0006 KOSCIUSKO STREET - BPA-14-1224 Z\ The Commonwealth of Massach DIVED
Board of Building Regulati 10MUsSERVICES CITY OF
Massachusetts State Buildinoc�80 CMR SALEM
nngg Reviser/Mar 2011
Building Permit Application To Construct, R��Ijj, ndZb{te D�m6 It a
One-or Two-Fmnily Dr�'W;g
This Section For Official Use Only
Building Permit Number: Date Applied: ��II
Building Official(Print Name) Signature uDale
SECTION 1:SITE INFORMATION
1.1 Prorertv Address: 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes_ n' O_ i Number Parcel Number
1.3 'Zoning Information: L4 Property Dimensions:
%Doing District Proposed-Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Iteyuired Provided Required Provided Required Provided
1.6 Water4 Supply: (NI G.I,c. 0,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 1$/ Private❑ Zone: _ Clutside Flood Zone?
Check if ves❑ Municipal Er On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP' r�
2.1 hvn}r'of Reco il: OI 1 U
C ICY1ar� from 6, ,�.bo A Q
Name(Print) City.Stale,ZII' ---
ll5ko S� - � �313
No. and Street — Telephone Imuil Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ NumberofUnits I Other ❑ Spccily: _
Brief Descriptio of Pr o ed V rk2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 7 _i 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑"total Project Cost'(Item 6)s multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (I[VAC) S List:
5. Mechanical (Fire
Su: ression) S Total All Fees: S_
Check No. Check Amount: Cash Amount:_
6. Total Project Cost $ ❑ Paid in Full ❑Outstanding Balance Due: _
S1F1-,3 0 1'-U (o QSC l U Sy
C, IVL=Vj c-b Gpn`v ��eso2 g ; /a M
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
_ ^ 't If License Number Expiration Date
Name of CSL Holder n
1 .) Cl Ry` List CSI.,Type(see below)
. ttCj
No.and Street Type Description
U Unrestricted(Buildings tip to 35,000 cu. ft.)
R Restricted l&2 Famil Dwelling
Cityll'own,Slate,LIP M Mason
ry
RC Roolin&Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Regis ered f ome Ina rQ°,v g tContrra—c+tor(1IIC) /�ln 0 / / ndl�
5��, ��'i ;1�ko 1 IIIC Regis/tra0[ion Number WExpiration Date
HIC C'om nny agte or I ll Registrant Namc 1
f� I ' 'ic 'ZII , d IW/*t-rj- fly, q 101VJ�CQ
No.told Strcct6al
kiTMA d1770 /a�� �i1a ��xQ Email add ss
city/Town,State,ZIP
/ / Telelhone OD
SECTION 6:WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(NI.G.L.c. 1.52.§ 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 Issuan a of the building permit.
Signed Affidavit Attached? Yes .......... d 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 �'^'� ' t (J Fat t—
to act on my behalf, in all matters relative to work authorized by this building perrnit applicatiio 7 L/
n.
R�CHA� Dm H, RGM �- � / 1 1 l� I
Pnnt Owner's i ', e(Electronic 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 a d accurate to th best f my no c ge, d understanding.
Pnnt Owner's or Authorized Agents Name(Electronic Signature) f ate
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 M.G.L.c. 142A.Other important information on the HIC Program can be found at
wxvw.n ass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dris
2. When substantial work is planned, provide the information below:
Total floor area(sq. F.)_ (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) _ Habitable room count_
Number of fireplaces Number of bedrooms
Number of bathrooms _ Number ofhalf/baths
Type of heating system.—___ Number of decks/porches
Type ofeooling system_ Enclosed _Open
3. "Total Project Square Footage" may be substituted for...l'otal Project Cost"
1
CITY OF S:1 zNf, A-kS&: CHUSETTS
fJCILOL�IG DEPAR- LENT
130 1V.ISHLYGTON ST zEET, Y°FLOOR
�. T EL (973) 745-9595
KIMBERLEY DIUSCOLL PAX(973) 740-994,S
N LA Yo:2 Tt-{onAs ST.PIE.ans
D18ECCOA OF PLOUC PROPERTY/BCILDD(G Co.OIISSIONEX
Construction Debris Dtsposai Aff7davit
(required for all demolition and renovation work)
11
In accordance with the sixth edition of the State Building Code, 730 QMR section l l 1.5
Dcbris, and the provisions of l`vtGL c 40, S 54;
Building Permit y this work shall is issued with the condition that the debris resulting from
l 11, S ISOA. be disposed of in a properly licensed waste disposal facility as defined by MGL c
The debris will be transported by:
yOvino AJO,40,u, --
oanw otIhaulcrJ
