8 MOULTON AVE - BUILDING INSPECTION r The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY SALEM
Massachusetts Revised Mar State Building Code, 780 CNIR Revised
2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Divelling
This Section For Official Use O y
Building Permit Number: Date pplied;
Building Official(Print Nime) . Signature Date%
SECTION L SITE INFORMATION
[Zoning
1 Property Address: 1.2 Assessors Map& Parcel Numbers
T /K 1oU o dc-
I a Is this an accepted street?yes_ no Nlap Number Parcel Number
3 Zoning Information: 1.4 Property Dimensions:
District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building SetbacIts (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 isposal System:
Public Private❑ Zone: _ Outside Flood Zone? Municipal O
Check if yes❑ n site disposal system ❑
SECTION1:, PROPERTY'OWNERSHIPF
2.1�9wnert of Record:
Ifea4y�,yfraes��ey f'c%�'•\ m. G/?26
Name— (P��,/ — City,State,ZIP
R /1 Ld U/2�/L ,ur. 977
No and Street ' Telephone Email Address
SECTION 3: DESCRIPTION OF. PROPOSED WORKV(check all that apply)New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s)X Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brie Descr'ption of Proposed Work: A w 3'de
Lj
"- n J
W r S
SECTION 4: ESTIMA ED CONSTRUCT N CO S-
Estimated Costs:
12. Electrical
Offieial Use Only..,
Labor and iVlatcrials
ilding S 1 Building Permit Fee-S Indicate how fee is determined:
S ❑ Standard.City/townApplication Fee
❑Total Project Cost',(Item 6)x multiplier x
3. Plumbing o- Other Fees:'S
4. Mechanical (HVAC) S List
i. Mechanical (Eire $
Sri t ressiun) Total:\Il Fees:S
Check No. Check r\ntotmt: Cash :\mnt.ou
I'Mal Project Cost: S S3Uv --
❑ Paid in Full— _ ❑ Outstanding Balance Duo:--
/ _ -
ion f- g-4 ScAp,ol 9,
f
1
SEC'rION 5: CONsrRUCrION SERVICES
5.1 Construction Supervviisor License(CSL) //- 2 _
License Numd•r Expiration Date
Name ot'CSL 1[older /^ List CSL Type(see below)
- ar- C J. QUeCdQn Type Description
No. and SlrbA
7— '& U Unrestricted(Buildings um y u el ing cu. tt.
C 00 R Restricted 15t2 Famil Dwelling
City/Town, State, Z[P MuDemolition
WindR000w
Covering
�JVI @ Ql f 7 d and Sel Burning Appliances
• 77�fo2� c Cn1'ele hone Email addres ion5.2 Registered HomeeImprovement Contractor(111C) �
�- o✓'f Vlue�tA®✓1 ll[C Registration Number E.epirationDate
I IIC Compa Nmne or I IC Rc istrant Name
7y l� Sc (c S rD Od cita.4C� Yglca.cdill.
No. and Streit Enmil adily ss
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 .......... ❑ No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO DE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
[, as Owner of the subject property, hereby authorize GPo! Ktt.PC�'I�t
to act on my behalf, in all matters relative to work authorized b this building permit application.
�c Crew( _ Y—z.3-13
Print Ot er's Name(Electronic Signature) Date
SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION
rentering name below, [ hereby attest under the pains and penalties of perjury that all of the information
is application is true and accurate to the best of my knowledge and understanding.
Date
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 M.G.L. c. 112A. Other important information on the IIIC Program can be found at
tsww.massAIuvbca Information on the Construction Supervisor License can be found at tvtvw.otass.yo�raps
2. When substantial work is planned,provide the information below:
Total floor area(sq. (tJ _ _(inCluding garage, finished basement/attics, decks or porch)
Gross living a ea(Sq. ft.) _ rlabitable room Count
Nnmberoftireplaces_--- Number ofbcdrooms ___-----__--
Number of bathrooms Nun(bcr of halbbaths
---------- -
fvpo of heating system
Enclosed-- - _-- . -_Open _
} fnlal Plojor.t tiyuaro Puottge' utny be ;ub;nnaed ror,l'otal I'rojed Co;t
I
SVr CITY OF SA .EM, AASSACHUSET s
t BLILDLYG DEPAR-MENT
1201U.13NLYGTON STREET, V FLOOR,
` TEL (978) 745-9595
;<IJtOERLEY DRISCOLL F•loc(978) 7•10-9346
,%,L-%YOIt T110mu sT.PIERRB
DIRECTOR OF PLBLIC PROPERTY/BL'MDLNG CO3LMISSION ER
Construction Debris Disposal Aflldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of bIGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of n properly licensed waste disposal facility as defined by NIGL c
111, S I50A.
