23 NAPLES RD - BUILDING INSPECTION (2) t _ c
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
r i, ' SALEM
�✓ Massachusetts State Building Code. 780 CMR
Rerisecl Slur 101/
Building Pennit Application To Construct; Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date 'ed:
�
Building official(Print Name) Signature )at"e
SECTION 1:SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map& Parcel Numbers
73 (lapels i2Z
I.I a 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 (1) Frontage(11)
11.5 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:
7one: _ Outside Flood/_one?
Public❑ Private❑ M
Check if ves❑ unicipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
Cods S Oo ft SvA MA Oten 0
Name(Print) City. State.ZIP
23 nuAe-\s 7BFli -ci
No.and 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. ❑ Number of Units Other eSpecify: PV 6660-
Brief Description of Proposed Work':-g,.4 Vn 4- 61124d -HFCl PV S G-9
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ 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 (HVAC) S List:
5. Nlechanical (Fire S Total All Fees: S
Suppression)
o0
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 2
7, qq7 ❑ Paid in Full ❑ Outstanding Balance Due:
Cc �� (Atli XNv,
�'70
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 7 CJ��—/3
✓ Ty�, J, Sy/ P(,� License Number Expiration Date
name of CSL Ilolder
/ 3 S( /pG o A List CSL l\pe(see belotr).
Ty Description
No,and Street d� � �,4 6�fr� / U Unrestricted(Buildin s u to 35.000 cu. ft.)
, Restricted 1R2 Famih•Dwelling
City/Town.State.ZIP M Masonry
RC Roofing Coverin
W S Window and Siding
�Vwl1-, fn ,v J�/S�Pl�/�/'� J SF Solid fuel Burning Appliances
I Lv /'C l-� r 1 Insulation
Tcle hone Email address r 1� D Demolition
5.2 Registered Home Improvement Contractor(HIC) /2�y ?� „�•
Jam._ e� HIC Registration\'umber Expiration Date
HIC Com am'i'ame or 4 IC Re S istran[Name S
J r + / n�
J (/�
No.an Str 1 A AGi3,,S 444 Email address
Citv/Town.State.ZIP K vTeele 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 Issuance he building permit.
Signed Affidavit Attached? Yes .......... oo� 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.
y-13-11
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering an ' name below, I hereby attest under the pains and penalties of perjury that all of the information
contained ' t pplication is true and(accurate to the best of my knowledge and understanding.
P nt Aut o zed Agent's Name(Electronic Signature) Date
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 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.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
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'
CITY OF S-U.E.\f, AXSSACHUSETTS
BUILDING DEPART%E.NT
• p• 120 WASHINGTON STREET, 3`a FLOOR
TEL (978) 745-9595
F.s-r(978) 740-9846
KI BERY FY DRISCOLL
MAYOR TtiOSLAs ST.PtFARE
DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG CONMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information '///��/,�r/ Please Print Legibly
Naine lBusi+xss:U(gamzaliowind+vidual): ('` �� -S / J �" `�"
Address: ! 36,- u��SC�% ay.AO Q
City/State/Zip: CX/, L LG� i � ['tl0e;: / �7�'���J' qw0
Are you an employer?Check the appropriate box: Type of project(required):
1 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
ct oyees(full and/or Part-time).* have hired the subcontractors
2 un a sole proprietor or partner• listed on the attached sheet.2 7. ❑ Remodeling
ship and have no employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No worked comp. insurance 5. ❑ We are a corporation and its
required] officers have exercised their
10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.[] Plumbing repairs or additions
myself. (No workers'comp. C. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13. ther Sat Alt ,�f.-/
comp. insurance required.]
'Any applicant dot dseks twx Al meet alw GII am the seam blow showing their worked cotnpensatian policy infurmatioa.
'I lomcuwmrs uhu xuhmit this andavil indicating they ate doing all work and that hire onside,mitmcrors mint submit a new affidavit indt=mg such
-Camranun that ehuk rho hux must anachcl an aalJitiorcil.hers showing Aw name of rM sab.eontrxton anJ+heir workcm'comp.yuliry in(ummtion.
lam on employer that is pruviding workers'c ompensation insurance jar my employees. Below Is the polfry and Job site
information.
Insurance Company Name:
Policy 4 or Self•ins. Lie. #: Expiration Date:
Job Site Address: Cityi State:Zip:
Match a copy of the workers'compensation policy deelaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA fix insurance coverage verification.
I du hereby certi r afns and penalties of pCe+rjuryy that the
information provided above is true and correct.
Sign nure _ /� Q QV4-- 514V`at ab
-4 Date' /i 1l
Phone z d: (�(/ i rrj• y"Leo
Official use only. Do nor write in this area,to be completed by city or town offic'iat
Cilyor'ruwn: _ _ Pcrmit(License# __ _
hsuing authority(circle one):
1. Board of Health 2. Building Department 3.City/rows Clerk A. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone#:
CITY OF S.0 EM. N'LkSSACHUSETrS
BUILDING DEPARTMENT
P• 120 WASHNGTON STREET, 3" FLOOR
TEL. (978) 745-9595
Fnx(978) 740-9846
1%{gFRI-F-MAYOR
FY RISCOLL
T1�omAs ST.PIERRE
Y D
DIRECTOR OF PUBLIC PROPERTY/BUMDNG CW (ISSIONER
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 c 40, S 54;
Buildin.- Permit# 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
1 11, S 150A.
The debris will be transported by:
C 11fE(-l.A fir/5-E �.
(name of hauler)
The debris will be disposed of in
_--- , (name of facility)-
(address of facility) ®l�J
sier e of permit applicant
- 13 - ��
date
debn.a0'Jue