24 MEMORIAL DR - BUILDING INSPECTION The Commonwealth of Massachusetts
CITY OF
1 xl Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR
�. ..
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Two-Fumi(v Duelling
This Section For Official Use Only
Building Permit Number: 1,13ate Applied: b
Building OtTicial(Print Name) Signature
SECTION I: SITE INFORMATION/
I.I Property Address: 1.2 Assessors Map ': Pya tubers
2'� N lC—'IA OtL-ZA-t O tZ ,
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 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposals)s stem ❑
Public❑ Private❑ Check ifyes❑ P P )'
ECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record: AV p_, r
rt.t-JJ�c-�yvE Pih�l�� t �JfYr--cv"`. IAA
Name(Print) City,State,ZIP
1 tt�� "fV6,zlP 1-&I 02 a -oSftf Cl�(tC3�Fc�Pw/Mri�1�
No.1 Street 'telephone Email Addres
SECTION 3: DESCRIPTION OF PROPOSED WORK(check aJJ that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) arl Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descriptitq_of P�ropossedd_Work': `� 6 �� Z.� 7-
/�YLWt moo" US ( w�`flk S4kE(J 2�01= t{� ygtu.�
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Estimated
and Materials)
I. Building S 1. Building Permit Fee: S Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4-Mechanical (11VAC) S List:
i. ;mechanical (Fire S Total All Fees: S
Suppression)
A� Check No. Check Amount: ----Cash Amount:---_-
6. Total Projcct Cost: S I 11 Paid in Full ❑Outstanding Balance Due:
r t
SF.C"IION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
Hr1r� 3, C SI _ t
dE 'i2/J� License Number lispi utit) Date t
N;unc
_— List C'SL I')PC(see bcluw)_1/l_ _
No. and Street 'rype Description
s� �L U Unrestricted(Buildings ti to 35,000 Co. It.)
Cigdfuwn..titnte.ZIP R Restricted I ?Pumil D......
M Masonr
RC Roofin,Coverin
WS Will ow and Sidin
SF Solid Fuel Burning Appliances
(' I Insulation
"rcic hone l mail address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
_ Ni1 r f,a Wit_ `S !3"7-
I IIC C ompany Name or I IIC'Iteb�istrm Name I IIC Registration Number I?spiratir t Dale
tA)tflcf l V(f lj No.No.�id t
(6- CX4 P6:5214L VO Lmail address
Crt /Town, State,ZIP Telc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 er '
Signed Affidavit Attached? Yes .......... No...........
SECT ION 7a:OWNER AUTHORIZATION TOIIECOMPLETEDWHEN
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 authorized by this building permit application.
Print Owner's Name(E:kctrum signature) l0 i201/
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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print 0%%ner s or Authorized Agents Name(Electronic Signature) Dale
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 Home Improvement Contractor(HIC) Program),will not have access to the arbitration
program or guaranty fund under SI.G.L.c. 142A.Other important information on the HIC Program can be limed at
wwt%.i11;1.s.gov tg:) Information on the Construction Supervisor License can be found at pww.mass.g2. tn'Jp;
When substantial work is planned,provide the intormation below:
Total fluor area(sq. ft.) _(including garage, finished basement'altics,decks or porch)
Gross living area fl.l Habitable room count
Number of fireplacceses Number of bedrooms
Number of bathrooms NUmberoffialfbaths
1)pe of heating system Number of deck ---es ------
TNpco(coolinL ----------
-------.----- — s porch _
-+�slent ___
_ Enclosed O cn
t "Total Project Square Footage"stay be substituted for-Toed Project Cost"
r ;
C'TY OF S,V-&`I, AkSSACHL'SETI'S
BUMDLVG DEP.IRTIEVT
120 W.UNLNGTON STIMM, J a FLOOR
ILL. (978) 745-9595