The debris will be transported by:
( � (name of h¢ulcr)
r 4,
The it bris will be disposed of in :
� (n¢ma of facility)
Tidies,Or facility)
Vaturn ut permit applicant t/
y�-zle-/3
1
Sohn �CLG��'l_
�1-
�9�
,bav�d Zeller insoraoc�-(o.
Wo(ju-� ew-gyp Pol i 6 s 4� a P� - y(o s P 1 - - ► I
Exp. S/id ► y
�, ab; I •+� vvSo $y 5g0 �x� ►0/�9�►3
CITY OF SALEM 1'vL1SSACHUSETTS
BLAMING DEP. MI.E`iT
120 WASHINGTON STREET, 3iD FLOOR
TEL (978) 145-9595
F.kx(978) 7-10-9844
KIJfBERLEY DR1SCO1L THo,%usST.PTL%U
MAYOR
DIRECTO R OF PUBLIC PROPERTY/0t:RDNC CO\MSSION ER
Workers' Compensation insurance Affidavit: Builders/Contracture/Electr)cianVPlumbers
Applleant information /� 1
6 Please Print Legibly
Name(Rusini,s7 orynizatiorvinr`diividual): c,,,4 r0 �P 71 4 sr-4-
Address: 0 � V e Asa/ J)te
CitylStatcJzip:cS16m ,iGfe. 0,070 Phonate: 97,r- 27Z-.920J6
Are you an employer?Check the appropriate bast Type of project(required):
1.❑ I am a employer with 4.XI am a general contractor and 1 6. I3 Now construction
einplayees(fW I and/or part-time).• have hired the subcontractors
2.❑ I am a sole proprietor at,
partner- listed on the attached.shcet 1 7. ❑Remodeling
.ship and have no employees These subcontractars have V. 0 Demolition
working for me in any capacity. un workers'comp.instnce. 9. 0 Building addition
(No workers comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
).❑ 1 am a homcownur doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'cump. c. 152,41(4),and we have no 12.JZJ Roof rupaim
insurance required.)t employees.(No workers' 13.QOther,
comp,insurance rcqulrcd.)
•Any eppikam our rh�xas bar II must also lilt out the%mleo below showing their"Ima',empmudun pulley ina,mouloo,
'I6vnauwrata who,ulmsit this amdavit indiealny thry am doing ell workmd then him w1sidecontraetpa must submit a new atHdavit(nd(cisins such.
�Cinrmuwn that cheek this beg meets anachud an asWitlurml+teal showing the name of the su?aantrsaton and ths4 woAten'sump policy infetsnadoa.
/urn un anrpluyer that/s provldln worktrs'rompermdon buurunet jar my employees Below is rAt policy and fah site
iajorrnutioa ��
Insuraocc Canipuny Nmne: l/�Q d•e./ef'iS
Policy 4 ur Scif-ire. Lic. d: 1 C -)r)%k/?P t!. 8'd Expiration Onto:
lulaSiteAddruss: a 4d66En 'JP _ City/Statrzfp: 3AAA42. 0/P7d
Altaeh a copy of the worlters'compensation pulley declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 23A of hiGL c. 152 can load to the imposition of criminal penalties of s
lineup to SI.500.00 and/or one-year imprisonmen4 as well as civil penalties in the farm of 4 STOP WORK ORDER and aline
of up to $230.00 a day against ilia violator. Ile advised that a copy of ihis.tawment may be farwurded to the 011ica of
Investigations ui ilia MA fur insurance coverage veriticution.
1,10 lids, 6 rnr!y«ado fre pular surd pdaulder ajperpary that rht lajerarutlon provided ubuvepix true surd correct.
ii,rn:uur:. — DatJ• —aJ ��t
r n cd, PZ! 1122/`Jo ZCJ
U/Jic ru!rue arty. Do rent wrist irr thlr area,m be cumpleterd by city ur town ojJlclud !
l
Cityor'I'usrn: Fermio.lcense4
Issulog Auliturily (circle one).-
1. Uuurd of Ifcaflh Z.❑uilillny Ucpartownt .1.Cilyifosrn Clerk 1. Veetrical Inspector 5. Pluntblo4 luspector
6. Other
Contact i'erson: