54 LINDEN ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
off Massachusetts State Building Code, 780 CMR, T" edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Two-Fumih'Dive liff
This Section ffi ial Use my
Building Permit Number: D e ppli
Signature:
Building Commissioner/Insp for of Buildings Date
SECTION l: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map At Parcel Numbers
S y L ,-VOIA1 sr
Ma Number Parcel Number
I.1 a Is this an accepted street?yes_ no.
p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
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.40,954) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yesO
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner[of Record. �
nA/TF V /Na n��f S(/ LINOf Al S
Name(Print) Address for Service:
978 - 7d41 - 6y�3
Signature Telephone
SECTION 3- DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ I Accessory Bldg. ❑ Number of Units__ I Other ❑ Specify:
Brief Description of Proposed Work': / of
NO t f1 d n S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building S o00.00 I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: SX
4. Mechanical (HVAC) S List: CCCJJJ"` (�
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ❑ Paid in Full ❑ Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Super isor(CSL)AU
/OU33 S
a e Number Ex ra on Date
N4 me of CSL- lder
'r 1 4/ SL Type(sec below)11,
Address Description
��l Ve f { Unrestricted u to 35,000 Cu. Ft.)
Signature Restricted IU Famil DwellinMasonnl Residential Roofin Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regis�gred Home Improvement�pnt�ctor(HJC) / /S J� 7 -
, 7 rii // l f
HIC Company ame o HIC Registrant Name Registration Number
{ v '69 A, ,rZ4 47 r /
Address qq�p f5` 1J JD/O
,L!g J,f —v7S$0 4 pir ion Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this a idavit 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
1. as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, , 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
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties 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 Home Improvement Contractor(HIC)Program), will nor 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 I I O.R6 and I I O.RS, 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 healing 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 SALEM
PUBLIC PROPRERTY
DEPARTMENT
.NP'. M'IS tMhl ,91
%I\ nt I LC W,\,t un\.I,^51:t Ui r • 5•vt r,t, M.\.Nst.III It l I,J197�
li.l. 778•713.`1543 • 17\s 9711-. 4i: M46
Workers' Cumpensation Insurance ` iftdavic Builders/Contractors/Electricians/Plumbers
Jt»lixaut hiforinalion Please Print Leeibly
Name Ia1hliN,y 1�! aN r.InTVlndt\gIUaII; o rn
�.Idr�ss: /7 4ll/S
City,St:uaRip. / Mont: i': 92sr
A,ree,sou an vm ployer? Check the appropriate box: 'f)pe orpnlject (required):
1.IJQ I inn a employer with -3 a. ❑ I am a general contractor and 1 /r, New construction
employees(full andilur part-unle).• we hired the sub-contracturs 7 Remodeling
1.❑ 1 ,un a sole proprletter or partner- listed an d:e nnachctl sheet. :
.hip And have no mnpluyccs These sub-contractors have g. ❑ Demolition
working for me in any capacity, workers' comp. insurance. 9. budding addition
Kn workers' cum insurance 5. ❑ We are a corporation ant) its
I P 10.❑ Electrical repairs or additions
I required.] officers have eserclscJ their
}.❑ I om a homeowner doing all work 5 P P'
ti ht of exem tion per N1rL 11.0 umbing repairs or addilions
myself. [No workers' conep. e. 152, Q t(3), and we have no 12. aucef repairs
insurance required.] r anployccs. (Ko workers' 13.❑Other
comp. insurance required.)
•,u, ,,ipLcan that checks box nt mall al)a fill Wl the tiCIIJII Wow showing Ihot,wurkces'cuntpenlaatutl J olicy ndiurt4tliuR
' t lomeuwtwll who aibmil this 21Tldavit indie.acing they its doing all work and then hire uuaide caurmlun must suhmil a new afGdavil indi"mg%itch.
-f,mtet:utn,hal,heck this box into#Jnaahed an+dJnional..h.vt,hawing the tunes of the rub<onlrwlon and their wurkere'comp.rmhcy mfurmariun
/tun un euyduyrr that i.v providing rvurkcrs'cumprneation insurnncc•fur ury rnrp/uyrer. Belnry is ale pulily and fob site
iujunnruion.
Iroorancc Company Vame: nARQ___ /7. S�I�✓en . _.. �i¢/S--_._i`/�sST ?ryf- �nl� �/�
I'olicv iJ or Self-ins. Lic. N: _-.. .. . .. ___ Expiral,on Date:�__ �_
lob Site Address: Set e , _-ST. City;sla \te/Lip: qI &/-, MA _
.,each o copy of the workers'eumpensallun policy declaration pate (showing the policy number and expiration date).
