95 MASON ST - BUILDING INSPECTION (2) 7 --- I'he C'ununonseealth of�btas�aehuxRs - .
Board of luilding Regulations and Standards CITY OF
klassachusetts State Building Code, 7JU CNIR ti,\LhSI
IIuilJing Permit r\pplication
'fo Construct, Repair, Kenuvatc Or Demolish a Reri,"r1l.I1ar 2 l
One-ur Tiro-i,InId Darellhnq
This Section Fur Otlicial Use Ool
Building Permit`lumber: _ / Date Ap
3D
IIuilJing Uliicial(Print Mane) Signature I)ute
SECTION 1: SITE INFORMATION
L I Pr�opperty Ad,yyl1ress•. 1,2 Asse mars Nlap& Parcel Numbers
G/S AIA<e-n S-/-
1.
1a Is this an acre led street?yes no Parcel Nunthcr
1.3 Zoning InformatIon: 1.4 Property Dlanenslons:
Loning District PnlposeJ(!se Lot Area Isy II) fmnlage(11)
L! Bullding Setbacks(R)
Front Yard Side Yams Rear Yard
Reyuin:d Provided Reyuircd Provided Required Provided
1.6 Water Supply:(M.G.I.c.ao.§sa) 1.7 Flood Zone Inrormatlon:`- 1.8 Sewage Dlsposas System:
Pablic❑ Private O Zone: _ Outside Flood Zone?
Check if aC Municipd O On site disposal s)stcm ❑
SECTION 1. PROPERTYOWNERSHIP2.1 s
P erloM car
Mane(Print)
(tly.State.ZIP
szr 1/ti.44 s� /- f6y s�y�
Nu.and Street °'
rclephona Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK,(check all that apply)
New Construction trf Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteratlon(s) O Addition ❑
Dentulition ❑ Accessory Bldg.❑ Number of U ' s Other ❑ Specily:
Brief Description of Proposed Work':
s�
r �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
llent Estimated Costs:
I Labur and.\laterials) Ofllclal Use Only
I. Building S (/Du r' 1. Building Permit Fee: S Indicate how tee is determined:
2. Llecimal S ❑Standard City.•Tuan Application Fee
❑Tulnl Project C'ust'I Item 6)x multiplier
I ). I'lumbing S v
_. Other Fees: S
J. \lech.utical ill\ \('1 S List:
�uvcisionl S rotar\ll Fccs: S -- -
n Iblal Project Cu%I: S ('hvck No. _..__('hack
O P.aiJ m F'ull ❑0111smildilig 11.11 mcc Due:
r r
SE('"I'ION S: ('ONtiI'RU("flON tiF.HVI('F.S
.9.I _struetto�Suprrvisor Licensr(Ctil,) ���/
`` �� I s I IcFins¢Nmuhcr I \Ii wln 1 U.na
N.mlc.,l'l'SLILdJer ._...__—_ lull'SI. I\Ix(ice hclu+\1.__.__.._ _—.._
G�t PC RrelriiveliecJlcJ UIuDilcJiinc ris Ii n
No u��eet t) nItl 0 14,11111)cu. IL1
IR?I'.unil I)wellin
l'igil'o n,Aldte,Lll' ..
u �I son
KC' Karin Cu\crin
µ'S Window,md Sidin
SF Solid I l lluming Appliances
3;71) Q4,st@ �Jnfrl, C�I, 1 h,s dmiun
----'—'— — fn,;lil;ddrv+i D Denu,lition
lele hale a ��- J
3,2 Rrglstared Home Im irovement Contractor(HIC)
r7 ' J G IIIC'I egisumiun Numl+/er li\ muit 1 Dwe
I IIC 'an, un) a lie or IIC I is rant Nanla ,v d`3Gf In W,7s-s, C°
l:mull uJJrcss
No..and Sugrt A �(/jQ U 141i U � ash 3 �v
C/5
citytTown,State ZIP tale hung
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 25C(6))
Worker Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this afidavit will result in the denial of the Issuance of the building permit.
