18-20 MASON ST - BUILDING INSPECTION (3) 4
-14 The Commonwealth of Massachusetts
—� Board of Building Regulations and Standards CITY
y Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Revised Junuury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
C� One-or hvo-Family Dwelling
\^ �� This Section For Official Use Only
\ Building Permit Number:,/ 4 oe Date Applied:
Signature: 1� 0� l
Building Commissioned Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: .� 1.2 Assessors Map& Parcel Numbers
20 MK1,-YhN st l _
I.I 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 11) Frontage(fl)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
I(A 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 ifyes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
BITS
Na (Print Address for Service:
4431- TJ89 -5R25
Sign ure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work': r?ROV10e SZDI: Aae,—S5 7-619,4I?KbUG AleeFn
�R/'fM �!?,4T 7✓r1X�2. 1AJSJV;+1. A.r&-W 50ink,`Poa&Ff -+ STXLrl2S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S / 4 I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ---. ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S ..�
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 1 G1'�G7r 00 ❑Paid in Full ❑Outstanding Balance Due: Li
c 7"b�" 2 "� / z �
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) C014-:9 2
MTiOLWar� nF+l�L.M '"1D5 License Number Expiration Date
a = —
Name ol'CSL-Ifolder List CSL Type(see below)
3n r r-Qcr �Q/qp LrYNN M1! �!9 .r Description _
Ad U Unrestricted(up to 35,000 Cu.Ft.
/� sr R Restricted 1&2 Family Dwelling
S lgna ore M Mason Only
7 4 -3H6- 25±0 RC Residential Rooting Covering
relephone WS Residential Window and Siding
SF Residential Solid Fuel Bumina Appliance Installation
D Residential Demolition
5.2 Registered Home Int vement Contractor(HIC) 16,314 30
Registration Number
[77Re Istrant NameI�E d,!/NN Mid O 75?4-2Nq'-1246 Expiration Date
relephone
KERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6))
rkers 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 ..........6( No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 7G1SEpl„� 'SF3T&� as Owner of the subject property hereby
authorize ArMW4,e2, l2H,6k Mz.—Y2S to act on my behalf,in all matters
relative to work authorized by this building permit application.
q /13 Li0
Si re of(honer Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 �1'�l 13Afi� ,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.
q '72S /
Print 14/2 Q!1,0
Si o Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 gJo have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,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"
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,A CITY OF SALEM
1;
PUBLIC PROPRERTY
DEPARTMENT
111P M111 'Mlv 1'd I
I �.�N IL\I.�+4V SCM kI'r �•�I1)1, St.\+i.\� III J
l'rt:vry-7aur;rS •1'.vt:971I.7+3-9a46
Construction Debris Disposal Affidavit
(required fur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40. S 54;
Building Permit p is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
Umtno of hauler)
The debris will be disposed of in :
(�N'�nartx u►7'aciLi� .
eDMM�"� 5'C: hYA7�V
(Admit of lacllu)if
Q
.Ignature of liernut applicant
hi/"'_:in1 o
date
Ic pn.lj,Sr
CITY OF S.u.Ems NL-%ss xcHusETTS
BI.QDLNG DEPARTTIENT
110 W.\SHNGTON STREET. r FLOOR
TEL (978) 74&9599
FAX(973) 740.9&W
KI.NtBEA"y DRISCOLL
.%4AY0I T11ob1AgST.P1gRRt
DtmcroR o►Ft BLIC pROPERTY/tV 1LDLNG CONMUSSIONF t
Wurkers' Compensation Insurance Alltdavit: guilders/Contractors/ElectrieirnslPtumbers
annlicant (nfortnaHos Please Print Ledblr
Varna Ina,uwevaoraaitlrarielvlwbvlAnll' 1�RMF� �lfi�l,MF�S DBL9 fUl�[,NU1.5'/ (�iJVS`T,t�[l'ti?-RAJ
Address: 9.52 JVAAA)VE 5721 `T AY
City/StatdZip: A�tV,/)?A c14'C25 Phone Al.
Are you to employes!Check the appropriate boa: Type of projeee(required):
I.❑ 1 am a cmployw with e. ❑ 1 am a general contractor and 1 b O New constsuction
2.[unplo (full and/or pan-time)." have hit"the sub-com actors
yses 1 am a sole prmprielar Iw partner- listed an the ansched d - g : 7. ErRemodeling
ship and have no employees These sub-contnwtm have t. O I inalition
workingfor me in any capacity. Workers'comp.inwnaoa
Y Pr ry• 9. 0 OuiWing addition
I No wwken'comp insurance S. ❑ We me a corporation and is
required)
offciets hew exercised their 10.0 Electrical repairs or additions
)•❑ 1 am a homeownar doing all work ^Its of exemption per MGL 11.Q Plumbing repairs or additions
myself.(No Workers*comp. C. I32,41(d).and we have no 12.Q Roof repairs
insurance require&] t :Mpkycm LNG worinrs' 13.0 Other
Comp.insurance required.)
-nay apyuaa d that anrraa to Of ear atat ten Ina the MOM brkw astride ladt eerbaa•I wins iribiriiiakm
I I Il Viouto as i who submit Air Same"indloliue'my an liaise all work ad thim his-min counsel"trot whnh a saw anldteit i,diyi.o wsL
=Cwwaysn ar cheek Ibis be ntat analMd as alldiliaat Jwr Janina da minio of no wdt•eea ftamt,and lhek wwrkwa'Coop.Policy insom-daft
/ow an ewp/oyly that ib previdht;workers'cowpenmdea/naeraawjor ay earp/eyma NeMr a timPN&P NAfdM d&
information.
Insurance Company Name:
Policy a or Self-ins. Lie. M: Expiration Date:
!cab Site Address: City/StawZip:
,\inch a copy of the workers'compeoandon policy dsclaratlea pap(showing the policy number and espiradoa dart).
Failure to secure coverage as required under Section 23A of MGL e. 132 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-yew imprisonment,as well as civil penalties is the form of s STOP WORK ORDER and a floe
Of up to S230.00 a day against the violator. Ile adviaxl that a cups of this statement may be furwarded to the Olggct of
I nresugmiuna of ilia DIA for insurance covcragt verification.
l I/e hereby core alert the inn and mollies of pe►Jury that the lnfo►wu/oo prom/all u va l ruff and"Preca
Da
O/Jfeid mse dnln Dona write in this area,to M.urnp/i/d by city or town It//la•iaL
I
city at ruwn: eermita.IcenseM__ _
I�tuint.\ulAunty (circle une):
I. Ituard of Ilrallb 2. Ruilding Dvpurtmcnt 9. Citytfown Clerk J. Electrical Inspector S. Plumbing impactor
6. Other
I�nl Last Person: _ _ ._ _.. Phone t•
Board of Building Rcgulatioos and Standards
-7,
luHOME IMPROVEMENT CONTRACTOR
1
RegistraGonst 163430
Expirations=fi!¢2/2611 Tr# 285643
t:
Type ivsdual
JAMES CHALMERS '-; �
JAMES CHALMERS -
� r-%
72 KESWAR AVE
LYNN,MA 01905 „{ ,..m - Administrator _
r
:�lassachuse[ts- Dcp:rrtmrnf of Public S; r
. Board of Buildin;; - af•.[r
l���fff RcUulationI:and Si,rnd:a-ds
Construction Supervisor and
License: CS 64318 EE
Restricted to: 00 i
MICHAEL E CHALMERS
37 Le8EL RD; t
LYNN. MA 01904 l
a r.... me� Expiration: 1/24/p011 -
,. Tr,-: 9079