1 MASSEY WAY - BUILDING INSPECTION (4) -7 -70
The Commonwealth of Massachusetts
° Board of Building Regulations and Stari LE'RVICES CITY OF
Massachusetts State Building CKS 11i SALEM
Revised Mar 207!
Building Permit Application To Construct,Repair,Renovate Qr I�n+so
One-or Two-FamilyDwe `1
This Section For Official Use Only
Building Permit Number: Date Applie .
Building Official(Print Name) - Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
lyiocssii� LY /
1.la 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water pply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage D' osal System:
Public Private❑ Zone: _ Outside Flood e? Municipal On site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recor r
SltotMvvS�L( LIG V-t-5, AA-,*t- U to, Z3
Name(Print) City,State,ZIP
tj �C- QV_C?.7,-3r t(f 4 S.Kc> t s.Aft`
No.and Street/p-4 PPA- I S . Telephone Email Address
SE TION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ AlteratBon(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
Lf S/h( {yr '4 1,
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ PS-pO(J 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical g �j ❑Standard City/Town Application Fee
/ 006 ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ D,000 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 421 060 ❑Paid in Full ❑Outstanding Balance Due:
Ma - lIL-%
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /
t
/ /� / r 6-5- o7gVsy -3-Z is
J6 4- ,SK6Ih wS h-1 License Number Expiration Date
Name of CSL Holder `
f'V� �3 Vim S �*-� �/� List CSL Type(see below)__C
No.and Street AAA—— Type Description
04 hU.IrS- p AA Q l S Z U Unrestricted(Buildings u to 35,000 cu.ft.
C:ty/rown,State,ZIP R*WMt,
1&2 Famil DwellinMRCoverinWSnd SidinSCi 0 � �Z_3 / r/ SF Burning Applianceso T 1Tele hone Email address Dn
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
Ci /Town State,ZIP Telephone
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 Issuan of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIE§FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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 ue d accurate to the best of my knowledge and understanding.
Print :er's r Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. n 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 HIC Program can be found at
ANm1w.mass&ov/oca Information on the Construction Supervisor License can be found at www.mass.aov/de
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"maybe substituted for"Total Project Cost"
i
CITY OF SALEM, MASSACHUSETTS
�t ! BUILDING DEPARTMENT
120 WASHINGTON STREET 3RD FLOOR
TEL. (978)745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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:
IVeU/ -E/l (C,Gi � J�I�
(name of hauler)
The debris will be disposed of in:
(name of facility)
?1464 -
(address of facility)
U �
)*igatur:eof appliant
i i
Me
CCI'Y OF Sm Em, INL-\SSACHUSETTS
!� 4 [SL'ImiNG DEPARTMENT
130 WASHLIIGTON STREET, 3r1 FLOOR
� baf� TEL (978) 735-9595
Rax(978) 7.10-98.16
KI\tBERLF_Y DRISCOLL
"A.kYOR THoiwST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/aumDIVGCO\LMBSS(ONER -
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbera
Applicant Informatinn Please Print Le iblY
SKdn.w I�
,V;Illlc lnusinesmOrganiealion,'Individu:d l� �j
A ddr"s: f -U• l� T 2.��
City/State/Zip: 0AAt,r4t AIA- Phone K: 50 347/r
:1 re you un employer:!Check the appropriate box: 'rype of roject(required):
I.❑ I a employer with ;• ❑ I am s general contractor I 6• ew eotswetion
employees(full and/or part-time).' have hired the subcontractors
2 lam a sole proprietor or partner- listed on the attached shoe,. t 7. Remodeling
ship and have no employees These sub-contractors have 8. C] Demolition
working lin me in any capacity. workers'comp. insurance. )• Building addition
INo workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repuire or additions
myself.(No workers' Gump. c. 152, §1(4),and we have no 12.❑ Roof«pairs
insurance required.) t employees.[No workers' I3.❑ Other
camp. insurance required.)
•Any applicant duo check,bux a 1 must also fill out the Sciron bctow showing(heir workers'mmpenaarion policy i"Aurnattun.
'1 lomanwwnx wha suhmit this amrinvir indicating shay am doing all work and then hint outside tontnetors most.mhmil a new allldavil indiswins such.
:('mnncwn thus chink This bux most anachad an addidurutl,hral showing ate mune of rhe sub•ecruncton and their workon'camp.Pulley information.
I ant an employer that Is providing workers'compeusadon insurance for my employees. llelow Is rho policy and fob site
information.
insurance Company
Policy it or Self-ins. Lie.N: Expiration Data:
tub Site Address: City/state/zip:
Attach a copy of the workers'compensating policy declaration page(slowing the policy number and explrmloo date).
f ailuru to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to SI,300.00 undlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up o$2i0.00 a day against[lie violator. Be advised that a copy of this statement may be forwarded to the 011ice of
Investigations of the OIA for insurance coverage verification. -
/do hereby rend ord.-tilt put'its ail pof perjury that the infurarullmr provided ubuuvee its true and correct.
Si• n I rc' v/f' Off`e rahl r Uatc: ..`/ ' �
P I •,1:
Of/iciul a (,nly. Du not rvrire in this area, to be curuplered by city or town afflt'ial
Cirvor'fown: _ Permit/l.lecnsc4
Issuing Aurhurity (circle one): -- -_ -- - --- i
1. Board of Ilealth 2. Buildlnq I)ep:lrtocnt I.Citylfnsvo Clerk 1. Electrical httpcctur 5. Pluntbiug Inspeoor
6. Other
(lints❑ Verson: Phone 3:
CITY OF SALEM
ROUTING SLIP
New Construction > LfiT �Z
Certificate of Occupancy
LOCATION FYI ¢SS �I/Yf( DATE fl s
ASSESSORS DATE
93 Washington St.
CITY CLERK l ADATE
93 Washington St. Y
PUBLIC SERVICES DATE
120 Washington St. I �/
WATER DATE
120 Washington St.
CROSS CONNECTION " V DATE l�
5 Jefferson Ave
PLANNING DATE (�
120 Washington SL
/CONSERVATION
120 Washington St.
ELECTRICAL DATE
48 Lafayette S .
FIRE PREVENTION C'. ^"--DATE
29 Fort Avenue
HEALTH �— DAT
120 Washington St.
i
BUILDING INSPECTO T jR
120 Washington St.