Signed ARldavitAttached? Yes ........,. No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE C55IPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize e
to act on my behalf,in all matters relative to work authorized by this building permit application.
Duta
Print Owner's Nwmc(Electronic Signulure)
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below I hereby attest under the pains and penalties of perjury that all of the information
costa' a in this cation is true an rate to the best of my knowledge and understanding. }I l
.J ale
1'r in •r's or: gcnt's Nunw 11!Wctrunic Signaulm)
NOTES:
I. .fin Owner who obtains a building permit to do his.hrr own work,or an owner who hires an unrcgisterrd eontracwr
(not registered in the Hume Inlprovrn,ent Contractor I HICI Programl.\vill nu have access to the arbitration
pragran,or guumil I•wid under M.G.L. V. IJA.Other in,ponant information on the HIC Progr_' am can be found at
I Information on the Cunslruclion Supervisor License can be found at+""` lu•1" �:^ II"
\Men substantial work is planned, provide the information below:
. 1 flour area anti 111 _ ____.._I ilieIuding garage, finished basement attics.decks or porclvl
Ilabilable rows cutup _ .. .
Grosi lining area I sq. 11.1 ....... Number of bedrooms
�un,her of lircplaccs .. __ Number of half halhs .. . .
\luuherul'hathroull,s . . . . . \Ilnlherold%%l Ilorches
I\pc olheating s>+mm
� I!ncla,eJ l,pen
I\pu„f A4+llllg i\ilelll
1, "loial Project Square I,h,l,lge" I„a) I+e ,uh,liuucd Ior..fatal Noic❑C'o,t'.
t
C TY OF SALEM, L1WSACHUSEITS
'' (3L'ILDING DEP.kttr- it
1_O ,'V.%SHLNGTON STREET, 30 FLOOR
TEL (979) 715.9595
:<i>I3E,U.BY DR)SCOLL F.�t(979) 710.9844
LkYO Z MOSLU ST.PTEAAS
DIRECTOR OF PL'9Lic P80PERTY/0L'1iDIJ,'G Cp1L\IIS�ION
Worker' Compensation (nsurance ,\ITTdavit:rit Uuilders/Contructurv/Electric)an.yP►umbers
\ 1 /1lcant Inrmatlnn
`/f�7 ✓17/'// ►case Prin Le•sibl
Nairn:(nII III t.Yt)l�anlJl hu LIa1hVl,h1.11) j/ �/f� /� C-
:Address: 7 y// r)lar j � /s�-
City/SrntaZip: (/�t hvs / V tq el �1 hand -3a7�
Arr yn a emyloyer'f Check the appropriate bait
I. 1 am a umptoyer with ._ a. Q 1 am a general cuniractor and I Type of project(required);
aulpinyces((fall and/or part-time).• have hind the sulseanlnctars 6• ❑Now cunstruclian
2.❑ 1 am a role Proprietor or purtnur• listed on the uttachcd sheet t 7• ❑Remodeling
.hip and have no empitayecs These sub-controetors have 4.wurking.li>r me in any capacity. workers'comp, insuronce. ). ❑Demolition
(No workers'comp, insurance J. ❑ We are a corporation and its )' ❑Building addition
rcquilvd.) officers have exercised their 10•0 Electrical repairs or additions
3.C3
.Q I am a homcownur doing all work right of exemptiun per MGL 11.Q Plumbing rcpeirs or udditlans
myself.once o worlikas/cutup. C. 152, 11(4),and we have no 12.Q Raof re airs
4 ) umpluyees.(No warkers' p
cutup,insurance required.) 1311 Olher
•.\ny.,pp lit:undWrhwktboa II 'es,ily,r 1111 nutiM wfaitr below.hil my Ihfir.akin'camptnudun pulley mnttmuUaa
'I Ii v Vu%fun W he""'mil Ihls&Ifleavit indleulne They rn dairy;I11'wrM a,d'hen
lhvl Owls'his box cowlmx hire uw Nfa
rlJe eretrre mlut n,htntl r now anfdavil indlain
$'",ortwWnhWt+n atWulurvd.haI huwina the nwnd orthe wb.untBrlun rod lAtlr Wniten'mm eweh
/con on durpluyer Ihuf to pruvlJ/Itr Ivorkdrs'rumprurar/un in.h my emp/uydra Bd/uw la Ju poNry and ubilaUe
inlUrnrullnlr,
Irteur:ulce(:umpiny .Name:
I'alicy J ur Self-ins. Lit. tl: —.......--
- Expirutian Date:
lob Sild Adtkuss.
