203 1-2 NORTH ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Buildinr Re ulations and Standards CITY OF
i�l i� 6 g SALEM
fly/
Massachusetts State Buildin r Code 780(,M b 4 � 'll 1
\ Reri.re�l. lur _ 1
Building Permit Application To Construct, Repair, Ren ate Or Demolish a
One-or Two-Family Droelling
This S to For Official e Only
Building Permit Nu der: Date A lied:
/
Building Officialt(Prin, N Signature D to
SECTIO 1• SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
o243 yz T 41,2,-Ak �f
—
[.I a Is this an accepted street?yes Ito Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(Il)
1.5 Building Setbacks(R)
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 QJ — Private Cl Zone: _ Outside Flood Zone? Municipal p Onsite disposal system ❑
Check irycsQi
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�a,-tee :Gt �%2�n
Nanie(Print) City,State,ZIi•,
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) Iteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': i6'l1 e4dJ- iz a:�h.bd ex� d
r'Cvrrn� / 6� ln,fhu//iw d-h&e-yt, ;
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
'. Electrical $ ❑Standard City/Town Application Fee
- ❑Total Project Cost (Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (11VAC) S List: %
5. N lechanical (Fire S
Suppression) Total All Fees: $
Check No._Check Amount: Cash Amount:
6. Total Project Cost: $
(r, SQ(J 0Paid in Full ❑Outstanding Balance Due:_
t• y
SECTION 5: CONSTRUCTION SERVICES
5A Construction Supervisor License(CSL)
4 9gN96 ao/z
Ayu0.r—�'2 to a c-ho do License Number P.spimtion Date
Name of CSI_ holder
List CS Type(see below)
No.and Street Type Description
/1/t U Unrestricted(Buildings u' to 35,000 cu. tl.)
R Restricted 1&2 Family Dwelling
Cnyll'own,Slate,ZIP
M rylasonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
97�-�/u-982z 1 I Insulation
Telc hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
//Z2—/dp O Zp
Irz.0.'4e Ma Ch a. 0(a 1 lIC Registration Number Expiration Date
I IIC Company Name or I IIC Registrant Name
/te 4//y_a sf .
No.and Street -mail address
-f�l/ems All? O/9 7
Ci /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 .......... M-i 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 .x t<Q r 4 mac h4 (2�)
to act on my behalf,in all matters relative to work authorized by this building permit application.
6�
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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 application is true and accurate to the best of my knowledge and understanding. .
L -4e 1k1i e.Gt4LC1(0
Print Owner's or Authorized Agent's Name(Electronic 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
(tot registered in the Home Improvement Contractor(HIC)Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 1 d2A.Other important information on the HIC Program can be found at
�o�'oca Information on the Construction Supervisor License can be found at o vxv.masS. , Ilp_
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basentent/attics,decks or porch)
Gross living area(sq. ft.) Fiabilable room count _
Number of fireplaces Number of bedrooms _
Number of bathrooms _ Number of half/baths
Type of heating system Number ofdecks/porches _
Type of cooling system _ Enclosed Open
3. "total Project Square Footage"may be substituted for"fatal Project Cost" --
CITY OF S.U.E.NI, NLkSSACHUSETTS
BLuDLNG DEPARTtEINT
120 WASHLNGTON STREET, 3'D FtOOR
` TEL (978) 743-959S
FAX(978) 740.9846
KIS�ERIEY DB:LSCOLL
MAYOR 'Il omaST.PtEms
DIRECTOR OF PLBLIC PROPERTY/HCIIDLNG COMMISSIONER
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;
