35 MASON ST - BUILDING INSPECTION (2) J I;
The Commonwealth of Massachusetts CITY OF
Ip a Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
t
Building Permit Application To Construct, Re
pair, Reno
vate Or Demolish a
One-or Two-Family Dwelling
Tlus-S&ii For O,ffictaLUse Only
Building Permit Number , D ;Applied x
t.-
r '^ Date..: ,
.. .
Building Official(Print Name) 'Sign, u J
$ECTIQN,1. SITE INFO ,
1.1 Property Adtss: 5y"' 1.2 Assessors Map & Parcel Numbers
/ 'q t0y
Ma Number ParcelNumber
1.1a 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(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? Municipal ❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2. PROPERTY OWNERSHIP':'
2.1 Owner'ofRecord: � M B19r1,�r
Name(Print) City,State,ZIP
per, �. . 5 /3
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WOR (ch , k all that apply)New Construction❑ Existing Building s Owner-Occupied Cl Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': fIS
n!b cL l✓a S / tl cdgZ Ag.
SECTION 4: ESTIrMAFED'.CONSTRUCTION COSTS. '
Estimated Costs: Official Usa Only- e
Item Labor and Materials
1. Building $ 1 Buildiii' Permit Fee $ Indtoate how fee is determined:
❑ Standaid City(Town Apphcation Fee
2. Electrical $
q Total Pto3ect Cost';(Item 6)xmultipher'+ x'
3. Plumbing $ 2 Other.Fees. $
4. Mechanical (I VAC) $
List:
5. Nechanical (Fire Total All Fees. S
Suppression
Check No Check Amount Cash Amount:
6. 'rot"" ProjectCost: $ (Saw. ❑Paid in.Full ❑ Outstanding BalanceDue:
=-Flolder
ECTION 5: CONSTRUCTION SERVICES
uu/pervisor License(CSL) /")f /, "
2�IC License Number E pirat' a Date
:NameList CSL Type(see below). Type Description
eo, bet ilq (/r gtod U Unrestricted(Buildings u to 35,000 cu. It.
��r 66'' R Restricted 1.4c2 FamilyDwe(lin
City/Town, State, [P N Masonry
C Roofin Coverin
Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telz hone Email address D Demolition
5.�Registered Home Improvement Contractor(HIC) _ 16 6 9 /
HIC FIIC Registration Number ,pin on Date
Company Name or 1-fIC Rzfli�an[Name i
No. a94 Street Email address
",AA, zy
Ci /Town, State,'ZIP Tele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. e. 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.
SiFoniny
ned Affidit Attached? Yes .......... ID/ No........... ❑
ECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
bject property, hereby authorize
in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
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.
Pant Owner's or Authorized Agent's Name(Electronic Signature) ate
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. 142A. Other important information on the FIIC Program can be found at
www.mass.00v oca Information on the Construction Supervisor License can be found at www.inass.gov/(I
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 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(leeks/porches
Type of cooling system Enclosed- __Open _
3. ''total Project Square Footage" ntay be substituted for'"Coral Project Cost"
CITY OF S�AL.EI%4 ANsSACHUSETTS
BuIIDL\G DEPARTMENT
P• 130 WASHiNGTON STREET,3° FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI.XtBEjt FY DRISCOLL
THostAs ST.PiF�tRti
LL4,YOR
ptitECTOR OF PLBLIC PROPERTY/BUILDING COIXMISSIONER
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
l 11, S 150A.
The debris will be transported by:
(name of hauler).
The debris will be disposed of in
A,( tfB WA5T((name of facility)
Mtk)bulp-l l &Abao`/fm�+
(address of facility)
signature of per i[ plicant
1 /3
date
L
CITY OF Sm Elml) NLkS&kCHLSETTS
• BUILDING DEPARTNIMNT
120 WASHINGTON STREET, 3'o FLOOR
1EL (978)745-9595
Fax(978)740-9846
KI\tBERLF_Y DRISCOL L THObb►s ST.PMRRH
MAYOR lltaFrt'nn nF PUBLIC PROPERTY/BUI DLNG CON0.115SIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Eleetricians/Plumhers
-Applicant Information - --.Please.Print LeeiblY
Name(Busim-ss.OrganiratioNlndividuaq: f�i.INf CCn!:( CaQWACr6V5
Address.—-SSiQ.Wa Uk►Lyr -0*1
City/State/Zip: ftii &0a 1 M 4 0101(oD Phone#: Cnlb-531- I(oM
Are you an employer?Check the appropriate box:- Type of project(required):
1. 1 am a employer with 1) 4. ❑ 1 am a general contractor and 1 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: �• [1 Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition 11-7
workingfor me in an capacity. workers'comp.insurance, g '
Y ❑Building addition
fNo workers'comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3111 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or udduions
myself.(No workers'comp. c. 152, ¢1(4),and we have no 12.[Ooof repairs
insurance required.]t employees.[No workers' 13.❑Other,
comp.insurance required.]
•Any applicant that ducks box of must also rill out the sntioo below showing their workora'compensation polity information.
t I romeownrn who submit this affidavit indicating they am doing all work and then hire outside Contractors mum submit a new affidavit indicating such.
=Commaors that check this box must attached an additional shut showing the name or the sub.Contrat ars and their workers'comp.policy hu motion.
t am an employer that Is providing workers'compensation Insurance for my employees. Below is the policy andjob site _
information.
Insurance Company Name: Li&t !yntny L Ir35URA4)CIL —
Policy p or Sclf--ins.Lic.N: fa1La.^ 3l S"33�`�'1 'O(��" Expiration Date:
Job Site Address: d91SW STi City/StatelzipQ141M MJf o/%96
Attack a eopy 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 c. 152 can lead to the imposition of criminal penalties of a
tine 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$230.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification
I do hereby cent'y tinder the pains and penalties of perjury that the information provided above is true and correct.
Si,• t ue' Date: / /.j
phone 4: -1924
Official use only. Do not write in thht areati to be completed by city or town official
Cityar'rown: _.._ Permit/I.fcense#
Issuing Authority(circle one):
1.Board of Ilcrlth 2,Building Department 3.City/fawn Clerk 4.Electrical Inspector 5.Plumbing inspector
6.Other
Contact Person: Phone#:
i