.ltbeb a copy of the workers' compenrattee policy declarulldn a e shdwln itthslul alley and npintlon date).
F litWel to tucuru cuveragd as required undw Section 1JA ol'JIGL. 72 can lead to the imposition of criminal penalties of.a
:ire up to S1,500A0 and/or role-year S impri.mnmcnq as Well is civil penalties in the lbrm ufa 5TOP IVORK ORDER and a lino
' r co -'SO.gd a Juy Igainst the viulamr. Ile advL+eJ that a copy ul(hit,talvmcnt may bu iurvardcd to dlc Oliico of
Id rc,tiyaliun.t dilw 01.1 Iarintuunct tuverage verilicaliun.
l /prrjury rh ul the inlunnul/un pruviJaJ ubuvd 'v tru♦,! J cJrercL
e,nJy. p,!not .viral in this 1, !J Sal cUl" _—,a/rfdJ Sy riry ur/ul.n"/JJviut
(.iry of h.nrn:
l••nidy.\uthdrily lrire!J ode): .
I, Uudnl„I llcdt4 !. II:I,fillm; l).'p.'t Iu'e,w 1, 1 :'r,'In„n �IcrA 1. :•:I:ctri:J li'pcth,f I'1•
5. Ulher
, n hi m; hn P:irdf
l n 01,1 i'rrvin:
CITY OF S.l(.E,til, AISSACHUSETTs
OL'u.DLVC DEP.1ATtSNT
1 :0 %VUJ4C1GTONSTXM, jwFtOOIt
r�c, 1978) 745-9591
KIMBERUY DRLSCOLL I?kX(971) 7 49844
NtAY01! f}tO.�NI ST.Ptll�ts
DIASCTOX CP PL SLlC PRCPIiTV/3t:MDD/C CO1011SS10N EI(
Con"ructlOU Debris DlSposai Affidavit
(required for s1!demolition and renovation work)
rn accordance with the sixth edition of the State Building Code, J
Debris, and the provisions of MCL a 40, 9 34; 780 C,�/R section 111.
9uiloshell be di
Permit M " issued with the condition that the debris resulting from
I I I11 work, S I JOA. s
1 posed "fin a properly licensed warts disposal facility as defined by&ICE c
The debris will be transported by;
a� G
(n+ma uf'htul�r)
The debris will be disposed Orin :
In�mf+or hah�y) 4""i-
f iJCrtff ol'ri,rl,ry)
r` permrf rppliunf
C rry OF S:UfE%[, 1
t 1
BUILDING DEP.mirmENT
It
120 1 -U-1LNGTON STREET 31D FLOOR
y TFL (978) 735-9595
Rkx(979) 140-9844
!v.%tOERLEY DRISCOLL
�L�YOR T3(OJL%5 ST.P1ERA8
DIRECTOR OF PULIC PROPERTY/0L'B.DI\G CONLWISSIONER
%V'nrkeri' Compensation Insur'ance,\tlidavit: Iluiideri/Cuntructurv/Electrlcians/Plumbers
koplicant In(itrm-Anis 1 �1 Plcare Print Lenrlhiv
V;Ilnd IDuainuvr.Urgamnliurl.Individu•il Y• �� �� �r'Y/� S / 7 Lf C,
Wdress: ar L A,� /'
City/State/Zip: v 4 YSv. / t�1q C� � hone N: 6-�? AS 9 —3a7C7
,1re yo o employer?Check the Appropriate bolt 'Type of prnjact(required):
I. I am a employer with ,L_ 1, ❑ I am s general cumrsctor and
eulployees(fall and/or part-time).• have hired the subconlnctors tS. ❑New ematruction
2.Q lain a sale proprietor or partner- listed on the atlachdd sheet t 1. ❑Remodeling
.hip and have no employees These subcontractors have 4. Q Demolition -
Working for me in any capacity, workers'camp. insurance, 9, Q Building addition
[No wurkcn'comp. insurance 5. 0 We are a corporation and its
required.( )fOccrs have exercised their 10.Q Electrical repairs or additions
7.❑ I ran a homeuwner doing all work right of Ixempliun perm , I I.Q Plumbing repairs or additions
myself.(No workers'sump. c. I52,11(4).and we have no 12.Q Roof repairs
insurance required.( t employees. (No workers' IS,Q Other
comp insurance mquircd.)
