0004 & 0006 MOUNT VERNON STREET - BPA-12-259 4
The Commonwealth of Massachusetts
S
Board of Building Regulations and Standards CITYOF
Massachusetts State Building Code, 780 CNfR SALEM
Rerivvd.11,rr?011
Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tuv-Funmilc Dn ellln.4
This Section For Il cial Use Onl
Building Permit Number: ate Applied:
Building Otlicial(Print Naune) Signatu a /5 n/
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Nlap& Parcel Number
N F (a M,1�d (L �a,
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 It) 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if es❑
SECTION2: PROPERTY OWNERSHIP"
2 Ownerl of Record:
Nenme 'nt) City.State -
✓ } 4?-� -y7al
Nu.: id-Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ I mber of Units_ Other ❑ Specify:
Brief Description of Propose Work':
S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(tabor and Materials) Official Use Only
I. Building S 0()0,00 I. Building Permit Fee: S Indicate how fee is determined:
Electrical S Cl Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier __x
1. Phunhing S '. Other Fees: S
4. .Mechanical IIIAC) S List:__
<. .Mechanical i! ..e
Suppression) S Total All Fees:S_ --- -
Check No. _Check Amount: Amount:
n, Total Project Cost: 5 ❑Paid in Full ❑Outstanding Balance Due:
�U • O C/ - -
� ' 40 fleo #n 49wa e�
t
SECTION5: CONSI'RIIC.TIONSERVICES
5.1 Construction Supervisor License(CSL)
License Numher----- -- lispiralian Date
----------
N;u»c ul'CXL IIUIJer -
List CSI.1)pe(sce h¢lUty)
NU. and Street --- —--'— ---- .f)PC Description
(j I nrestricted(Buildings up tU 35,000 cu. 11.)
_ _.._-.._ R Restricted Id:2 Family Dtcellin
Cityfrosvt,State.ZlP M Masonry
RC Roolin,C'uvcrin
- WS Window and Siding
SF Solid FuelllurningApplianccs
I Insulation
telephone hmail address D Demolition
5.2 Registered Ilonte Improvement Contractor(HIC)
I IIC Registration Number Fxpinnion Date
I IIC Company Name or I IIC Registrant Name
No.and Street Email address
City/Town.State,ZIP relc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 Issuance 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
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(Electrunic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
. my name below,I hereby attest under the pains and penalties of perjury that all of the information
By enter'
conta' ed in this application is true and accurate to the best of my knowledge and understanding.
Print, anefs or Authorized Agent's a ne llileclrunie.Signature) 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 IHIC) Program),will not have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be Found at
oe.) Information on the Construction Supervisor License can be found at tt_,nytss.Ljp� dp,
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.l (including garage, finished basement'attics,decks or porch)
Gross living area t sq. 11.) _- _ Habitable room count
Number of fireplaces.__ Number of bedrooms
Numher of bathrooms Number of half halls
I)pe of heating system _ -___-- _- Number of decks, porches__--
I)peofcoolingiyslcol--_ —.- --. Fnclosed ---__ Open ... .
i "'Fot;d Project Square Footage'nim he substituted for"I'otal Project Cost"
CITY OF S.U.E.Ni, �LNLiSSACHL'SETTS
8L'am4t; Dmut-nONT
110 W.+sHLVGTON STREET, 3iO FLOOR
Tom. (9711) 745-959S
FAX(978) 740-9846
Kll®ERLBY DRL4COLL
MAYOR THo.+W ST.Pmmw
DIRECTOR OP PI:BLIc PR0PERTY/9UMMLNG CONNISSIONER
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 t 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit Al 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 by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
— (name of facility)
(address of facility)
vV
signature of permit ap cant
date
Lhn. dlw
I
V `
I
CITY OF SALE.NI
PUBLIC PROPERTY
DEPARTMENT
w.aWAL"o.MUXL
H..rae i�o v�ou►w�oN sneer.sua� uoR aT,s ONro
i1L 9'8.1+5`9S"•t:.,A 978.7469w
HOMEOWNER LICENSE EXE.MMON
Pkaw filet
Date
Job I ocadm q w t!o ML Vernon '�bk, nip ,l(1 A n 1glo
Home0womAddress 4 fY1-k VPrnnn j*, gnjern WA nIA-40
Home Owner Telephone q1(�- 7 4H-41 a I
Presw Mailing Address 4 fY VP.rnnn �1- . Q t q-tn
no current exemption oC'Homeownen"was extended to inchtds owner-occupied
dwellings of two Units or leaf and to allow sub homeowners to engage an individual for
hire who.does not possess a livens%provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Persons) who owns a parcel of land on which he/she resides or intends to reside,on
which there is, or is intended to be,a one or two family dwelling, attached or detached
structures accessory to such use and/or farm structures, A person who constnrcta more
than one home in a two year period shall not be considered a homeowner. Such
"lwmeowner'shall submit to the Building 0®cial,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned"homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner certifies that he/she understands the City of Salem
8uilding Department minimum inspection procedures and requirements and th he/she
will comply with said'procedwes and requirements.
