14 MAY ST - BUILDING INSPECTIONr
The Commonwealth of Mass7RcnovalcOr
Town of
Board of Budding Regulations anards
\� Massachusens State Budding Code, 787'a edition BudJt p
ttummwkvm
Building Permit Application To Construct, cpai . Demolish aMOM
Tuu-Fu/ t Dspei
( � s$ccyali For Official Use only
J� Budding Permit be . Doe Applied: /�2 )D
Signature:
Buildin Co oner/- iorofBuddmp Dats
SECTION 1: SITE INFORMATION
1.1 Property Address: MIT
1 Numbers
1.2 Assesson Map• Parcel Numb yo
I.to Is this an tic to street!yes no Map Number Parcel Number _
IJ oning luformatloe}7 \ 1.1 _r�Dg�tnlom:
2omng District Prop-ossed Usee�l Lot Area 1'sq�R)) Frontage(R) ---r—
I.S Building Setbacks(ft)
From Yard - Side Yards Rear Yard
Required Provided Required Provided Required F Provided l 1
r
1.6 Water Supply:(M.G.1.c. 40.154) 1.7 Flood Zone Information: t.g Sewags Disposal System: Q
Zons: Outside Flood Zo_ ne? Municipal) On site disposal system O
Public IK Private O Check if srB:
SECTION 2: PROPERTY OWNERSHIP' (� _ �A
2.1 w r'of R 1 R/6� dd�/�n�Joe Spq��v9M St�{�/�1�'M/
Name(-Print) ^teC,ZNb A (CO )irl)%— 1 IV 1
Si attire Telep
litani-
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction O Existing Building O Owner-Occupied BF I Repoirs(s) Cl I Altenti O p
Demolition AFC Accessory Bldg. O Number of Units-e Other O Speei
Sri f sc ' tion Proposed Wo r'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OOtcW Use Only
Item Labor and Materials
1. Building f `'Q tg� d I. Budding Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical f � ooG O Total Project Cost'(Item 6)x multiplier x
J Plumbing f %6 0 d 2. Other Fees: 11 /L
a mechanical (HVAC) f t0 (Ud List: l
S mechanical tFire f X pu Total All Fees: f
Su ression
- p� Check Vo. _Check Amount: Cash Amount:
h T, Project Cost f �V poo O Paid in Full O Outstanding Balance Due
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supenimr ICSL)
License-Number —�O E%pnibon Date
v yoe of L'SL fig ` �_^ \
a-P;tiscrjd S)r • !/`� \M t IS7 List CSL Type lxr lwluwl
A s Q' 7� Description
non
U I Unrestricted(up to)7.000 Cu. Ft
R Restricted IBZ Family Daellmst
Sig aiwe N M Nfasceirv,Only
—w`Z RC Residential Roofin Covenn
W Telephone S Residential Window and Sitting
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 R�{(stared 1{pm��Ins ro eme t CgnIre or HIC \
\ `M +J/�V�erp� 6�cca
Hl��eompany N or HIC Iti N ��s Qt�^° O�p� Registration Number
Admen. QJI
Eaptratton Dole
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL ISC(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 Aflldsvit Attached? Yes.......... *Inc No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, / / , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work a tad y t i ilding permit application.
z2 a
Si o her Date
SECTION 7b:OWNER` OR AUTHORIZED AGENT DECLARATION
as Owner or uthorized�Omyv
ereby declare
that the statements d information o the foregoing application are true and accurate, to knowledge and
behaYL a fJ
Prin v ` to
Signori of nn Authorized Agent Date
(Sisined under the poins and penalties of
NOTES:
1. 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 a&have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR Regulations 110 R6 and 110.RS. respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft) (including garage, finished basemenUartics,decks or porch)
Gross living area ISq. 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 Enc Io.ed ._Open
1 "Tool Project Square Footage'may he.uh.muted for 'Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
.I'.11:' Mlhl ' Nly 'tI
I'C�'.m it ll.\L:�LV)1'N LIT O SA 1]1, M.\".\l i11 a l l�:l't
.I.rl.978.74 9?95 • 1'.\x:978-743-1IdI6
Construction Debris Disposal Affidavit
(required fur all dcnwlition 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 H is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11. S 150A.