The debris will be disposed of in
(name of hu[lity) —
(adJass of taeihty)
• �1/ J
V ,
V
signatureufperrnit.ippficant
CITY OF SAI.EN1, A-1SS.ICHUSETTS
BUILDING DEP.\R'TMr—NT
9 4 r 51 120 WASHINGTON STREET, 3"s FLOOR
T EL (978) 745-9595
RA-X(978) 740-9846
Ki\tBERLEY DRISCOLL
MAYOR THO\tAs ST.PI>vaRg
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\RIISSIONER
1V'orkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I,�p, Please Print Le ibl
�iainL'lilusiness Orgmiration'Individ d): '""� I W�
Address: I ((�,IUn✓� ��"
Cily/State/Zip: Phone lt: UY�l / /
Are you can employer?Check the appropriate box: FN
ect(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1nstruction
nntpinyees(full and/or pan-time).' have hired the sulacontractors
2. 1 am a sole proprietor or partner. listed on the attached sheet. t eling
ship and have no employees These sub-contractors have itionworking litr me in any capacity, workers'comp. insurance. g addition
[No workers•' camp. insurance 5. ❑ We are a corporation and iUrequired.) officers have exercised their al repairs or additions
7.❑ 1 am a homeowner doing all work right of exemption per MGL 1111 Plumbing repairs or additions
myself. (No workers' sump. C. 152, 41(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' I3.❑ Odder
cutup. insurance rcquircd.J
'Any applictvn Haar clwcks but r l must also rill caul the cectwo below showing their wotken'compenudun Policy inlipmarian.
'I L,meuwnvn who whnio this smdnvit indicating thcY are doing all work and then hire uutride contractors ,or suhmit a new nfndavit indicating such.
mawtun ihul chock this but mast attachnl can uddiduruai,heal thuwing Ilea mane of the sob4cruncion and their wmrkcrs'comp,pulley infurmalion.
I cans can employer that is providing workers'eurepe tsarlon insurance for my employees. Qeluw Is dsa pollry and Jab.rile
hifarnration.
Insurance Company
Policy 4 or Self-ins. Lic. it: Expiration Date:
Job Sue Address: City/State/Zip:
.attach a copy of the workers'compensating policy declaration page(showing the pulley number and expiration date).
Failure to secure covenge.as required under Section 25A of X(GL e. 152 can lead to the imposition of criminal penalties of a
line up to S 1,500.00 and/or one-year imprisnmncnt,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S2S0.00 a day against the violator. Ile advised that a copy oft h is,.statement may be to nvordcd to the Office of
Invest i gal ions ol'tlie Dlr\ for insurance co vcrage verification.
l do hereby re 'y can er the p is at Urn `fperjury tout the infurntodun pro vidud ubave!s d ue all correct.
of
rc
Phunc i'
[01ficialusemily. Do"of write its fhi. area,tube completed by city urtown nfjlrial
nr'I'uwo: Permit/I.lccnscNing Awhurity (circle one):
oard of Ileahh 1.IluiidlnG Ucllarhncut 3.Cily/fnrvu Clerk1. F:Icctrical Inspcdor 5. Plnmbiug Inspee❑Ir
dterha I'ervt n:
__...._.___ Phone 1:
l
e Soa„ ,,ry„rue,�l�/ofn GtInWIC!«jetG
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
- ME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
.egistration: „1217,82 Type: Office of Consumer Affairs and Business Regulation
xpiration F6l1220:16 Individual �� l0 Park Plaza-Suite 5170
IM
STEPHEN D.WHITTI = Boston,MA 02116 j
,a In
STEPHEN WHIT-rii �� �/✓ •�
10 RIVER ST \� �¢i o ;I
�� i=�� �— (I( ii r
SALEM, MA 01970 - Undersecretary f� *at d without signature ,
S
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r
Stephen D. Whittier
Building & Home Remodeling
10 River Street Salem Mass.
978-744-6076
7/2/2014
Koscuisko St.
Salem, Mass.
Construct new bathroom on first floor:
Remove existing shiplap paneling to provide material for new bath wall.
Open outside wall and infill with fiberglas batt insulation.
Frame walls and door opening for new bath.
Install barnboard paneling salvaged from existing. Finish with new materials as needed.
Provide and install baseboard stock to match existing.
Provide and install ceiling beams as needed to complete bath walls.
Open chase on first and second floor for plumbing. Repair wall and skim coat to match.
Install/tape and joint moisture resistant gypsum on bathroom walls.
Provide and install baseboard and door trim to match existing for bathroom walls.
Total $ 9,140.
Bath floor to be determined : option 1- 12"x12" self stick tiles $500. plus materials.