231 NORTH ST - BUILDING INSPECTION (3) L .
SL} q q i8iy _ , / 335
y O
th m e Commonwealth of Massachusetts
��� Board of Building Regulations and Standards CITY OF
'•'/ Massachusetts State Building Code, 780 CMR SALENI
+ Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised;llar 20//
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number,
Date; plied:
Building Official(Print Name) (o
. � Signature• D
SECTION I SITE INFORMATION
ate
1.1 Property Address:
eQ Z / ti O L �� 1.2 Assessors blip Parcel Numbers
I.la Is this an accepted street?yes_ no Map Number
1.3 'Zoning Information: Parcel Number
1.4 Property Dimensions:
Zoning District Pr�posedProposed UsU
LS Building Setbacks
Lot Area(sy fl) Frontage(11)
(ft)
Front Yard Side Yards
Require) Provided Rear Yard
Required Provided Required
Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information:
Public❑ Private❑ Outside Flood Zone?
Zone: 1.8 Sewage Disposal System:
_
Check ifyes❑ Municipal❑ On site disposal system ❑
2.1 Owner'of Recor d•
SECTION2: PROPERTY OWNERSHIP'
Q /�
Lay,state,ZIP
Nu. mtd stria 7a 4: av_¢- n y� o •p..Tr C' t.�
Telephone Erna)Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units
Brief Description of Proo 1Vork': Other ❑ Specify:
sed
✓-L v
IDS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Building ,S I. 11 Buildin g Permit Fee:,; Indicate how fee is determined:
�tJ c�G O
2. Electrical S /S-0 U C2 ❑Standard City/Town Application Fee
3. Plumbing S ,
Total Project Cost'(Item 6)x multiplier x
I�C7U U 2. Other Fees: S
55 M. Mechanical (' S �UOc,,c.7 List:
. Alechanical (Fire re
Su ressiou)
r0ta1 rill Fees:S
6. Total Project Cost: .S ,� Check No._Check— Amount::
Cash Amount_
C�CiU ❑Paid in Full ❑Outstanding Balance Due:
�/S o
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction -032
lI Supervisor License(CSL) License Number Expiration Dal
1� A r 11
Name of CSU Holder List CSL'Type(see below)�—
'1 Type - Description
Unrestricted Bui:ldn I"
No, Street � ^ Family D wetoll i3n
R Lesc n 5,000 eu. tt.)
M Mnson
City/rown,State,LIP RC Rootin Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
�� I Insulation
lele hone Email address
p Demolition
5.2 Registered Nome Improvement Contractor(NIC) tl[C ,g,,un.ri Number Expiration Dote
HIC Cu 1ptay Name or HIC Registrant Name
Email address
No.and Street —_
City/Town,State,ZIP
Tel hone _ _
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.O.L.c. 152.§ 25C(�T:.
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 72:OWNER AUTR CT �TION:TO BFO BU LETED PERM
OWNER'S AGENT OR CONTRACTOR APPLIES FOR DUILDING PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Date
print owner's Name(Electronic Signature)
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 application is true and accurate to the best of my knowledge and understanding.
Date
Print owner's or Authorized Agent's Name(Electronic Signature)
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an oillneAt havho etires an access to registered tractor
e arbitration
(not registered in the Florae Improvement Contractor(HIC)Program),
caul' nJ at
program ssunadd information HIC Program
he Construction License can be found at Il , "ls
� oInfor fundmaot on
When substantial work is planned,provide the informctliuding garage, finished basement/attics,decks or porch)
(including g g
i Total floor area(sq. B.) Habitable room count
Cross living area(sq. R•)— — Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches
Type of heating system Enclosed__________Open
Type of cooling systcnt
e11 may be substituted for-rotal Project Cost"
} "(oral Project Square Foot
i
CITY OF SAL.EM5 %L�sSACHUSEITS
/ o 13u=ING DEP:IRTMEINT
Q h t a 120 WASHLNGTON STREET, 3'FLOOR
TEL (978) 745-9595
F.A.e(978) 740-98.16
Kl\tBFR1 FY DRISCOLL
MAYOR THOMAS ST.PiERRE
DIRECTOR OF PUBLIC PROPERTY/BCILDLNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information I Please Print Lellibly
Name (Business Organi:miun.'Individu;J): I a^"�- O
Address: / P� rZ✓ �. . Y�
City/State/Zip:`;, —,(�Spa A- Phone M: err�_/'
Are you an employer? Check the• ppropnate box: Type of project(required):
1.;2�1 am a employer with 4• ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation mid its
required.) officers have exercised their l0.❑ Electrical repairs or additions
3,❑ I tun a homeowner doing all work right of exemption per MOL I I.❑ Plumbing repairs or additions
myself.[No workers'cutup. c. 152, 41(4),and we have no 12.❑ Roof repairs
insurance required.)1 employees. [No workers' 13,0 Other
camp. insurance required.] .
-Any applicant tut checks box PI must also fill out the wctiun blow showing their workcn'cumpenmion policy inll,00atiun.
'I fomcowness who submit this atndivil indicating lhcy arc doing all work and then hire Outside cantneton must uihmil a new affidavit indicating such.
Cnumetun thus check this box mint aoachod an additiusul sheet showing the,none of the subeontneton and their workcn'romp.policy information.
l ant un emtployer t/tat is providing workers'c•ontpemsailon insurance for my entplo),ees. Below Is the policy and job site
information.
Insurance Company Name:
Policy 4 or Self-iits. Lic. q: __.._ Expiration Date:
lob Site Address: City/slate/Zip:
Attach 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 4IGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine
of up to$230.00 a day against the violator. Be advised that a copy of this statement may Lw forwarded to the Office of
Investigations ol'the DIA for insurance coverage verification. -
/do hereb the and penalties of perjury that the infor manor provided ub/a is true nd correc4
Poe 1: 7 Q (�"— �� e1'C� Y/
Official use only. Do not write in dris area,to be completed by city or town officiuL
City ne Town:
I.,suing Authority(circle one):
1. Board of health Z. Building Deparinteut 3.Cityffuwn Clerk 4. Electrical lnspectur 5. Plumbing Inspector
6. Other
Cuntact Person:--- _. _ _ Phone tt:__---_------
I
� CITY OF Siu.EINI, tiWSACHUSETTS
` t BLILDDIC DEPAR'Il. LE`:T
120 MASHCYGTON STREET Yo DOOR
T EL (978) 745-9595
F,mx (978) 740-9846
Kf3iHERLEY DRISCOLL
tiNLAY012 THOSLAs ST.P1ERRa
DIRECTOIL OF PUBLIC PROPERTY/BUM.DQVG 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 t 1.5
Debris, :uhd die provisions of MGL c 40, S 54;
Building Permit 4 is issued with the condition that the debris resulting from
this work shall be l 11, S I SOA. disposed of in a property licensed waste disposal facility as defined by tNfGL c
The debris will be transported by:
L
(name Ot'hauler)
The debris will be disposed of in
(name Ot'tacility)
(address of facility)
7 ,ignawre Of permit applicant
7 -
Ja e