32 LAWRENCE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Q Board of Building Regulations and Standards CITY'
Ois SALEM
Massachusetts State Building Code, 780 CMR, 7a edition
Revised January
-� Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
One- �r Two-Family Dwelling
Th s Section For Official Use Only
' Building Permit Nu er: Date Applied:
Signature:
B it i4 ommissio / pector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
3 haw 4 nce- 5 f
1.1 a 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(sq fn 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 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal El�On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
IY[An1 Ri f7,Inre- 3 a �CIN1r`BK6.C. '5+,
Name(Print) Address for Service:
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply).
New Construction❑ Existing Building 0' Owner-Occupied � Repairs(s) ❑ Ahcration(s) Addition ❑
Demolition la' Accessory Bldg. ❑ Number of Units i Other ❑ Specify:
BriefDescriptionofProposedWork': t-k Remade
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ 5 O , 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
S(70r ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 3 STO 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
n Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 'I 0 S� Lb ❑Paid in Full ❑Outstanding Balance Due:
of ��2 ? / �'ta; 79 69A /rgc —Icpye '
1
a
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CS (1-.;q Is C, LA
: 5yf— 4i License Number Expiration Date
Name of CSL-Holder U
�� ��-7 v List CSL Type(see below)
Address g lJ.'l-�,U`c�'4 Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
SignatureN M Masonry Only
7 F,�^53`3�5�. RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Cot actor(HIC)
t5a�flelf ,,2 Sk2�dwcati �✓A b Jg4 Tnc
HIC Company Name or HIC Re istrant Name Registration Number
6� UiAhWe S >ti1Arbl�G�ea�( 10131dGi/
2y
Addre &"�,yq
//J�//�
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 ..........❑ No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 06i rq as Owner of the subject property hereby
authorize 1iIZrz.lia✓vf S"�Pae�t'LLuN to act on my behalf,in all matters
relative to work authorized by this building permit application.
,M 5"- a 7
nature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
Ik,m'tat
I, rtU 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.
Print Name
16
Signature of Ownef or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I HLR5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"may be substituted for"Total Project Cost"
CITY OF S'U.E.N1, 2UNSSACHUSETTS
• BuEMLNG DEPARTNIENT
120 WASHNGTON STREET, 3" FLOOR
� �"� T E1- (978) 745-9595
FAX(978) 740-9846
KINiBERLEY DRISCOLL
MAYOR T HoNus ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUM.DLNG COMNQSSIONER
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 transported by:
(name of hauler)
The debris will be disposed of in
1
or'stcXQ Ccl,r'"(1 n TV1C.
(name of fac ity)
a Swa wCo'f (Zcj
(address of facility)
signature of permit applicant
date
'a
is
CITY OF S.�Nt, NLxSSACHUSETTS
BuMDLNG DEPARTMENT
' 120 WASHINGTON STREET,3a0 FLOOR
TIM (978) 745-9595
FA.X(978)740-9846
KlJ(BERLEY DRISCOLL
MAYOR Il-1ohfAS ST.PIFstItE
DIRECTOR OF PLBLIC PROPERTY/BUILDING CONMUSSIO,iER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
AnDlicant Information Please Print
Leeibly
Name(Businessorganizatio vinndividual):-jar
V
Address: 7 Vida, C� Q Sf
a/9 y'J Phone #: '���' 3/ 9 OZ
Arz)•ay an employer?Check the apprgp0zle bcx: T
- ..
ype of project(required):
LQ 1 am a employer with 4. 0 1 am a general contractor and I 6. ❑New construction
employees(full and/or part-time),* have hired the sub-contractors ��
2.0 1 am a sole proprietor or partner- listed on the attached sheet.: ?• U remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance 5. 0 We are a corporation and its (0.❑ Electrical repairs or additions
required.] officers have exercised their P
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp, c. 152.§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. LNo workers' l3.0 Other
comp. insurance required.]
•Any applie u l that checks box el most also rill Out the sectim below showing their workers'compensation policy information.
t I lomeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Commurs that cheek this box must attached an additional sheet showing the name of the subcontractor and their worker'comp.policy infomtation.
1 am an employer that is providing workers'rompensadon Insurance for my employees. Below is the policy and job she
information. /J
Insurance Company Name:_._.
