12 LYNN ST - BUILDING INSPECTION {�a,t — -7,z -7 S�
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
M
Massachusetts State Building Code, 780 CNIR
1 Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dtvelling
This Section For Official Use Only
Building Permit Number: , Date Applie✓ /
Building Official(Print Name) _ Signature.. V On
SECTION 1: SITE INF RNIATION
1.1 Property Address: 1.2 Assessors NIajr& Parcel Numbers
m'9 \ ,.
1.1 a Is this an accepted street?yes X no Map Number Parcel Number
1.3 Zoning Information: 4.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) 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:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP,'
2.1 Owner'of Record:
�✓A L%.ER 1-40,6—ciIA vS -sA«M AN A
Name(Print) City, State,ZIP
ix /_Y^rA ST. 9'78 . `785•GGGS
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check.all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) Cl I Addition ❑
Demolition ❑ Accessory Bldg. Cl Number of Units_ I Other ® Specify:CXZi f/ — h/P•,40t
Brief Description of Proposed Work': AXI,6�-E'/ol— 174P ve o/= ArrJ7-
7—o 7'iQ/--I Amxn �LApszo�ea2
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Estimated Costs:
Item Official Use Only
Labor and Materials
1. Building S �—���, 1. Building Permit Fee: S" Indicate how fee is determined:
Electrical ❑ Standard.City/Town Application Fee
2. ❑Total Project Cost' (Item 6)x multiplier x
3. Plumbing 'S 2- Other Fees: $
4. Mechanical (IfV:AC) S List:
5. Mcchanical (Fire S
Su ressio 1) Total All Fees: S
Check No. Check Amount: Cash Amount
6. 'futol Project Cost S 0 vo 0 Paid in Full ❑ Outstaiuiling Balance Due:
w
SECTION 5: CONST12UC1'ION SERVICES
5.1 Construction Supervisor License(CSL) v 3
PA;-4�CW /"N �-j.5�aon _ License Number 4pllatm&
Name of CSL [folder U
List CSL Type(sae below)
/' o B
No. and Street Type Description'
G U Unrestricted Buildin s u to 35,000 cu. ft.)
� "�f / el � g/ R Restricted 1&2 Family Dwelliu
6tyrTown, State, ZIP Nf Masonry
RC Rooting Covering
WS Window and Siding
SF Solid FIICI Burning Appliances
5F72 7510 /tlo� dSGdoD.S�89 ) di✓�r/✓ I Insulation
"rele hone �^ Email nd ress D Demolition
5.2 Registered Home Improvement Contractor(HIC)
t75 Giut�/> �i4/nt T +�f6' SP.P✓/G� S HIC Registration Number Expiration Date
_N_IC Company Name or m FIIC Registrant Nae
P BvX I/ V
No. and Street Email address
Ci /Town, State,ZIP of Tele hone
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 ..........X No ........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize_ � A/cc
to/act on in half ' ue relative to work authorized by this building p6rmit application.
Pixn O%vncr's Name(Ele tronic Signature) Date
SECTION 7b: OWNER`OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties o(perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
PA�iQ i co( 41
Print Owner's or Authorized:\gent's Name(Elecn'onic S'mature) Date
% 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. I42A. Other important information on the HIC Program can be found at
uvww.mass.,,ov:%oca Information on the Construction Supervisor License can be found at vvww.mass.sov.ClLr;
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _(including garage, finished basement/attics, decks or porch)
Gross living :urea (sq. rt.) Flabitable room count
Number of fit replaces_ Number of bedrooms —--
Number of bathrooms Number of hAf/baths
fypc of heating systems _-- Number of decks/ porches " _--
F)Peofcoolingsystems _-- Enclosed.— ---opcil --
d. ` total I'rojecr,�qunre Fnotrigo" inuy be sub_tihital fnr'_Cotsl 1'rojeetCost" -- _ _-_ -
i� CITY OF SALEI(, l/L1SS.-1CHliSETTS
BULMING DEP.IRTM NT
120 WASHINGTON STREET, late FLOOR
TM (978) 745-9595
Flax x(973) 740-9846
KIN(gFRT RY DRISCOLL
T
MAYOR Homs ST.PmRRS
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COSLNIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informatfnn �j��y�� r /Please Print Leeihty
Nance(Busiiwss.Organizatiarvindividual): dO='R � A41,V ///•6 ANh C X)'A4C1--11Ve
Address: A0 dam( // p
City/StatcMp:!�/&/11.Z6td /{1/-� Phone N: 7 V !2-Y
Are yyoou-an employer?Check the appropriate boxt Type of project(required):
1.LJ i am a employer with 2-,0 4. Q I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.Elinto a solo proprietor or partner- listed on the attached.sheet t 7• ❑Remodeling -
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑Building addition
(No workers camp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ i am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself.(No workcra'comp. C. 152, §44),and we have no 12.❑ Roof repairs
insurance required.)t employees.(No workers' IJ.QOther
cump.insurance required.)