The debris will be transported by:
In otlhauler)
The debris will be disposed of in
(name ut acm rty)
.p(address of facility)
�7
signature of permit applicant
date
hhu.�11 doh
CITY OF S.U.E.`Ia ANL-kss.Aoit;SEm
v Bl:BXI6NG DEFARTMIUNT
I_'0 WASHINGTON STREET. 300 FLOOR
TEL (978) 745.9595
FAx(978) 740-9846
KI%l3 ar FY DRISCOLL
MAYOR Tuomu ST.Pmus
DIRECTOR OF Pt:eLIC PROPERTY/lIV ILDLNG CO.%L%DSSIO\ER
WV rkers' Compensation Insurance AlI davit: Builders/Contractors/Electriclans/Plumbers
A t ldcant Infarmatloas PleaPrint
Nalnc tBusin�v OraamrariotialrxLv,duall:�\r`l � U`^ -,r t'L9 V M( cry
Address: VL
City/State/Zio- V )oy(� S \' �� P60neM:
Are you as employer!Check the appropriate box: Type of project(required):
I.El I am a employs with e. ❑ 1 am a general contractor and 1
employees(full and/or part-time).• have hired the sub.cwm uetore 6. ❑Now construction
2.Er 1 am a sole proprietar ,ar partner• listed on the attached sheeL : I 1 7. R Remodeling
ship and have no employe= Theft sub-contrsotots have V. 0 Demolition
working for the in any capacity. worke t'comp.insumoee. 9. Building addition
(No workm'comp, insurance S. ❑ We are a corporation and its
required.] offices have exercised their 10.0 Electrical repairs or additions
7.❑ 1 am a homeowner doing all work tight of est mption per MOL I I.❑Plumbing repairs or additions
myself.(No workers'comp, C. 152,f 10).and we have no 12.0 Roof raps"
insurance requited.] ► employees.LNG workers' 13.0 Other
comps insurance require&)
-Any applicant ilia chocks ban II mutt aim fig use this section below sl owing their waters'mmpate im policy ialunnyleR
'I Lawuwwn who whose this aAhhvit indicates ihey on,doins all wart ae1 than him euatidr t seminars unuuM suhnb a now ambvil indlorip ark
i.wnnryn the cheek this boa mW swathed m 3"ok id.has showing do,nrr e/tha wi►ssetrncre salt that=aloe'comp•polity infaiuuouou.
/nm.mtt entphyer that b providint workers'conateensarbn/nearionce fer ate earpfeyeex r7Naar/s rAe perky end/eA xI&
inlorarYllOn.
Insurance Company Name:
Palicy N or Self-ins. Lie. N: Expiration Date:
Job Sire Address: City/31atrl2:ip:
Attack a copy of the workers'eamponsanen policy declaration pap(showing the policy number and expiration date).
Failure to secure coverage ar required under Section 23A of MGL C 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and s flty
Of up to S250.00 a day ayainsl the violator. De advj*Cd that a COPY of this Astemcnt may,be furwurded to the Oftice of
I nvcangations of ilia MA for insurance coverage venftcatiae.
/Jo hereby avrri under rise pains and Pena/Nos dAperfury Ober'Aff in/ormar/otr prov;dad sibs is true and correct
"" l Dote:
OJffc•ie/we dn/y. Do era write in this area,te be.urnp/ired by rify or town d//ic•;aL
Ciry or fuwn: YcrmiUl.lccnre N �
i
1%suing.whorily (circle une):
1. Ilourd of llvaltb 2. Huilding Department ). City/town Clerk t. Electrical Inspector 5. Plumbing Inspector
6. Other
( ,nlact Person:-- _. Phone e•
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