114 MARGIN ST - BUILDING INSPECTION (2) Lr The Commonwealth of Massachusetts
SAOF
Board of Building Regulations and Standards LEM
W
Massachusetts State Building Code, 780 CMR Revised,l/ar 2011
:BuiId:ingPcrjmit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
t` This Section For Official Use Only
1 j� Building Permit Number. Dato Applied:
u , . . AI G
*�(Prin,.N7ainw)._gOtticial(Print Name) Signature• '- D SECTION Ii SITE INFORMATIerty Address: M 1.2 Assessors Map all:Parcel Number( tt 2 1'rlQf/ ( � S' e2ti-DSDU- Uw ris an accepted street?yes no Map NumberParcel Numberming lnfonnad 1.4 Property Dimensions: �&ei,daAra`ha� OSOoistrict Proposed Use Lot Area(sq it) Fromage(It) . 0dingSetbacks(R) .- . r d Rear Yard
Front Yard Side YaidsnJ , ProvideJ Required Provided. . Requited" - Provided
1.6 Water Supply:(M.G.L 0,§54) 1.7 Flood Zon!Information: 1.8 Sewage Disposal System:Priblic� Private❑. Zone: _ Ode Flood one? Municipul�,On site disposal system ❑
k If es
SECTION2: PROP6RTYOWNERSHIP!1' l
2.1 Ownerto0- j W-G Af0.1nen05Gy Vf 1 ` 0.1.207.1 .
0.
me(Print) City,State,ZIP
161ct,1,lovj25 —yZtraco fo11-R67-7226 I I Ll IlMi-Ril'A cauh
No,and Strcet.I Telephone Em it Ad s
SECTION 3.:DESCRIPTION OF PROPOSED WORK;(cheek all that apply)`
New Construction❑ Existing Building Owner-Occupied ❑ I Repairs(s) ❑ 1 Aliemtion(s) Addition ❑
Demoliliun ❑ Accessory Bldg.❑ I Number of Units1_ I Other ❑ Specity:
Brie fscription of Proposed Work':
ra o _ ajDW�
1
SECTION-1:ESTIh1ATED CONSTRUCTION COSTS :
Item Estimated Costs: Official Use Only -
Labor and Materials)
1. Building S �D 00 D 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City(fown Application Fee
2. Electrical $
�' Od ❑Total Project Cost'(Item 6)x multiplier x -
J. Plumbing S —4000 2N Qther Fees: S
d.Mcchanical (FIVAC) $ 0 Dad List:
5.\[cc hanieaI (Fire S 5-1000 Total All Fees:S
Su ression)
Check No._CheckAmount: Cash Amount:
G. Total Project Cost: S ( aSDO O ❑Paid in Full Cl Outstanding Balance Due:
mra \ � c, Ml z� li.1c, It
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS lc*so y. 12 22 J14r
�U -r1t3 WIL &FAS License Number E.xpfrjtioh Date
Name of CSL Holder
List CSL'rype(see below) �
ZsS FnYS Ate' Type Description .
No.end Street
U Unrestricted(Buildings u n to 35,000 cu.11.
L�/NN 1',4A R Restricted 1&2 Family Dwelling
Cily/Ibrn,State,ZIP M Masonry
RC RoofinitCoverinit
WS Window and Siding
1� SF Solid Fuel Burning Appliances
SOPW•3$3�I�� �YL�,Ir1IG�1r f e Vldtmoaa'coy, I I Insulation
Tele hang Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) b 2-4
W It_t,_I MIS HIC Registration Number Espnmti n Date
I IIC Company Name ar IIIC Registrant MIM: 1
255 MA 9 AVM • _ lllevwo�lnc @ �)06yyII CONI
No.m"Street - ^� moil address
1 /,J0 ' t�(A • 00104 �3S3 �14
Ci /Town State ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION 1NSURAiYCE AFFIDAVIT(M.G.L c.152.§2SC(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 Istuance of the building permit.
Signed Affidavit Attached? Yes ..........id No...........O
SECTION 7a.OWNER AUTHORIZATION TO BE COMPLETED WHEN;
OWNER'S AGENT ORCONTRACTORAJ `PPLIE,S`FOOR BUILDING,PERMIT
' _
I,as Owner of the subject property,hereby authorize _JVlh rn A W\ l�\�MW 5 C1t5�I\//"�
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Mtn �nC _Hlac7G1 LLC `D
Print Owner's 1 ame(Electronic Signature) '
SECTION 7b:OWNERt 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 and accurate to the best of my knowledge and understanding.
tf' //1 &� ro2�1 /S
Print Os Authorized Agent's Name(Electronic Signature) ate
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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 Ligi have access to the arbitration
program or guaranty fund under M.G.L.c. Id2A.Other important nnfdimaHon onlheHIC-Program can be to`und—i
wow mnss.eow'our Information on the Construction Supervisor License can be.fnund at www.mass. ov,'dLs
2. When substantial work is planned,provide the information below:
'rotal floor area(sq. ft.) I_�,B / 'L (including garage, finished basementlattics,decks or porch)
Gross living area(sq. 11.) 130 Habitable room count 3
Number of fireplaces D Number of bedrooms 2
Number of bathrooms Number ofhait)baths O
Type of heating system C Number of decks/porches D
Type of cooling system Enclosed Open
J. "Total Project Square Footage"may be substituted tar"'rutal Project Cost"
The Commonwealth ofMassachusetts
:l Department oflnduslrialAccidents
I Congress Street,Suite 100
Boston,MA 021I4-2017
www.massgov/dia
Wworkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information. - Please Mat LetlN
Name(Business/orgw&.Ation/Individual): �InSTIf� W 1(�U�1"1S
Address: 25S FA`6 �
City/State/Zip: LYN h-A• 019 0 4 Phone#: JO`� `3S3 q IDS
Are you an employer?Check the appropriate box: Type of project(required):
1.Q I am a employer with employees(full and/orpart-time).' 7. New construction
2.6fl am kettle propridoror parmership and have no employees working forme ht 8. �Rtunodeling
any capacity.[No workers'comp.instance required]
3.Q I sm a homeowner doing all work myself.[No workers'comp.insurance required]t 9. Q Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work an my property. I will 10 a Building addition.