Building 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
111. S 150A.
The debris will be transported by:
�U2r r'-de 0-a ¢'4g
(name of hauler)
The debris will be disposed of in
(name of facility)
Sa/sue» .v 0
(address of facility)
signature of permit applicant
date
4.bnvlf.Lk
•' ��, CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
NN,Nt
IIC\VAvttl.\lat)\SlxCl•1' • 3.11f•.N,M.1.11d1.111 v)I Iv J1'17�
ft•.1:'AL•71S'/3'13 IS1'1x. Y7NJlC•''846
Wurkers' Compensallon Insurunce .%nuavit: avilders/Contractors/Electr(c(ans/Plumbers
%unlicant infurinutlon PlcrNe Print Leethly
Nairse lHimIwsalt7rganvaiory Indlvulual): 1.t 0-K4e IU a /ne3. r-/
Address: A[ L ovs c-f-•
City,Srarc,%ip! S'ct, V. Hf9- nI990 Phone III: q-),P /U -4E zL
.\to)lots an etslployer?Check the appropriate box:
'Type of project(required):
I I.ca' --Inl a cmplu)cr with�_ 4. ❑ I ;un a gunural contractor and 1
L
yccm(lull and/urpsn-lime).• have hired the sub-contractors
f'' new construction
sole pmpriculr or partner- listed on the attached sheet y Cg-Remodeling
ASnd have no empluycum These sub-contractors have tt. rhmolirion
ng for Inc in any capacity. workers'comp. insurance.
Noorkers'comp. insurance 3. Q Wd ar6 a rnlporstion and its q' ❑ Building addition
d.) oty1cen have cxercimvvl their IO.0 Electrical repairs or additions
homes>wnet doing all work right ofexemption par tifGL 11.0 Plumbing repairs or additions
. (Ko workers,comp, c. 132.§1(0),and we hove nn12.❑ Rutsl'repairs
ce reyuired.J I employees.(No workers'
comp. insurance . irnd.J I3.❑Ud1er
wiq.yuplucmil 111.111 cheeW box it must:Jae Im w,t the Wet lull Wave dNlwnta uheir wwkwi cum nuaiwr
'I lumw,wmn who Submit this anldsril indiutina IsNa aIs douse ail Wurt and Ince hit,wlvide cepnvneroo mils''•uVy.6lnMna nor u1RJaYi1 Imlieylina Ylca.
d'.nttravbwv'hill eMch this Pox must anachod an aJJiliwtal Tholes dluwina The nanta of Ilse IW"Imeraet, and thew wwkon•rants.policy inrbrmajim
/bur an eutployer that It pruviding workers'curnpenraden hisitranre jor thy Spin IS,Belaly is Iht pu/fay and/ub sih
iujurmuliun 7
Insurance Company Vame:
1'41licy 11 ur Sulf--ins. Lic.M; ( 7IUS '77 3,P ^ e)-I- _....Expiration D;Ite: U 7-L61'
lob Sint-\duress:_ a 13 %z Al, 6i` Clt 'slateizi -ra/ern
y p: 667 . 4�r
attach it copy of 111e workers'cumpensation pollcy declaration page(showing the policy number and expiration date).
I"ailure to sccura coserage as required under Sccliun 23A ul'.ML c. 132 cast lead 16 the imposition of criminal penalties of a
tine uP To SI 50-WI and/or one-year imprimmunent,as Null as civil penalucs in the form of a STOP WORK ORDER and a fine
of up(n i230.00 is day.lNuinst The violame lie advi.4ed(hut a copy urlhis slutcmunt may be l'urwarded to the Uflice of
111c�shgauuns ufdw UTA for lavurance cnvctage serilicanon.
/du hereby certify nn.lar the p,rinr,aril prow/ties u�Pnjary that the in/urmu/Ion Provided above is true and eormcf.
�l��lllbl'e.
I'lu a:a n 9 7P- i/O —9P--Z-7—
Unlriwi use uu/y. Oil nnl n•rite in I/dx arch, to bs rmnP/tied by airy ur town a//iriuL
i
('ifs ur'flotra: Pcrinit/I.Icenme 1f_ .. J
Iwulwsl Authutity (circle arse):
I. Beard if Ilvallh 1. Iluildin� I)cparoncnl 1, t:il):'Iba o Clerk J. L••Icclried Inspector I. 1 lumbing filils for i
6. 01 her
l'�nuael l'c nuts: I'hune-7:
r i
Information and Instructions
\I:15i.IG huSCnS licneral Law$Chapttr 152 w4ulreY all Crll{)IJyCrs fn provide workers' colnpensaturn tor their employees.
ofhir es.
