2 MASSEY WAY - BUILDING INSPECTION (3) Tt3 - lu - foil
i1 The Commonwealth of Massachusetts ���VED
°t Board of Building Regulations and Standards RE $ RV� FAY OF
4 Massachusetts State Building Code, 780 CMNSPECfIONAI -SALEM
Revised Afar 2011
Building Permit Application To Construct, Repair, Renovate O D lis a ��: 23
One-or Ttvo-Family Dwelling iji
This Section For Official Use Only
Building Permit Number: Date Ap iew. I
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORNIATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
� 1JA srp+� c�AY - �7 Do ?r
I.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 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
X% _3 o• 2s`
1.6 Water Supply:(M.G.L,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public LAB Private❑ Zone: _ Outside Flood Zone?
Check if ycs❑ Municipal®fin site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
P.Qsta y,4 IJnIR LLD ✓�LD�c's�J JaG �- ynJ�� Zr r. o / y c�z
Name(Print) City,State,ZIP
,71
No. and Street Telephone P.mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction F1Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed work`: L'an/S7GZ of CTre� e+ F F DJA1.Ds i se+J v dL
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Ilem Estimated Costs: Official Use Only
Labor and Materials
1. Building $ /g o.d 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard Cityffown Application Fee
2. Electrical $ []Total Project Cost'(Vern 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (1-IVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
G. 'fotal Project Cost $ /fjsoa ❑ Paid in Full ❑Outstanding Balance Due:
CA`t--t_G:V L4 P- u (:)v lq , D tD
fWTUF LPAK� \ N S I R> -FtL3
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
r"iQQ/l7 ��o�lUuf:r�:tt License Number Expiration Date
Name of CSL Holder
"' List CSL Type(see below)
g Air > tn�
No.and Street
Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
asttHA ' rAz1 y/AdS R Restricted 1&2 FamilyDwelling
City/I'own,State,ZI M Masonry
RC Roofing Covering
WS Window and Siding
6 r 7 _ SF Solid Fuel Burning Appliances
2 I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or IiIC Registrant Name
No.and Street Email address
City/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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... 93'� No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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 true and accurate to the best of my knowledge and understanding.
9 a f
I rint Owner's or Authorized Agent's Name(Electronic Signature) Dat
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 Horne 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
www.ntass.eov/oca Information on the Construction Supervisor License can be found at www.nutss.,_,ov/dos
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 decks/porches_
Type of coolingsystem Enclosed Open _
4. "Total Project Square Footage" may be substituted Ior"Total Project Cost"
CIL i o Jitr . 'l �� 1%L-uS CH Us E- lJ
,A Bl.'tLDLNGDEPAR-MLENT
�hT. 120 W-UHLNGTON ST R
ZEET, 310 FLOO
Eti,.,, T�L (978) 745-9595
KIMBERL-EY DUSCOLL FAX(978) 740.9944
NL3 Yo;a 'Maws ST.FtEqA,
DIRECTOR OF PUOLIC PROPERTY/OL:LMLNC,CO\L\(I55ta,VER
constructiun Debris Disposal At'tTdavit
(required for all demolition and renovation work)
In accordance with the sixdl edition of the State Building Code, 730 QjR secton l t 1.5
i
Debris, -and the provisions of AdGL e 40, S 54;
Building Permit p is issued with the condition that the debris resulting frorn
this work shall be disposed of-in a properly licensed waste disposal facility as deBncd by v19CL e
l 11, S 150A.
The dchris %vill be transported by:
y
y �ffa-<22L X r.ogm—
(name uf'Itaulcr)
The dchris will be disposed ot'in
(name of 1:11ity)
(afdles.s of raglny)
ih1lJfUfd U(�CI RtI(.1)lvtll',111( --
-- 6
CITY OF SM , %E-1SS;\C
EM ` HLSETTS
� •,� i . �: l7CILOLNG DEP.IRTSLGVT
120 \U.I�HLVGTOV ST iEgT, 1°FLOOR
TEL (973) 745-9595
KlmoERUY DRISCOLL FA_X(973) 7-k)-904,S
L CAYO;t
I1-tOJ GA3 ST.PicgRg
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONNISSIO�NER
Construction Debris Disposal Arridavit
(required for all demolition mid renovation work)
In accordance with the sixth edition of the State Building Code, 730 QjR
Dcbris, mid the provisions of tMGL c 40, S 54; section l l t.5
Building permit N 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 resulting
bJCL c
l 11, S I SOA.
The debris will be transported by:
.q oe6..-
(11"mc ufhaulcr)
The debris will be disposed at-in
(ume of tacility)
(-J�ross of raeility)
si gn1mrc u['permit dpp(ieant'..._
1 / 3 7 -�$ 7
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy ` J
LOCATION 16a.Ijv DATE
ASSESSORS DATE G ��
93 Washingt h St.
CITY CLERK DATE
93 Washington St.
PUBLIC SERVICES DATE
120 Washington St.
WATER DATE
120 Washington St.
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNING DATE
120 Washington St.
CONSERVATION DATE
120 Washington St.
ELECTRICAL DATE
48 Lafayette St.
FIRE PREVENTION DATE
29 Fort Avenue
HEALTH DATE
120 Washington St.
j BUILDING INSPECTOR DATE
III 120 Washington St.
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION o2 DATE
/ASSESSORS DATE
93 Washington St.
CITY CLERK DATE
93 Washington St.
PUBLIC SERVICES DATE
120 Washington St.
WATER DATE
120 Washington St.
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNING DATE
120 Washington St.
CONSERVATION DATE
120 Washington St.
ELECTRICAL DATE
48 Lafayette St.
FIRE PREVENTION DATE
29 Fort Avenue
HEALTH DATE
120 Washington St.
xBUILDING INSPECTOR DATE
120 Washington St.