HOMEOWNERS SIGNATLIU
APPROVAL OF BUILDING GNSPECTOR
See other side for state code
a
DURABLE POWER OF ATTORNEY
I, Ora L.Anderson of Salem, Essex County, Massachusetts, appoint Gail A. Whitney as my attorney,
to conduct all my affairs, with full power and authority to act in my name and on my behalf as fully as I
could do if personally present. Without limiting the generality of my attorney's powers, I specifically
authorize my attorney to do the following:
(1) To manage and have the general control and supervision of all my property and interests in
property, real or personal, tangible or intangible, including power to buy, sell, lease and mortgage.
(2) To maintain bank accounts for me in my name, or in the name of my attorney, and to make
deposits or withdrawals of money belonging to me in such accounts, and to disburse any money from
such accounts on the signature of my attorney and to be remove my name from accounts.
(3) To pay all my bills and to expend funds for any purposes which my attorney deems for my
benefit. t
(4) To collect, demand and receive any income, interest, dividends, rents, profits or other property
due or payable to me.
(5) To borrow money on my behalf, to execute contracts on my behalf and to execute on my behalf
any other deed or instrument in my name or in the name of my attorney, which, in the discretion of my
attorney, appears to be necessary or advisable in the management of my affairs.
(6) To have access to all safe deposit boxes in my name and the right to remove their contents.
(7) To prepare or have prepared and to sign tax returns of any sort on my behalf.
(8) To prosecute or defend or submit to arbitration any claim by or against me or my property and
to receive and give full or partial releases of any kind.
(9) To consent to surgery or any other medical procedures or assistance to me.
(10) To authorize my admission to a medical, nursing or residential care facility and to enter into
agreements for my care.
(11) To purchase flower bonds(meaning U.S. or Treasury bonds, redeemable at par for the payment
of federal estate taxes) from my assets.
(12) To transfer funds or property of mine to any trust established by me, whether before or after the
date of this instrument.
(13) To make gifts or transfers of any kind on my behalf to any individual as my attorney deems,.
appropriate; provided that my attorney shall not have power to make gifts to or for the benefit o1
attorney.
(14) To exercise all rights I may have under policies of life insurance whether on my life or that of
another, including the power to borrow on the policy, name as beneficiary any revocable trust created
by me, change beneficiaries, elect settlement options, and surrender for cash.
(15) With respect to retirement accounts in which I may have an interest, to exercise any option, or
to roll over the proceeds of a lump sum distribution into an individual retirement account or into
another qualified pension or profit sharing plan.
(16) To exercise any power I may have under any will or trust, including the power to make
withdrawals and to assent to or oppose the allowance of accounts.
(17) To substitute another to act under this power of attorney and to revoke the substitution at any
time.
(18) To do any of the foregoing in this Commonwealth or elsewhere in the U.S.
(19) I nominate Gail A. Whitney as my conservator, guardian of my person and guardian of my
property yshould the nee
d arise in the future for the appointment of any such fiduciary for the protection
of my person or estate.
No person dealing with my attorney shall be required to see to the application of any funds or property
paid or transferred to my attorney. Any person may rely on this power of attorney or a copy of it
certified by a notary public until notified in writing of its revocation.
I intend that this power of attorney shall not be affected by my subsequent disability or incapacity.
Executed as a Massachusetts sealed instrument on September
/16, 2005.
Ora L.Anderson
COMMONWEALTH OF MASSACHUSETTS
ESSEX, SS.
On this day oL5j,4/ 2005, before me, the undersigned notary public, personally appeared,
Ora L. Anderson and proved to me through satisfactory evidence of identification, which was a
Massachusetts License,to be the person whose name is signed on the preceding or attached document,
and acknowledged to me that she signed it voluntarily for the state purpose.
O1RwtEE�/ S i ff Signature and
otNrvary
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