131 NORTH ST - BUILDING INSPECTION (2) I The Commonwealth of MaZindSiandards
s Town of
t� Board of Budding Regulations Massachusetts State Building Code. 7 . 7'"edition Budding Dept
Budding Permit Application
To Construct. Repvate Or Demolish a t1tB"M
One.ur rsso-Furrrt/c DnThis Section For ORcnlBudding Permit Nu bet: Dat
Signature:
Building tsstoner/In t o I mile Date
1 N 1:SITE INFORMATION
1.1 Property AdQreee: 1.2 Assessor$Map R Parcel Numbers
M Number Parcel Number
I.la Is this an acc ted street''yes no 'p
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
La Area(sq R) Frontage(R)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.2 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Cheek if
SECTION 2: PROPERTY OWNERSHIP' 1
2.1 Qwner'o�Resord:
y �o
Name(Prim) Address for Service:
signature SECTION
SECTION l: DESCRIPTION OF PROPOSED WORK'(cheek ail that apply)
New Construction O Existing Building O Owner-Occupied O Repair(s) O Atteration(s) O Addition Cl
Demolition O Accessory Bldg,O I Number of Unib_ Other O Specify'
Brief Dexnption of Proposed W rk':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item #Iabor and Materials
I. Building f I. Building Permit Fee: S Indicate how fee is delncd-
2
O Standard Ciry/Town Application Fee
Electrical S O Total Project Cost'Iltem 6)a multiplierI Plumbing S 2. OtherFees: S
a. Mechanical (HVAC) S List:
s Nechantcal (fire S Total All Fees: S
Su resuonCheckNCheck Amoune Cash Amount
6 Total Project Cost S 7j ���, O Pmd m full 0 Outslandmg Balance Due
i '
SECTION S: CONSTRUCTION SERVICES
S.r. nLai
I Licensed Construction SupeisorlCSL) 10'
• �.� ��� �„ S�s„ Laen,e.Number E.ptuuo ate
Name or CSL Hplder � `\ M L CSL 7
A "JO C,N'T "t 1�Jv✓�-1 1�' �,r ype(xe below)
Address ,I ) T Descn ton
—� U Unrestricted u to 17,000 Cu. Ft.
5�snamre R Resrnard IA2 Farad Owelhn
RC Residential Roolmll Covering
Telephone K'S Residential Window and Sidra
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Reglst1ges} Home Imp wemeat Contractor(HIC) ' �d gr2
`,.�,' i � ,S -e
HIC Company Name a HIC Regtsuam t Regtstrauon Number
C�� v Jar lI J 3 II 0
Addn!s^f� \ �-f
/rt ), a 4'�g'�J"(7"'7-��/7 Eiprnuon Date
Sigw nae Telephone 'T"
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2. 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
I
his affidavit will result in the denial of the Issuance of the building permit.
Signed AMdavit Attaches)? Yn.......... O 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 authorized by this building permit application.
Signaling of Owner Date
l SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, y 1 ' �" S k-L,- , as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Q ; 1�N 1v-
Print Name
Signature of Owner or Kwhorized Attire Date
(Sisined under the pains and penalties of r
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nor registered in the Home Improvement Contractor(HIC)Program),will Rg 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 R7, respectively.
2. When substantial work is planned, provide the information below
Total Gaon area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Fi.1 Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
T ype of hearing system Number of decksi porches
Tnpeofcooltngsyuern Enclo,ed Open
t "Tool Project Square Footage"may he,uh,muied for 'Total Project Cast'
CITY OF SALEM
Il PUBLIC PROPRERTY
DEPARTMENT
r.r: NI rt !•slv„t 1
\I IIC\%'•%it ItXG;,INS!'NUT • ).0 I'M,
fFl:978.74 9595 0 11%X:978.74491146
Construction Debris Disposal AMdavit
(required lur all demolition mid 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
I L 1. S 150A.
The debris will be transported by:
(name ut hauler)
The debris will be disposed of in
(muse ul laci sty)
S J4,\ �
(address of lacday)
+ignall/re of per�canl
I 1 221
date
CITY OF SM.&My AASSACHUSETTS
BI:aMLHG DEP.%znWNT
110
WA3HINGTON STREET, 320 FLOOR
TM (978) 74S-9S95
FAx(978) 74499"
KIMBEUEY DR)SCOLL 1110IIIASST.PlEXAS
HAYOR
DIttECTOR of Pl:eL[c PttovERn/et:tLDac coNaBss[oN Eli
Workers' Compensation Insurance AI1ldavit: Builders/Contractors/Electriclans/Plumbers
annlicant Information Please Print Ledbir
Nalna Iauairw+rOrynuuiotrlydmv dualY W , i o
Address-
City/State/Zip. sz J Y� 1S phone M:
ov as employer!Chal the appropriate bee.: Type of project(regtslred):
1 1 am a employer with 4. ❑ 1 am it genteal Contractor and 1 6. ❑New constrtictior
employees(full and/or pan-time).• have hired the sub-canractors
2.❑ lam a sole proprieoor or partner- listed an the attached shcaL : 7. ❑Remodeling
,hip and have no employee Them sub-eontmeton have N. ❑ Demolition
working fns me in any capacity. workers'comp.insurance. 9. ❑Building addition
I No workers'comp insurance S. ❑ We ate a corporation and is
requital.]
officers have exercised their 10.0 Electrical repairs or additions
y.❑ 1 am a homeowmsr doing all work right of exemption per MOL 11.❑Plumbing repairs or additions
myself.(No workers'comp. c. 1 S2,f 1(4),and we have no 12.0 Roof repairs
insurance required]► employees.(No workers'
comp insurance required j 110 Other
-Any appxrad the choose boa st mow atw ran ud tM scoria belay arwina tMY wallies'cuaymudrt pulley in6unmrlae,
'I Lerwuwnee wM submit this sAld vie indicating they am doing all work ad dual Mrs a acids eneaso a nisi"limit s new alQdwir Wleasp nub
T.wnusome der rbmck ibis bat mud awashed ad addimimmmf dhmt sMwisa she mho Of Of IYb4entmalm and Aide reties'ramp.pdky isarmnWoa
/us age rntp/oyer rAr b pnrldGrg worters'rasrprnrsdow lnarnrwea for wq rsayleyeas i)rMar 4 IM pallq awdm sUr
injorwadom
t
Insurance Company Name: o �
Policy for Self•ins. Lie. p: � ��o\Y. (o Expiration Deter \�
Job Sire Address: City/Stas/Zip:SAR-� l�c \t11
.breach a copy of the werhars'compensation polley declaration pap(showing the policy number and explradon date)6
Failure to secure coverage as required under Section 25A of bIGL a 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment,an well as civil penalties in the form of a STOP WORK ORDER and a tier
Of up to S250.00 a day against the violator. Ile adv red that a copy,of this statement maybe forwarded to the OIYlce of
I n.,cangalium ul'tha MA for insurance covcralp verification.
1110 hrrrby arrrib ua�Aii Prins end
P001 u/d6�s ojperIM7 rim'At injwmadda provided oblige is true and ruereca
/ rf ;l�•��Yo�"' Dale: l
Phunc4 Ql�✓ �J�10 I�y�
OJJlriel use only. Do not whin in this grew,lobe eutdp/ded by dry or team n1fl4q rI
City or ruwn: _ rermica.lcenseM__.
i
lswing.\uthorily (circle one):
I. Itoard of Ilrallb 2. Ruildlnu Ilrpartment I C'ily/rown Clerk A. Electrical Inspector 5. Plumbing Inspector
6. Other
lunlael Person: ._ Phone a:
iI