9 LARCH AVE - BUILDING INSPECTION (6) ah• o�
The Commonwealth of Massachusetts
� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code 730 CMR SALEM
o , O
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised d/w 2011
One-or Two-Family DlveUrng
This Section For Official Use Only
Building Permit Number:
Date,Applied:[3uilJing Official(Print Name). J '`�'h0E 3Q l
. Signature
SEC Date
TION 1 SITEINFOR�(ATION
1.1 Property Address:
n'� y d //, P --- 1.2 Assessors blip&Parcel Numbers
I.I n Is this an accepted street?yes_ ❑o—. Map Number Parcel arcel Number
1.3 Zoning Information;
1.4 Property Dimensions:
Kning District PrupuseJ Us---;e--__
Lot Area(sy tl) Frontage(II)
L5 Building Setbacks(ft)
Front Yard Side Yards
Provided Re
Required Provide) Rear Yard
Required Required y Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information:
Public❑ Private❑ Zone: _ Outside Flood Zone? l.8 Sewage Disposal System:
Check ifyesO Municipal❑ On site disposal system ❑
SECTION2: PROPERTYOWNERSHIPi
2.1 Owner'of Record:
2ze,ee /1 a Ile �tr,State,ZIP p
No.anu Strict
Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED SVORK?(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Altemtic n(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1Number of Units
Brief Description of Proposed Work-: Other ❑ Specify:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
I. Building S I. Building Permit Fee:$
2. Electrical $ ❑Standard City/Town Application Fee
ate how fee is determined:
3. Plumbing $ ❑Total Project Cost'(Item 6)x multiplier x
2. Other Fees: $
4. 'Mechanical (lIVAq $ List:
5. ,Mechanical (Fire
Su ression) $ Total All Fees:$
6. Total Project Cost: $ `j7 Check No._Chet—•k Amount: Cash Amount:_
❑Paid in Full Cl Outstanding Balance Due:
i
SECTION s: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ,
License Nun Expiration Date
E
List CSL'rype(see below)
Nnnte oCCSL Holder ,
.type Description
Unrestricted Buildin St to 35,000 cu.it
No.and Street U .
R Restricted I&2 Famil Dwellin
M Mason
City/ruwn,State,ZIP RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
D Demolition
Email address
Tile hone
5.2 Registered Home Improvement Contractor(HIC) [tic Registration Number Expiration
IIIC Cumpany Name or HIC Registrant Name
Email address
Nu.and Street —_
Tele hone -. .
Ci /Town,State,ZIP
SECTION 6:WORKERS,.CONIPENSATION INSURANCE AFFIDAVIT(M.C.L.C. 152.§ 2�C(
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 ..........❑
No........... ❑
ZATLON TO BE.COIVIPLETED WHEN
SECTION 7a:OWNER AUTHOR
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Date
Print Owner's Name(Electronic Signature)
THORIZED AGENT DECLARATION
SECTION 7b:OWNEW OR AU
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.
h5, v � �ll� — �te
Print Owner's ur r\uthorize Ment's Na c( ' ceu'unic Signaiure)
NOTES:
I, r\n Owner wild 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�LG.L.c. Id2A.Other important information on the H[C Program can be found at
rrrvw.mass. dl r�dCa Information on the Construction Supervisor License can be Fotmd at wwry m______�'+"t��''`h?s
2. When substantial work is planned,provide the info l"cdo�tnl�ange, finished basemenVattics,decks or porch)
focal floor area(s4 ft.) Habitable room count
Gross living area(sq. BJ Number of bedrooms
Number of fireplaces Number Ofhalf/baths
Number of bathrooms Number of decks/porches Type of healing system�— Enclosed_—__.—"—.—Open
Cype of cooling system
}. `"Coral Project Square Footage"may be substituted for'"total Project Cost"
QTY OF SALEM, MASSACHUSETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET,3w FLOOR
fEL. (978) 745-9595
F
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR TTrIOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date i 3D /
Job Location 9 4a-,-e4l Alm
Home Owner Address 7k. ,p
Present Mailing Address
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling,,attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR
3`
9 LARCH AVENUE 578-14
Gis# szzs COMMONWEALTH OF MASSACHUSETTS
Map: 36
Block CITY OF SALEM
Lot: 0497
Category: RENOVATIONS
Permit# 578 14 BUILDING PERMIT
Project# JS-2014-001278
Est. Cost: $1,500.00
Fee Charged: $25.00
Balance Due: $.00 PERMISSION IS HEREBY GRANTED TO:
Const. Class: Contractor: License: Expires:
Use Group:,. -Homeowner as Contractor
LotSize(sq ft.): 8343.918r!g
Z-onmg r^ '. "'*`Rl are`I Owner: ST PIERRE JUDITH A
Units darned. `Applicant: HOMEOWNER
Units Lost: ]A T.
AT. 9 LARCH AVENUE
ISSUED ON. 30-Jan-2014 AMENDED ON. EXPIRES ON. 28-Jul-2014
TO PERFORM THE FOLLOWING WORK:
BEAM INSTALLATION
POST THIS CARD SO IT IS VISIBLE FROM THE STREET
Electric Gas Plumbing Building
UaIcerground: Underground: Und erg ramd: Excavation:
Service: Meter: Footings:
I ,. h..
Rough: Rough: Bough: Foundation:
(-I&+ i. ..
