workers--'_cutnpensruon affidavit completelyhone muchecking
Ibe4l)along-with-their ewirscrLeLs]—osituatif ---
and,if, --- —
necessary,supply sub-contmctor(s)nameW,addresses)u�d p
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.u policy is required Be advised that this affidavit may be submitted to the Department of Industrial
em loye s for confirmation is lion of insurance coverage. Also be sure to sigh and date the affidavit. The affidavit should
he returned to the city or town that the uppiicauo ofae rega the rding law license if you
are required to obtnequested, not ullu workerat of
compensation
Accidents. Should you have any qu
estions 8 8
cornpensatiun 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 he slue that the affidavit is wmplete and printed legibly. The Department has provided u space at the bottom
of the affidavit for you to till out in the event the OIYce of Investigations has to convect you regarding the applicant.
I'lousc be sure to fill in the permit/license Millibar which will be used as a reference number. In addition,an applicant
that must submit multiple pennitilicense applications in any given year, need only submit one affidavit indicating current
policy information lit'necessary)and under"Job Site Address"the applicant should write"all locutions 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 afrrduvit is on file for future permits or licenses. A new at7iduvit must be tilled out each
year. Where a home owner of citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dug license or permit to burn leaven etc.)said person is NOT required to complete this affidavit.
I he t>liix of lnvesti8atiuns would like to thank you in advance fur your cooperation and should you have,ny questions,
please do nut hesitate to give us a Call.
the Department's address, telephone and tux number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
'Pei. p 617-727.4900 ext 406 or 1-877-MASSAFE
Fax A 617-727-7749
t.•. .cd ;. u.u5 www.mass.gov/dia
CLARKE BROTHERS
36 PULASKI STREET PEABODY MASS
PHONE- 978-532-9521 CELL-781-838-1415
SAMUEL BROWN 414 JEFFERSON AVE SALEM
MASS 01970 9782105470 WORK 6176268590
1] GUT 2nd FLOOR BATHROOM .
2] MOVE OLD TUB AND INSTALL ALL NEW
PLUMBING -HOT-COLD WATER LINES -DRAIN-
SYMMONS ALLURA SINGLE-HANDLE TUB
SHOWER FAUCET - A PISTON -STYLE PRESSURE-
BALANCING VALVE ADJUST THE HOT AND COLD
WATER AUTOMATICALLY.
31 INSTALL NEW WHITE 5' BOOTZ INDUSTRIES
RIGHT HAND DRAIN SOAKING TUB, TUB IS A
PORCELAIN ENAMELED STEEL ENCASED WITH
SYNIRON 2 AN ENGINEERED COMPOSITE
MATERIAL DESIGNED TO IMPROVE HEAT
RETENITION , REDUCE SOUND, A 40DEGREE
LUMBAR SUPPORT FOR COMFORTABLE BATHING.
4] WALLS IN TUB AREA WILL BE TILED WITH
WHITE 6X6 TILE OVER CEMENT BOARD.
51 WALLS IN BATHROOM WILL HAVE %2"GREEN
BOARD WITH ALL SEAMS AND NAIL HOLES
FILLED WITH JOINT COMPOUND AND SANDED
READY FOR PAINT.
6] INSTALL NEW WHITE TOILET AND 30" VANITY.