2 MASSEY WAY - BUILDING INSPECTION (4) -V- Civ, l 5 L[ (F
T(3- ICI - I31 S
170
The Commonwealth of Massachusetts
Board of Building Regulations and Standards REC IVER
Massachusetts State Building Code,780 CMR INSPECTIONAL U�&S
W
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Deis I P I. 02
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date App' d:
Building Official(Print Name) Signature D to
SECTION 1:SITE INFORMATION
L1 Property Address: 1.2 Assessors Map&Parcel Numbers
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 fi) Frontage(fi)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water upply:(M.G.L c.40,§54) 1.7 Flood Zone Information* 1.8 Sewage D' osal System:
Public Private❑ Zone: Outside Flood Zpfie?
Check if yes Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
SK-t m tv sKt DeUt(op n.«T c LC- 0�.,t.��s t hear
Name(Print) City,State,ZIP
52)3-9(�1-39(f JSK6rh "ACI ' G - cam
No.and Street Z D9- 13v4 S ,&7- e_ Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work 2:
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ OD0 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ /6 oe0 ❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ /0; 000 2, Other Fees: $
4.Mechanical (HVAC) $ /S7/060 List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
�d Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ` �V�l ❑Paid in Full ❑Outstanding Balance Due:
Mkl 1.g7o q r t'0 261, GY�G.,To a3 tyr .
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) GS — O�q�1ST 3 —Z6
(li
�( License Number Expiration Date
Name of CSL Holder G 5
/o-_? 3 List CSL Type(see below)
���. ,e.(
No.a�p,�$Jtreet Type Description
(/Qhv,fyS ftAA- Unrestricted Buildings u to 35, M cu.ft.)
City/Town,State,ZIP R Restricted 1&2 FamilyDwelling
M Maso
RC Roofm Coverin
WS Window and Sidi
S-ok'1C Z .3 y.lt I Solid Fuel Bum ng Appliances
Insulation
lelefohone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expvation Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Tele hone
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 lissuamn5ce of the building permit.
Signed Affidavit Attached? Yes .......... 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:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contaiAithis lication is true d a orate to the best of my knowledge and understanding.
P,Print 0orized Agent's Name(Electronic Signature) _ Date
NOTES:
1. An wner 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
www.mass.eov/oca Information on the Construction Supervisor License can be found at ww•w.niass.gov/dps
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 cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
QTY OF SALEM, MASSAC HUSEM
SK BUILDING DEPARTMENT
s { ! 120 WASHNGTON STREET,3m FLOOR
TEL. (978) 745-9595
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR TrIOMAS 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:
�j er, E, f f 1, C So r(G\ wGJ
(name of hauler)
The debris will be disposed of in:
�4f 2 I�- W4a)
(name of facility)
(address o facility)
ig ature of a plicant
Date
CITY OF SALEM, INL1SS.ICHUSETTS
i ct
BULDING DEP.1kRT1,IE.\T
3 q '�reSl 120 WASHIINGTON STREET, 3'a FLOOR
TEL (978) 745-9595
F.L.r(978) 740-•9846
KI\IBERLHY DRISCOLL
:AAYOR THon41S ST.FIERRB
DIRECTOR OF PUBLIC PROPERTY/Bui:LDt\G co%NISSIONER
Workers' Cofnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbere
A)tlilicant Information Please Print Le ihly
Name tnusi1c1s0(gao ivaliam'I ndi vidual)f SKOb.,L t:$Kl r £7CVm 16 rLe.
Address: P U• �°� 7!X
City/State/Zip: 9411"l-gc MA— PhoneY: Z - 3y/�
Are you on employer.'Check the appropriate box: 'Type o roj7oradditions
I.❑ I m a employer with 4. ❑ I am a general contractor and I 6. U/N/tv w construction
•ntployces(full and/or part-time).* have hired the sub-contractors li
2 I ans a sole proprietor ur partner• listed on the attached sheet. t �• emod
.hip and have no employees These sub-contractors have S. (]Demol
working for me in any capacity, workers'camp.insurance. 9. Buildin
)No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electricpns
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.(No workers'Gump. C. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.) t employees. (No workers' 13.❑Other
comp. insurance required.)
•any upplicmo nut checks box 21 must also fill out the acctiun below showing their workrri<ompartudun pulley inlinmollun.
'I IemeewAT who suhmit this Whinvit indicating they are doing all work and then hire outside moms,,.most Uhnih a new amdavit indicting such.
f\nnmcron shut check this box mmt anached an addoiurtul.hcet shuwing tice natne of the mb.ornnetun and their woken'comp.pulley information.
I ant an enrptuyer that is providing workers'cunrpeusatlon inauruncejar my runployees. Ileluw 1s tha policy and job silo
fafirnnution.
Insurance Company Name: ---_-.----
Polity ii or Self-its. Lie,th Expiration Date:
Job Site Address: City/State/zip;
Attach a copy of the workers'compensatlOa Policy declarallon page(showing the policy number and explratlon date).
Failure to secure coverage as required under Section 2JA of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,300.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and o line
of up to S2i0.00 a day against the violator. Ile advised that a copy Of this statement may be funvardcd to the 011ice of
Invrstigutiuns ul'Ihe MA for insurance coverage vcrilicutiun.
1 do hereby cerdfjy nde doe pafys ms nuif/rs rjury hot the it funuwian proyid,,d ubbuuve;.v-true aaa d ccororr�ect.
Si••n I re' /w( _I J - !/ Uatu: _O
PF t •,i: �
Oj1h iul use urdy. Do not write in this area,to be cuprpieted by city ur town njjiciuf.
City or'fusvn: _ --_ PermidUcense N
Issuing Authority(circle one): -�- - --- ---
1. Huard of Ilealth 2. I)uilJint; Dcparlun•nt I.Cilylfnwu Clerk J. B:Ieetrial luspcefur 5. Plumbing luspcentr
6. Other
Contact l'ersu n: __ Phone;t:
CITY OF SALEM
ROUTING SLIP
New Construction /'/ ( ,,T
Certificate of Occupancy
LOCATION I�irsS�`j WAJ( DATE
ASSESSORS DATE a4
93 Washington St.
CITY CLERK 4 DATE 8 IS-) Z01y
93 Washington St.
PUBLIC SERVICES DATE Mdul
120 Washington St. dI
WATER DATE
120 Washington St.
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNINGD� DATE
120 Washington St.
L/CONSERVATIO TE a I
120 Washington St.
ELECTRICAL ATE
48 Lafayette
FIRE PREVENTION DATE
29 Fort Avenue
HEALTH DAT 8 I f 1
120 Washington Sty
BUILDING INSPECTO ATE
120 Washington St.