KJMSERI RY ORLSCOLL F"(978) 740-9846
MAYOR I�to.+W ST.PtEnRs
DIRECTOR Op p( BEIC PItOPEgTY/9E:MDCqG CONOUSSION Ett
Construction Debris Disposal Aff7davit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I
Debris, and the provisions of MGL a 40, S 54;
Building Permit a is issued with the condition that the debris resulting from
11 work shall be disposed of in
1
I 1, S 1 SOA. a properly licemed waste disposal facility as defined by MGL c
The debris will be transported by:
(m+me act The
)—i—
The debris will be disposed of in
y� 1 me or
(�ddreaf orF�clli�y)
tf !t�ppl!cant
,:ate
,
CITY OF SALEM
`;`► _1/ PUBLIC PROPRERTY
1' DEPARTMENT
of 1 Y',„IN"If
\1,11r/
- I!: \VAH11Ab 1U•\jI:ICYI' • j.111'N, .M.111.11,111 ,rI „yl'i7,^,
1►'urkcn' Cumpensatton lnsurunca lillollej \Iflduteit: Uullders/Contrncturs/Ele trlclynyplumbere
nt In nnnuflo
PI ' In Le N
V11lnu I nuullr,Yf)rayf,iarilrrvinJ,r111uu11:^'�'F�C�}-� S (t/�J'1lSC,/JeU�
�1111res.v: O6 W ff�TjC<,3-,j ST
Ciry,Srarc,7ip c�cEsf�w
e14'Ce►'hune rl: IT"
<eAu o '3
I .l ry nu an.vnployd►:'Ch-vN th@ appntyrlure box:
1.❑ I:fill v cmpluyvr with I. Q 1 :feel a`unuml contraelor and I I'ype"rfirvlJvet(regtflred):
nylu)euY(11411 und/ur pwmitite).• fluted hired the+uh•cunnravu s fi' Q
I•feel told prnprivr4w fir punner• listed on the anached.,huur t "'It"Irucliun
Alip:lml have no vrn lu euscontcro 7• Resnot olind
!larking fin and m y pacily. tvorkorli nprsnyura ce
rs have tl• ❑f)emolirion
t Kn wuncurs'cutup, iltsuraflce J. Q we are a cn'poralion and its 9, ❑0ulldfnd addition
nquirud.) onTccrs have mmi.vud their Q Von a hofneutvner doing afl work righr of"Ol" lien 10.Q Elect rfcal«pain ar additions,
mywlr.1N,o worker@'cum P fifer lv%t n I I.Q plumbing repairs or additinne
p• c. 1 SI, �}I(J),and 1vr h11vd nn inrurunco required.) r cmpluyvva, tA•o tvorkdn' II.Q Ruol'npuirs
ctnnfitin..urancarcquimd.J I)Q01hor
''1">.,grLaaf�nf.Y chcYa Yea el muM 11w Jill"the Vol.,brhlr
'11,1„y,lvri,n val„1a1,ni1'his of vie indl. 4.00, .Auwlnx lAey wwYW rue,-nfunlw,
T..e,rknn 1h lyr m)droll ill work L,d 1Mw him
1"'flsr ma,rsrdiup
sl,M'r@ this Yea mtt alwhMd•1a xtd,liulyl.Pun Jlurine ItM,unN o/fti sue.ca,Yr r� Must aulvnY•nw ilnllsvN 1
iC1aYa and 1YeY wwe,Ys' nJkadnq„S
/mY fen vefp/Dyer[hut Lr prvvlrllgr rverJteri'rurnprfanlloe Lr.mnl/rre/u-/ay enu, �'s.aKy lnlbr„lsafsa
irf`Y/II14flII/L r•• J em Br/uIV/r fAe pu/l•y a/rJ/eb.,i4
Insurance Ct1mpany.V,fent
Policy-ur Svlr•ins. Lic,r{ — "
—�—.'lob 5ity Expiration Date:��
�1dJrc..-: �
lttach 1s copy ferule workers'cumpvnranun polls) devlarullun pug@ (show)M1 the Policynumb--and esplrarlu■4de@).
1'a1 "to111) to,ccure culeruue as required wrier Secliun:Jr\ vl'blGl c. 1 JI eau lead to ote IJnposition ot'eriminal yenolliee of a
rinv up ro it )nO.Iln unJlur w1t•year impri!fanmcnt, at well.1a cited nalllcx in Zhu Lunn ura STOP WUR
,)(till rn i?id M•,Jay lgainll file fr i,tl.lrar. Ile aJvf.w•d tAuf a cu In,,.,nyam m vl':Iw DIA ;or 1,1,or.ut PY urfhlh ,Ivlcmwll may bu IunruJvJ uthe URID��fnJ a fine
cra;u ,culi,anun.
/,lu h.•rrAy t.rri/1.11n./ate I r inr u J
inuh/vr u/prr/nry rhYJ Nir in/LrA1Y/IWr pN Yldtll bore i 7r s rord rarrvra
rl•1 —"Alcw lot
11//li iul rnr uu/y. /)a 0141 "ire in rhir arru, !d A,rY„rplrl.r ey,;ry dr mwq,y�h'iuL
(!Ivor 1'u1rn:
1„din l 1 —ir I',rmlf/I.let ties1
y . u h11rUy (circlo nnvl:
I Iti1.1rJ •,(Ifruhh 1. Ih1dltin� Iralf.lrnncnl 1. I:ill.'Iu�,n c.1l I
r
, J.Clerk J C'Icc7in+ laclur ..
G. I)II a•♦ I Plumbing In,yecrar
•I 1 •W ,al I'1 nuu:
—' __ I'hu11e 1•
Information and Instructions
�I d»adw.etu General Laws:hapter lit tegwres ulleYeltl°`iron m the farvlc tat anothereni let uty cuntnct f hire.
s.