1'alluly h),ccurc cu\emge as required uudcr SCeliun 25A ul'.?IOL c. 152 can lead to the imposition of criminal penalties of a
tin: up h,il.500.00 anJ/ur one-year imprisonment, as hell as ci\d penalties in the lurm of a STOP WORK ORDER and a fine
,,(kill CO S250.00 it Jay .Igainal the violator. lie advt.acd that a copy of this,tatcmcnt may be Iorwarded to the Office Vf
Im:nli{auum vi-liv DL\ :Or iii,warce aner.,gc ,arili,.al:on.
l Ju hereby t crtifv IUIJc he dun'and prnu/liev of perjury that the infurrnation provided above is true and correct.
I•I ,.�'. . :, 9��
11 f/iciul ass Ludy. no not n•rite in this area, to be crwrrpleled by wily ur town a/ficial. '
( ilv ur fawn: _-- Pcrneit/Liccnse 0_
I\,ui nq .\utburiev (circle noe): i
1. Il•,arl of Millie L nodding 0cpurtulcul 1. (.itv.-funs Clerk J. Electrical Inspector 5. Plumbing la,pcctor
G. Other
G,ntavt 1'cnun: .. .. Phone is:
Information and Instructions
\fa�saemsetgs (.isncral Laws chapter i?2 requires all employers to provide workers' compensation ti)r their employees.
puou.utt to mis +Iaruic, an empluree is defined as" escry person in the service of another under any conflact of hire,
c.press or iinplicd. oral or wruten."
\n employer Is derined as "an Individual, partnership, asboclatlou, corporation or other legal entity, or ally two or more
,II the Ioregou,g engaged in aphint enicrpnsc. and including the legal representatives of a deceased employer,or the
rCeCNer or trubice ul .ul Individual, piumehhlp, association or other legal clingy,employing employees. However the
owner ofa 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 011 the.rounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
�IGL chapter 152. §25C(6)also states that "every state or local licensing agency shall withhold the issuance or
renewal of a license fir 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."
Udiuonally. sIGL chapter 152, 425C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the perfomtance of public work until acceptable evidence ofcouipliance 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 certificates)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
.\ccidents for confirmhation of insurance coverage. Also be sure to slgn and dale the affidavit. The affidavit should
be renirned 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.
(-ity or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a Space at the bottom
of the affidavit fur you to till out in the event the Office of Investigations has to contact you regarding the applicant.
PlI a:%c be surc to till in the pcnmit/license number which will be used as a reference nuniber. In addition, an applicant
that must submit multiple permitaicetue 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"at) locations in (city or
town)." A copy of the affidavit that has been officially stamped or narked by the city or town may be provided to the
applicant as proof that a valid affidavit Is On file thr 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. it dug license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
I lid I)111cc of IoY C5fhallun) would llne to dlallk )'ou In advance fur your COoperanoll and slluuld y'utl 110\'e .sly que)IlOtls,
please du not hesitate to give us a call
ncv Dcparrncnl';address, telephone and fax number
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office offavestlrstlons.-_
600 Washington Street
Boston, MA 02111
Tel. q 617-7274900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
www.mass.gov/din
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
'.I .. .0 A II'1�..�C�1:?IIr ♦ 1.%I1 %1. %IA"V
III- v'8 ):-ij • 1 \Y' 'i-X V:'1S4,.
Constrtiction Debris Disposal .affidavit
(rcyuiied fix all dcnwlition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 C NIR section 1 1 1.5
Dcbiis, and the provisions of MGL c 40, S 54;
building Permit h is issued with the condition that the debris resulting from
this work shall be disposed of in a pruperly licensed waste disposal Iacility as defined by MGL c
Ill. S 150A.
The debris will be transported by:
isn 99
(name of hauler)
I he debris will be disposed of in
-�;ul�s.ul l]nlilVl
a�nalwe of innit .ytp Icanl
3 OS o
ale
�7g - rya- 98y�
� �/re FOoaitmeoreuea/di o�✓�jaafar/�ueo(p
-\ tBoard of Building Regulations and d S License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
. Registration: 151574 Board of Building Regulations and Standards
Expiration: 6/12/2010 7r# 268827 One Ashburton Place Rm 1301 i
Typo: DBA Boston,Ma.02105 i
I
CORY ROUSSEAU ROOFING CONTRACTOR n j
CORM AU
17 DAVIS IS RD RD C:; +?
BEVERLY, MA 01915 Administrator Not v id without signature i
,ctp _ Department ul Puhlic �afM)
R�ulatiutts and ctand;u ds
>1:o•:Khu License
1 Board ,d Builditt�ervleor Specialty
Construction Sup
�J License: GS SL 100335
Restricted to: RF
CORy ROUSSEAU
V DAVIS ROAp1915
BEVERLY,
E><Pir anon: 112/2012
Tr#: 100335
„nuui.•ioncr _