\icy.-ppll,am iIW tl0.cka bac rl mual aloe rill our iha uctiva below shawiny their"Itg l'tumpenutlun pokey indirmalto6
'I t, nvuwm"who,uhmit rhlr ritldevil indlullne they+re daine ell%writ cad Then hire uunide rot,aMc an mtul a.hmh a now allldaril indiaina wok t'minuwnthat tha�kihie box mwl machvd rn a,Wtaurtd.ha,l.huwiny lha nwna of the rubuurim"and that,workeri camp.policy lnrwmanan.
fain un rarpluyer rhurlr provlJbrX rvorkut'cumprurarlon lnsurnnce�or my ernp/uyrra Bdow/e du policy and job We
inforraurinn.
In.urmcu Company Name:___......
1'olicy 4 or Srlf-its. Liu. d: Expiration Date:
lob Site Address: CityiStaleizip:
.Utach a copy of the workers'compensation policy daclaralldn Me(showing the Polley number and expiration date).
h'.Worts to sveura cuvero,d as required undur.Section 2Jr\of MGL c. 152 an lead to the imposition of criminal penalties of A
tire up to S 1,500.00 and/or one-year iinprimnmcnt as well as civil penallies in the farm of a STOP WORK ORDER and i line
,If uyr to S250.00 a Jay lyaillit file violatar. III advised that a cllpy of this nlalvirieni may ba turwurdcd to the Otlicu of
I.Ive�il yJllUn.r ill llte 1)IA I:)rltlallraliec iovernya vCriiicAun.
/do lrrrrby dr erne uu pan uUlrr r/p.•rjury chur r/re Lf�unnur/un pruvir/eJ-a�b/wr 'a vw r J corrvice
U//kill me.uJy. O•r nor aviN in drr:r:rrru, ru:4t runrplrleJ by city ur rm.n.rjj/rfvL
City-or fawn'
I•tniny.\uthorily (c irelJ uda): .--._. . ..__ .
I. IArartl ul Ilnnh !. Iluifding IJell I'llneut 1. l it ,T-ovn Clerk. 1. "lectric.rl 1'110-hlr i. I'himhiny Intprc hit
Utller
l o,lLLLl vcrt... 1'horte r:
CITY of S.t[.Ear, 4tiws.WHUSETTS
dt:[LDLV(; 0Ep.%A-nMNT
I 10 WASHLVCTON 5TxBV, 1'O FLO01!
rEL k973) 145.9595
'UJBEAI SY DUXCI L FAX(973) 740-984
MAY01 Mcmu ST.PtzM
Of"CT04OpPt xtcPRQPLIATY/sULDLYCcowasstONER
Construction Debris Disposal At'fidavit
(required for sll demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 190 CZ R section I
Oebris, and the provisions of MCL a 40, 3 34;
Building Permit A)this work shall be d is issued with the condition that the debris resulting from
1 11, $ I JOA. isposed of in a properly licemed waste disposel facility as defined by,NICE c
The debris will be transported by:
apl
L
(n+ma ut'hauhr)
The debris will be disposed of in :
(r
(n.m�or hc,lilY)
1lJdrrtr orr�cil,iy)
permit rpph.lnt
,sip