Final: Final: Final: Rough Frame:
Fireplace/Chimney:
D.P.W. Fire Health
Insulation:
Meter: Oil:
Final:
House# Smoke:
Treasury:
Water: Alarm: Assessor
Sewer: Sprinklers: Final:
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF ITS
RULES AND REGULATIONS.
Signature:
FeeType: Receipt No: Date Paid: Check No: Amount:
"G BUILDING REC-2014-001283 30-Jan-14 4936 $25.00
GeoTMS®2014 Des Lauriers Municipal Solutions,Inc.
J 9,` �l< C�FrcS 3 P YOB
t Commonwealth of Massachusetts
Sheet Metal Permit
Date: . Pcrmit tt_— _--
Estimated Job Cost: S . 000. Permit Fee: 'SA—b
Plans Submitted: YES NO Plans Reviewed: YES NO
Business License # ��/ Applicant License tt -- --
Business(�Intbrmation: Property Owner/Job Location Information:
Name: YEJie nnT GL .r2w`e Name: �C-T f Q I tnct�T
Street: 3� A,Ala,^ ,S j Street: /U ,
City/Town: IN2.vtr,'�L�wr �/u/(¢ City/Town:
Telephone: q7�' ?(og ,��Jy Telephone: _ 711- a05-- J 72
Photo I.D. required/Copy of Photo I.D. attached: YES NO
— smrnnia�t
J-1 0-1-1-unrestricted license
J-2/ iM-2-restricted to dwellings oriel or less and commercial up to 10,000 sq. It. / 2-stories or less
Residential: I-2 family_ Multi-family_ Condo/Townhouses Other
Commercial: Office_ Retail Industrial_ Educational
Institutional _ Other_
Square Footage: under 10,000 sq. fit. — over 10,000 sq. ft. _ Number of Stories: 1
Sheet metal work to be completed: New Work: Renovation:
I IVAC_ Metal Watershed Roofing_ Kitchen Exhaust System
`fetal Chinmey/ Vents_ Air Balancing
1'1'0vide detailed description of work to be done: n `
INSURANCE COVERAGE:
I have a current liability insurance policy or its equivalent which meets the requirements of M.G.L.Ch. 112 Yes a-40❑
If you have checked Yes,indicate the type of coverage by checking the appropriate box below:
A liability Insurance policy ❑ Other type.of indemnity ❑ Bond ❑
OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 112 of the
Massachusetts General Laws,and that my signature on this permit application waives this requirement.
Check One Only
Owner ❑ Agent ❑
Signature of Owner or Owner's Agent
By checking this box❑,I hereby certify that all of the details and Information I have submitted(or entered)regarding this application are true and
accurate to the best of my knowledge and that all sheet metal work and Installations performed under the permit Issued for this application will be
In compliance with all pertinent provision of the Massachusetts Building Code and Chapter 112 of the General Laws.
Duct Inspection required prior to insulation installation: YES_ NO
Prouress 111S000HOUS
Date Comments
Final hisnection
Date Comments
Type of License:
By ❑ Master
rilie_ ❑ Master-Restricted
Cityi%wn ❑Journeyperson
Signature of Licensee
Pannil z.
❑Journeyperson-Restricted License Number:
Foal _—
❑ -- -- Check at:•r.v.v.in.c;s.rlovhlL
Inspector signature of Permit Approval
CITY OF SALEM, 1LNSSACHUSETTS
` r BUILDING DEPART\ff-NT
120 WASHLNGTON STREET, 3'a FLOOR
�1 TEL (978) 745-9595
F.A,x(978) 740-9946
KIJfBERL.EY DRISCOLL
MAYOR THOMAS ST.PIERAE
DIRECTOR OF PUBLIC PROPERTY/BUILDIDG CONLMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �r �[ Please Print Legibly
Name (BusitussOrganization,'Individual): �Pr �erir, C.c�CG(i,,,/A
Address:
City/State/Zip: [,✓�GL(nrw, l4 01�N Phone #:
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1
6. ❑New conswction
employees(full and/or part-time)." have hired the sub-contractors
2.❑ 1 tun a sole proprietor or partner- listed on the attached sheet.t 7, emodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. w comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. RKc are a corporation and its
required.]
officers have exercised their l0.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. (No workers'cutup. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers' I3.0 Other
comp. insurance required.]
•Any applicant dun checks bux#t mwi also fill our the scaion bcfowshowing their workea'compensation policy inhumation.
'I huneuwixxr who submit this affidavit indicating ihry,are doing all work and ilun hire outside contractors must submit a new alydavit indicating such.
Comr aon that check this box must attach d an addiliuwl sheet shuwintt tlw none of the tub<on,neton and their workers'comp.policy information.
Ionian eirtpluyer tout is providing workers'compensation inrurancefor my euployees. Below Is the policy and Job site
information.
Insurance Company Name:
Policy q or Sclf-ins. Lic.U: Expiration Date:
lob 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 Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
tine up to S1,500.00 undror one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigutiuns of the DIA for insurance coverage verification.
/r/o irrreb cerriJy r t er tr pair d penalti - dory that the information provided a rave es a and correct.
,to
/1 _
Phone d:
OJJic•iul use mdy. Do not,write in this area,to be completed by city or town of ciuL
City or Town: __ Permit/Llccnse#
Issuing Authority(circle one):
1. Board of liealth 2. Building Department 3.C'ityrrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _- _ _ ___,.. ___ Phone N.: