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184 NORTH ST - BUILDING INSPECTION - Iq - (, ­7 �� 5� 1 y (n I he Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM ��• l Massachusetts State Building Code, 780 CNIR Reeised.1/ur?011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Divelling This Section For Official Use On! Building Permit Number: Date Appli Building ORiciui(Print Mane) - Signature Date SECTION t:SITE INFORMATION' L1 P o arty Address 1.2 Assessors Map&Parcel Numbers I.la Is this an accepted street'?yes no Map NLanber Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: i Zuning District Proposed Use Lot Area(sq It) Frontage(II) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L c.40,§54) T7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ P p SECTION2. PROPERTY OWNERSHIP'! 2.1 Owne IorRecord:ti r )1m// ``''e�,,(Prit t) City,State,ZIP u.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bidg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': k_y� qCe— SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Rent Labor and Materials) I. Building I. 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 J. Plumbing S 2. Other Fces: .S I. Mechanical (fIVAC) S List: i. \(echanical (Fire S Total All Fees:S Su ressiunl Check No. Check Amount: Cash Amount: G. Total Project Gtst: S ❑Paid in Pull ❑Outstanding Balance Doc: SECTIONS: CONSTRUCTION SERVICES 5.1 Constructinn Supewisor License(CSL) /vL4 License Number Ex iru on Date ;uneofCSLH der 'LJ 3 List CSL'rype(see below) Type Description i No.and Street _ I, Cy U Unre ustricted Buildin s -to 35,000 cu. it.) V/�,V ©� /�5 R Restricted 1&2 Family Dwelling C'ityfrown,State'ZIP M Mason RC Roofin Coverin WS Window and Siding: SF Solid Fuel Darning Appliances 17 1 Insulation '1'cle bona Enmil address D Demolition 5,2 Re lstered Home I/mJJprovement Contractor(HIC) OL5'Y,� Zax y AlfllkL 3 HIC Registration Number E. pir tun Unte H,jS;Cum `�ameorp li�gistr nt Name S lSI Nye Street jZ V4.1 n G�r�X7-0�Z Email address Clity//Trown St.the ZIP H /J 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 .........Cp, No...........0 SECTION 7a:OWNER AUTHOIUZATIONTO BE COMPLETED WHEN. OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize ZM 11 4� t9 act on my behalf,in all matters relativeork authorized by this i�permit application. tq�t e 5Al o w Printn�r's N:une(Electronic Signature) IDaV 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 a plication is true n lccurate to the best of my knowledge and understanding. / l Print Owner's or Aa m 'ud r\ to(Electronic Signature) ,ne 1-1 NOTES: I. A 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(H(C) Program),will LLoj have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at www.mass.eov:'oca Information on the Construction Supervisor License can be round at wtvwv.niass.�ov'dM 2. When substantial work is planned,provide the information below: Total floor area(sq. It.) (including garage, finished basementlattics,decks or porch) Gross living area(sq. It.) Flabitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths type of heating system Number of decks/porches Typeofawlingsystem Enclosed Open 1. I'uial Prujst Square Fouta�c"may be substiuitcd for"rued Project Cost" ry� . CITY OF Si1L.ENf, ;tiL1SS:ICHUSETIS ♦JC MNIG DEPARTIEVT l� 130 WASHCYGTON STREET, 310 FLOOR 1ti�!s 4� T EL (978) 743--9595 F.tie(978) 740-9844 IUJtBEltL�Y D8ISCOLL A-woR T HOacis ST.FIERns MUCCOROFPUBLICPROPERTY/81,: DLNGCONWISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section It 1.5 Debris, and the provisions of i'YIGL c 40, 5 54; Building Permit f# is issued with the condition that the debris resulting from this work shall be 1 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by rV1GL c The debris will be transported by: y��� 7, (name ot'hauler) ['he debris will be disposed ot'in (name of facility) (addressor facility) _ Stt. re of permit applicant I:rt� i CITY OF Sc1LEM, INLNSSACHUSETTS BulLDLNG DEPART EINT 120 WASHLNGTON STREET, 3se FLOOR Y TEL- (978) 745-9595 FA.x(978) 7.10-9946 KI N IBERL FY DRISCOL L THOMAS ST.PIERRE ,NLAYOR DIRECTOR OF PUBLIC PROPERTYIBUBDING CO\L%iISSIONER Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apitlicant Information Please Print Legibly Name (nusinesvOrganizationtlmlividual): �t�r b�� �'�f jU ev Address: City/State/Zip: �tfloefljyqq 0/9/ Phone #: 92?_)-7,6,7 -OW7 Are you un employer?Check th appropriate box: - Type of project(required): I.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction s.employees(full and/or part-time)." have hired the sub-contractory P7•I ana a sole proprietor or partner- listed on the attached sheet.t Remodeling ° .hip and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, workers'comp. insurance. 9, ❑ Building addition [No workers'camp. insurance 5. ❑ We are a corporation mid its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ 1 ran a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself.(No workers'camp. c. 152, g 1(4),and we have no oof repairs insurance required.) 1 employees. LNo workers' cump,insurance required.] I3.❑ Other •Any applicant that checks box 91 must also till out the action chow showing their worked cumpens idun policy inlbmnatiun: '1 lomcownen w'ha ubnnit this aHldnvit indicating they arc doing all work and then hire outside contmelon must suhmit a new aMdavit indicating such. :(:,,ntmcwn lhm cheek this box must atmuhed an additiuwl sheet showing the name of the sub<ontmctors and their workers'cump.puliey!n(ornution. 1 unt an empiayer that is providing workers coolpensadmt insurancefor my eatplayees. Below Is the policy cold fob site information. Insurance Company Name: Policy 4 or Self-ills. Lic, d: 6 _2! DU�2,.q �!J,� ` Expiration Date: Job Site Address: 19Y A.2cA City/State/Zip: 14- ,lttach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of%NIGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S230.00 a day against the violator. Be advised that a copy of this.statement may be forwarded tothe Office of Investigations of the DIA for insurance coverage verification. I do hereby certify tinder the pains tenalrlrc of perjury drat the h furnmtion provided above i true and correct. 1 tie' - Date: Q f0 Phone 1. ! • 07 Oflic•ial use mdy. Do not write in this area, to be completed by city up town off elat - City or'fuwn: -__.. . .__ Pennidl.lccnse f! _.._ Issuing Authority(circle one): I. Board of health 2. Building Deparlincnt 3.Citylruwu Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other . Calif act Person: __. Phone tt:�—.—___—___