•Any appllcum that checks box el must alto rill nut old section W'owshowing rhea worker'compenudun policy infurmatloo.
t 1 huneuwm"who submit this aeiMvit indicating thcy are doing all work and than him outside contrcon most submit a new,amdavit indicating such.
lCowmion that cheek this box moat attached an additional Awl showing thenarne of the sub/ wftrrlool and oheir workers'comp.policy infomuatim.
I am an employer that Is providing workers'compensadan Insurance for my employees. Below Is fire pollcy end fob site
ioformerlon, ,@@� qq y� ,/ /n�"� n
insurance Company Namr.�]�� iti Ay h��'��///Q� �//1rCI + /vPTvv`?
Policy Al or Self-ills. Lie. q: �VExpiration Data, /�T
Job Site Adtkcss, /-I- '�• N/ol
City/Statr/2ip, �/ � �.__
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 e. 152 can lead to the imposition of criminal penalties of a
line 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 S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of ilia DIA for insurance coverage verification. •'
I do hereby certify under the pelts and penuldes of perjury Mail ilea hrforarerlo t provided above is true and correct.
/�ZSiemnure: - 'Duto.
P o f• 7g / �U
OJjic ial use curly. Do rat write in thht arei4 m be completed by city ur town offletatt
City nr,ruwn: ___.__ Permit/I.lcenseAt
Issuing Authority(circle one):
1. Board of licallh Z. Building Department 3.Cilyfrown Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: _...._.. .. _..__._..._ Phone th
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
k Boston, Massachusetts 02116
Home Improvement Contractor Registration
.; Reqistration: 134220
Type: DBA
_ Expiration: 10/12/2013 Tr# 217414
OSGOOD PAINTING SERVICES
PATRICK OSGOOD
PO BOX 1111 -
MARBLEHEAD, MA 01945 `
r' Update Address and return card.Mark reason for change.
- Address [7) Renewalj Employment I-] Lost Card
)PS-CA1 0 50M-04/04-G101216
,per Consumer Affairs Regulation License or registration valid for individul use only
�-\ Office of Consumer Affairs&Business Regulafioo g Y
Q HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration 134220 Type: Office of Consumer Affairs and Business Regulation
FY Expiration 10/12/2013 DBA 10 Park Plaza-Suite 5170
' - Boston,MA 02116
OSGOOD PAINTING SERVICES
PATRICK OSGOOq -
44 FOX RUN RD.
TOPSFIELD, MA 01683..
Undersecretary Not valid without signature
1
1
nic n+ u1
S Hrr�t r'rl of l3uildinL KI� �Ic��
-+ ulafinn` and �LuW;r rrl.Construction Supervisor License
License: CS 97643
PATRICK M OSGOOD
PO BOX 1111
MARBLEHEAD, MA 01945
--
r n nlw�ni w . Expiration. 5/28/2013
u
Tr= 16492
CITY OF S.1L.E,NI, i�'L-kSSACHUSETTS
BL IM11NIG DEPARTM&NT
• p+ 120 WASHNGTON STREET, 3" FLOOR
TEL (978) 745-9595
F.ix(978) 740-9846
KIN
LBERLEY DRISCOLL
MAYOR THo.%w ST.P1HRRa
DIRECTOR OF PUBLIC PROPERTY/BLILDNG CO\LMISSIOSIER
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 1 11.5
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
1 11, S 150A.
The debris will be transported by:
^1 .C' � D
(name of hauler)
The debris will be disposed of in
(name of facility)
--(address of facility)
siy atu a permit applicant
/J r��T�icc1 M d SC�r'o�
date
dcbn::aif.d.x
�(ONDlT,r
.c 1 6/-,
Salem Historical Commission
120 WASHINGTON STREET, SALEM. MASSACHUSETTS 01970
(978) 619-5685 FAX (978)740-0404
CERTIFICATE OF NON-APPLICABILITY
It is hereby certified that the Salem I3istorical Commission has determined that the proposed:
❑i Construction ❑ Moving
Reconstruction ❑ Alteration
❑ Demolition ❑ painting
❑ Signage ❑ Other Work
as described below does not involve an exterior architectural feature or involves a feature covered by the
exemptions or limitations set Forth in the Historic District's Act (M.G.L. Ch. 40C) and the Salem Historic
Districts Ordinance.
District: McIntire
Address of Property: 12 Lvnn Street
Name of Record Owner: Walter I d rhaus
Description of Work Proposed:
Repair/rej?loce rotted clapboard and fascia as needed to replicate exisi.ing. No changes in color, material,
design, location or outivard appearance. Nov-applicable due /o being in kind maintenance/replacenzeni.
Dated: November 20 2012. S T C� OMMISSION
By:
l
The homeowner has the option not to connrience the work (unless it relates to resolving an outstanding
violation). All work commenced must be completed within one year from this date unless otherwise indicated.
THIS IS NOT A BUILDING PERMIT. Please be sure to obtain the appropriate permits from the Inspector of
Buildings (or any other necessary permits or approvals) prior to commencing work.