ensure that all contractors either have workers'compensation insurance or are sole - 11.E Electrical repairs or additions
proprietors with an`n3ploYce9' 12.0 Plumbing repairs or additions -
5.❑1 sm a general coobactor and I hamhimd the sub-contractors listed on the attached sheet.
nhese sub-contractors have employees and have workers'comp.insruancal 13.Q Roof repairs
6.❑We are a corporation and its officers have exe wised their right of exemption per MOL c. 14.❑Other,
152,§1(4),and we bare no employees.[No workers'comp:insurance required.] - -
-Any applicant that checks box#1 must also fill out the section below showing their workers'compmsetion polity information:
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such
IConnactors that check this box must attached an additional sheet showing the name of the sub-contmam s and state whether or not those entities have
employees, If the sub-contraGors have employees,they must provide their:workers'-comp.policy number.,
lam an employer that isproviding workers'compensation insurance for asy employees. Below is the pohley and jobsite
information.
Insurance Company Name: 8 LL N e1 E
Polity#or Self-ins.Lic.#: G 7,31 ,C2 (o qS-D I S Expiration Date: ( 11?
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$I,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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
1 do hereby certify under the pain/s�and penalties ofperjury that the information provided above is true and correctt,
signature: Date: 10 h s
Phone#: SOS 3�3 �Il�f
Ojrcial use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/Lfcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers'compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or writtep."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a 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 on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the Issuance or
renewal of a license or 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."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance 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 certificate(s)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
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license 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"all locations in_(city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for 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.a dqg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-NlASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALEA MASSAaA SE M
BuimmGDEPAR7mw
120 WASfIDVG7Y7 MEET,3IDFLODA
7LL(978)745.9593,
FAX(978)740.9846
%IIv18ERIEYDRiSQ77.L
MAYOR TMAW STJP E=
DIRECTMCFPURUCPACmn/BuuDnc comimcmit
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 c40, 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 deposit 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:
(name of facility)
(address of facility)
Signature of applicant
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""�D SUFPIEH�P
" LAND SURVEYING AND MAPPING
CONSULT CIVIL ENGINEERING SERVICES
I, C.A.BUDNICK P.O.BOX 14 TEL:800.675-1591 ENVIRONMENTAL CONSULTING SERVICES
A REGISTERED LAND SURVEYOR, 00 CLINTON,MA. 01510 FAX.978-365-7419
HEREBY CERTIFY THAT THE ABOVE DATE: FEBRUARY28.2015 RECORDED AT: ESSEXSDUTH COUNTY REGISTRY OFDEEDS
MORTGAGE INSPECTION PLAN WAS CLIENT: LOA.BALDIZZONE DONOVAN BOOK: -3113.1 1 PAGE: 19 L.C.CERT#
PREPARED FOR: CLIENT REF: NIA PLAN REFERENCE: -
CHICAGO TITLE INS.CO. P.O.# 303015 DRAWN PER TOWN/CITY OF ASSESSOR'S
MAP# PARCEL# DATED:
IN CONNECTION WITH A NEW MORTGAGE AND IS THE LOCATION OF THE ORIGINAL DWELLING SHOWN ADDRESS: 114 MARGIN STREET
NOT INTENDED OR REPRESENTED TO BE A LAND OR HEREON EITHER WAS IN COMPLIANCE WITH THE LOCAL SALEM MA 01970
PROPERTY LINE SURVEY. NO CORNERS WERE SET, APPLICABLE ZONING BYLAWS IN EFFECT WHEN BORROWER: MARZA,LLC,PAULA PEARCE&EMILY STUART
IT CANNOT BE USED FUR ESTABLISHING FENCE, CONSTRUCTED (WITH RESPECT TO HORIZONTAL INA 100 YR
LANDSCAPING. OR ' BUILDING UNES NO DIMENSIONAL REDUIREMENTS ONLY). OR IS EXEMPT SUBJECT OWELLING IS IN FLOOD ZONE HAZARD ARiA {
RESPONSIBWTY IS EXTENDED HEREIN FOR FROM VIOLATION ENFORCEMENT ACTION UNDER AS SHOWN ON NATIONAL FLOOD INSURANCE PRO RAM FLOOD -
ENCROACHMENT. OR TITLE MATTERS THAT MAY MASS G.L TITLE VIL CHAPAGA. SEC. 7, UNLESS INSURANCE RATE MAP DATED: JULY 16,2014
SUBSEQUENTLY BE DISCOVERED BY AN OTHERWISE NOTED OR SHOWN HEREON. IF ANY COMMUNITY-PANEL# 250102 0419G
INSTRUMENT SURVEY.THE LAND SHOWN HEREON IMPROVEMENTS ARE SITUATED WITHIN Ft OF AN
IS BASED ON CUENT FURNISHED INFORMATION AND APPARENT PROPERTY LINE,AN INSTRUMENT SURVEY FIELDED DRAFTED CHECKED ESS259 €0
MAY BE SUBJECT TO FURTHER OUT-SALES, IS RECOMMENDED. BY: CS CS CA
TAKINGS.EASEMENTS AND RIGHTS OF WAY. DATE: 26-FEB-15 27-FEB-15 28-Feb-15 I F.B. JF:?2—i