Policy H or Self-ins.Lic.N: /CUB /o �O((dc3Q`J Expiration Date: ////6 ZZO
Job Site Address�3,)- ten CLJf j<} _ City/Statc/Zip�-!err[ y 11/1? 0/9-?o
Attach a copy of the workers'compensation policy declaration page(showing the polity number and ezplraden 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 S 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 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ufthe DIA for insurance coverage verification.
f do hereby cert fy un the pains and penalties of perjury that the information provided above is true and correct.
i n iure: Ooi Date: S—,/ -41
Phone X: ` l-6 T /- gfe
OJrchd use only. Do not write in this area,to be completed by city or town afftciaL
City or'rown: Permit/13cense N
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.Cityrrown Cterk 4.Electrical Inspector 5.EPIumbingpeetor
6.Other
Contact Person• Phone i!:
aCORD CERTIFICATE OF LIABILITY INSURANCE OP ID Kl DATE(MMIDDIYYYY)
BARTL-3 OS 27 10
PRODUCER THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATIO
ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE
Thomas Gregory Associates Inc. HOLDER. THIS CERTIFICATE DOES NOT AMEND, EXTEND OR
601 Edgewater Drive S235 ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW
Wakefield MA 01880
Phone: 781-914-1000 Fax:781-246-2601 INSURERS AFFORDING COVERAGE NAIC#
INSURED INSURERA: Harleysville Insurance 26182
Bartlett S Steadman Plumbing
INSURER B: National Onion Fire xns. Co. 19445
S
R67PVilla a Street INNSURERURERD:C:
Marblehead MA 01945
INSURER E: '
COVERAGES
THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED.NOTWITHSTANDING
ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR
MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,EXCLUSIONS AND CONDITIONS OF SUCH
POLICIES.AGGREGATE LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
LTR NSR TYPE OF INSURANCE POLICY NUMBER DATE(MM/DDYYY PDATE EXPIRATION
MPDD TION LIMITS
GENERAL LIABILITY EACH OCCURRENCE $ 1,000,000
A X COMMERCIAL GENERAL LIABILITY SPP00000024571E 11/16/09 11/16/10 PRE MISES(Eaoaarence) $500,000
CLAIMS MADE ®OCCUR MED EXP(Any one person) $5,000
PERSONAL B ADV INJURY $ 1,000,000
GENERAL AGOHEGATE is2,000,000
GEN'L AGGREGATE LIMIT APPLIES PER PRODUCTS-COMP/OP AGO $2,000,000
POLICY JET LOC
AUTOMOBILE LIABILITY
COMBINED SINGLE LIMB $ 1_r
A ANY AUTO BA00000021759E 11/16/09 11/16/10 OOO,OOO
(Ea accident)
ALL OWNED AUTOS
BODILYPerson) $
$ SCHEDULED AUTOS (Per Person)
X HIRED AUTOS BODILY INJURY
X NON-OWNED AUTOS (Per accident) E
PROPERTY DAMAGE $
(Per accident)
GARAGE LIABILITY AUTO ONLY-EA ACCIDENT $
ANY AUTO EA ACC $
OTHER THAN
AUTO ONLY: AGG $ '..
EXCESSNMBRELLA LIABILITY EACH OCCURRENCE $ 1,000,000
A X OCCUR [] CLAIMSMADE CMB00000024572E 11/16/09 11/16/10 AGGREGATE $ 1,000,000
E
DEDUCTIBLE $
X RETENTION so $
WORIU=RS COMPENSATION AND X 70RV LIMBS TH
EMPLOYERS'LIABILITY
B ANY PROPRIETOR/PARTNER/EXECUTIVE WC6782305 11/16/09 11/16/10 E.L.EACH ACCIDENT s500,000
OFFICERIMEMBER EXCLUDED? E.L.DISEASE-EA EMPLOYE E 500,OOO
tt yrees,describe under
SPECLAL PROVISIONS belmv E.L.DISEASE-POLICY LIMIT ESOO,000
OTHER
DESCRIPTION OF OPERATIONS I LOCATIONS I VEHICLES I EXCLUSIONS ADDED BY ENDORSEMENT I SPECIAL PROVISIONS
Job: Mary Ritchie, 32 Lawrence Street, Salem, MA 01970.
CERTIFICATE HOLDER CANCELLATION
CITYSAO SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATIO
DATE THEREOF,THE ISSUING INSURER WILL ENDEAVOR TO MAIL 10 DAYS WRITTEN
City of Salem NOTICE TO THE CERTIFICATE HOLDER NAMED TO THE LEFT,BUT FAILURE TO DO SO SHALL
Building Department IMPOSE NO OBLIGATION OR LIABILITY OF ANY qNO UPON THE INSURER ITS AGENTS OR
120 Washington Street, 3rd Fl. REPRESENTATIVES.
Salem MA 01970
ACORD 25(2001/08) 1�.,. S RD CORPORATION 191