I'llrSa:Lrt W 1{11Y>uwte,an empfoYte is defined as"...every pcl.aO11 in the service of another under:u)y :unir of hire.
apress or Implied,oral or written."
\n ornployer Is defined as"an individual,partnership, dlitig the le corporation li other 3 de entity,of many two r' more
t the toregohtg engaged in+Joint enterprise.and including the legal roprescntatives of a deceased employer,or the
alloa of
r Ito
owner r r dwelling house having notulnore thanhree apartmentseand whotres des therein. rtity,employing nhe occupant ofployees- vher the
stro work c
h dng house
,Iwelling house of another who employs
persons
to do shall aintnoteca ce e.of u hemploymcnt be de med to be inelli empl employer."
or on the grounds or building appurtenant
NIGL chapter 112. p25C(6)also states that"every state or local licensing agtlney shad withhold the Issuance or
renewal of a license or permit to operate a business or to coastrue hill the t buildings In the insurance
coverage
required."
e th for any
applicant who has not produced acceptable evidence of es he commonwealth n r any of ifs political gtubJivisiens shall
VP ' '1 states"Neither insurance
7 sthe
1 i_. . _rmanliance with
' 'email • �l(rL shaper i evidence ufwnrp
iddttt Y ul' tlblie work until acceptable
�e
• c r into an contract for the perforntan P �) authority."
re e y the contracting Y
f this ehr tar have been presented to
requirements u �
Applicants
Plen+e till out the workers' compensation all3davit completelyhona numbers)aing tile long with theoxes that ir certificale(s)of situationy to your and, if
necessary,supply sub•contraclor(s)name(s),addresses)and p with no empIOYU9S
insurance. Limited Liability Companies(LLCworkelrs'tcom pensatioed Liability e insurance(f an)LLC or LLP does have
er than the
members or partners, are net required to carry
employees,a policy is required. Be advised that this atTtdavit may be submitted to the Deportment of Indsvit. Tile dustrial
be tell in to fire airy or town that th eapplication for the perc coverage' Also be mit orlicense is being reque The sted not he DOpa+trncnt of d
Industrial Acotile cis Should you have any 4LLesnoas regarding the law or if you are required to obtain a workers'
the number listed below. Self-insured companies should enter their
compensation policy, please call the Department at
self-insurance license number on the apPM riate lino.
City or Town Officials
partment has provided a space Lit the bottom
please be sue that the affidavit is complete and printed legibly. The De
Of die affidavit for you to fill out in the event the Office of Investigation has to contact you regarding the applicant
I'I:ax be sure to fill in he wrmitRicense.nuliber which will be used as a reference number. In addition,an applicant
ven year,
that,inubt Policy formation inulliple
necessary)and tinder"JobtSi a Addressns in any "he applicant should only twrite"all lu it one affidavit
tionslinicuting( ry ur
the affidavit that has been offlcidily stamped or marked by the city or town may be provided to the
cown)"A copy of
id affidavit is on file for future permits or licenses. A now affidavit must be filled out each
applicant as proof that a val
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
permit to burn leaves ere.)said person is NOT required to complete this affidavit.
(i.c. :t dug license or
a
111,
I)11iec ill,Invesrigations would like to hank you in advance fur your cooperation and should you hove;,ny yueauans,
pleat do nut hesitate to give us a call.
fhe L)eparment's❑ddreY4, ccicphune and fax number:.
The Commonwealth of Massachusetts
Department of Industrial Accidents
OfRce of Investigations
600 Washington Street
Boston, MA 02111
'rel. # 617-727.4900 ext 406 or 1-977-MASSAFE
Fax 0 617-727-7749
www.mm.gov/dia