I'unuAnl w tilts ,tatule. an r,eplurre is JctineJ as every
orauun tar other legal cnnty,or arty Iwo or more
;,pros Jr nnphcJ, dill or svnuen." ur the
An .mpluyar t+JctincJ as"m individual. Purtnenhip,assuelauoa.:oN ces. Hawcvcr the
rise, arid,cludingthetagalrapnna,°temsluytnl{cmpla)employer,
A the plu) u,d engaged n a joint cntorp ,auoo or other legal ' y, P ant of the
,e:mver or uustea of.at', IVIdualI pstmenhtp, asaoed e d Wilt ion or repua work an wcbtt+�elling ers"
,)wrier of a Dwelling house having not more than ilit oils to Jo nai�enan e. J who resides n"n sba ulk'c 1 cu house
appurtenant thereto shall not because of such employ
.Iwelhny deem
huuie of another who emp y f
or ,tn the vrountla ar building app a ese shad withhold the Issuance or
�IGL cfor may
hapter 152, 425C(6) also states that"Ivory'r�te or Ioeal Ileislag R y
lb
druct wllb the Insurance courage required,
resws1 of a license of penult to uporafe s he"", ac or to eoulruet bulldings le tha Comm d<I subdivisions +hall
Applicant wlho has not produced aceap
table erldeau of t umP of iq p
1dJiti,)naily, %IGL clapter l S., S�SC(11>rataf"Neither the until
3ccoIIIJbI h not m
vuntraet for the parforotanca of public work until uecptable evidence of cuntpliartce with the insurance
inter into any ' st,entcd to the cmnracting auhority."
requlramunls of this 01010111 aw been p'
>,ppllcithte checking the boxes that uPPIY to year mommmmoomm situation att4 if
nation ),Adige, and phone nunber(s)along with their t:or►iflcutots)of
Plane fill out the wtsrkors' compensation ).Adigit completely,by PaMairships(LLP)with no employttts other thin the
neectsarY supply sub•contractor(s)
sw anca, Limuad Liability have
Casnpsnics(LLC)or Limited Liabilityinsurance. if an LLC
f I
inetnban,)r pangpurtn L are nut required to carry warkars' contpdn""O y bmitted to the Dapurannem of industrialLLP
,mployeee,a policy is requied. as advised that this affidavit may aRmcnt of
Alto be sun to slgM and date the allldevil, Tlta otlidavil shoo
ld
nnit or licdnsa is being requasteJ. no$the to obtain d workers'
d reitunte r'or contlrty Of town thutr hi�pplicuion for e a pa the low tar if you An requited
ha rcatmeJ a the airy ou haw any gttestiaru regarding
I nJustril
ial Acuidanu. Should y ent it the number lisud below. SdfineunJ companies should center the
compensation policy, Please call the Deptutm
sclFinsorange license number on the a lima.
ro riate
Clq or Towe OMeIsU g the s licant-
rinted Ic Ibly. The Department Aces Provided u space at the bullom
g
please he sure that the aftlduvit is cumplen ;tnJ P Itcant
Of the atidavll for you o fill out in tho event the Chic Of ill be ii atiait has to contact you roger rig P
ev, need only submit une atlidivit indicating c`neui
pl:a>e be sure to till in iha pOnnit/liunta nwnl'er which will be used r.Ca l,shouldrence twrita''dl lucauu spin n aPP t' Y
dots must>utittlit multiple pennitllicatssa aPP"cutios A any given y be rovidad o the
of dis affidavit that has been Joboffl Swily stamped tar matkod by the city or town nay P
Policy information lit'necessary) and unbar"lob Siu Address"Permits tar lice nses. A now allldavit musl be tilled nut each
town)., A COPY
tUff
applicant as proof that a valid citizen i is on obtaining
for Marc
year.twuhert A hu x owner
Cif burn leaves Cie.) s�d Pecs nos VOTirequited ocomplete to any this utfidav es or mn'erets van
i u ti ,)uf:O,) eralion and+huuld you haw any quuuons,
I he s)t li:e ,t lnve,tigatiuns would Itee w thank you in advance 1'ut y P
pka,e do not hesitatd to give us a call.
nc� L).p•trunent'+ Atjra+e, tcicphuna and fax ommonwealth of Mi"ttehusetts
The Comm
04pu went of Industrial Accidents
()face of Isvesdgildons
600 Washington Street
9o3ton, MA 02111
ra. a 617.727-00 7
ext 02 07749"•MASSAFE
•arww.mass.1jov/dig
93 pp / d lfaeau%,
r
Office of Consumer Affairs&B mess Regulatim f
HOME IMPROVEMENT CONTRACTOR Type. f'
Registration. ,s138472 {
Expiration 4?l2013 DBA
t '
MI ELJ MCKEARNE*CARP INRYBCONT,RACT g
Y
MICHAEL MCKEARNEYN
1064 R WASHINGTON
Y a ;el
GLOUCESTER,MA 01930 :` Undersecretary;
.`i
�'.. itssachusetts- Dcparttneot of Puhlic SufeI%
Boar' of Ruildini, Regulations and Standards
Construction.Supervisor License
License: CS 79511
MICHAELJ MCKEARNEY
1064 R WASHINGTON ST r
GLOUCESTER, MA 01930
I�
a—
��" Expiration: 5/1/2013 ;
('nnwisvioner Tr#: 16021