18 NORTHEY ST - BUILDING INSPECTION Iu
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7`h edition ALEM
Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
l ' This Section For Official se Oily °'n„
:BuddmgPermitN mber.,�" =,5 DateAp red., gl Kh„m":n.M. �_. �` . W.-
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St nature .� },. :r. = ° "L
4°=Building Commissioner/Inspector of Bu tdi A '°Date,�
_.__.
=SECTIO S E 11VFORMATION ,« PrHIM M-111
1.1 Pro err dd e s: 1.2 Assessors Map&Parcel Numbers
1.1a Is this an accepted street?yes k no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions: „
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
t 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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
; "' ' SECTION 2nPROPERTY OWNERSHIP` --
,.s , _�. _ _
X 2.1 Qwner of Rec rd•
AtRA41q` trrse �I szP /c, ' er /VyYa� ev `l/
Name(Printy Address for Service:
Signature Telephone
y
t,SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply) _M °'®°= w "
New Construction❑ FExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify;
Brief Description of ProposedWork 2: h 2
VInVI 11I tcn
" ,. 'tp SECTION,4:ESTIMATED CONSTRUCTION COSTS U?K., '..
Item Estimated Costs: i�ea: ,.�, s0.e & «. ". '6� rz!°:i .,a e r,N anC a"'.:
Labor and Materials
. Ow1cial USe Only n.q r ai nV_.
1.Building $ eO 1 Building Permit Fee $ a. Indicate how fee is determined:
❑Standard Crty/Town ApphcationFee is �`��'„27�"ita� , ``
2.Electrical $ f9
❑Total Project Costa{Item 6)x multiplier
3.Plumbing $ 2 Other Fees $
4.Mechanical (HVAC) $ List
5.Mechanical (Fire ;
$ A " ';Suppression) TOtal ll Fees
6.Total Project Cost: $ �2/ 7 /I� Check No Check Amount R s:Cash Amount- E
(0 c 6 ❑Paid in Full `, 4 , , " El Outstanding Balance Due .
r}� 1�q.00
/ -I
9
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V
:iSECTION 5i CONSTRUCTION SERVICES
5.1 Licens/gd Construction Supervisor(CSL)
(�G X11j e License Number Expiration Da e
Name of,CSL-Hold ! ist CSL Type(see below)
( P . -
as
U Unrestricted(up to 35,000 Cu.Ft.
It Restricted 1&2 Family Dwelling
t ature / M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Ilom�I rover ent ontractor(HICK L /' /I O •7
HIC Comp any�NamCCeor Registrant N ie P( (/ d Registration Number
Y `�
A gqq Expi ation Dat
Si ure 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.
r
Signed Affidavit Attached? Yes .......... ❑ No...........❑
SECTION,7a:OWNER AUTHORIZATION-TO BE COMPLETED WHEN gyfflCI
OWNER'S AGENT OR Z
CONTRACTOR APPLIES FOR BUILDING PERMIT i-O"
x 1, //x j'1 R'/ , (/!11 SZbL94 I K' - as Owner of the subject property hereby
authorize A__u _ gwe to act on my behalf,in all matters
relative to work authorized by this building ermit application.
A�'9�� 4/_
Sigrfature of 0&fier P Date
SECTION 7b:OWNFR�t,OR AUTHORIZED AGENT DECLARATION • -M dr kaar „,
I, N -1 .Cffe 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.
k(!
Print Name
7
Signature of 01fder or Authorized Agen Date
Si ed unde the pains and penalties ofperjury)
EM3 „ ° °..," '°t:,Phi —'� ':n : ��E � : NOTES:,,.`+ ..:? —.Ym6 u..Rd�e�.,.L, rrz, =,r ?ar.:t� ,.,.:°
xv..,,.z: I9 e:....w..:, md y r, ,3„':;EnE d rexwrt9:.
v. .m. .::rs .c.
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
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CITY OF S.1I.E.`19 ANYWSACHL:SE-M
BLMDING DEP.%M.LLiT
120 WASHINGTON STMET. !'e FLOOR
TEL (970) 74S-9599
F.ut(978) 74496"
Klm®ERLEN' DalSCOL.I. THONUsST.PMRAS
HAYOt
Dlnlecroa oP vL ecu n11oPEaTr/n.'aDac co.%aRsslo.iEJl
Warkers' Compenaatloe lnsuranee ARldavit: Duilden/ContraetorWElectrlelangiPlumben
16111111ca"t Information
Valle tevnne..arymranenlmry mrr►'
Address. 7
city/stateizip: r_fa 1�4 glffy/ Phone w `lZ(z
.\re you to emplayor!Cbeek the appropriate Nat Type or project(regvdra*
1. 1 am a Mployor with 4. ❑ 1 an a e"Now conamew sod 1 6. ❑New constructing;
employees(fill and/or part-time).• haw hied the strbearnraetora
is❑ 1 am a sole proprietor or porter- limed an the attached sheet t 7. Oft, M lins
.hip and haw no amploycs Thm sub-eomtnamn have e. Q Demolition
working rar me in any captcity. workers'comp.insumaaa 9. Q Duiltling addition
[No warktns'comp insurance S. ❑ we age a corporation Wall its rugeited.1 odkas have imardsed their lec IO.Q Eniral repairs or additioes
1.❑ 1 am a homeowner doing all work ri1p� ke orcump por MO6 I I.Q Plumbing repairs or addWoro
myself.[No workers'comp. a IA f 1(41 wA wet have no 12.0 Rearrepaire
insurance required.)Is cmplayes.LNo workers' I).❑Othor
comp insurance req ba J
-nny apyara/�kr csole lea el ntttM>r.n0 w�M saris 6eMw atwly ta,k raA1a'orgwwio palsy insr"Asoo.
'I Lwwuweew who rulew Olt enlbeb inslodq they ate aft YI W"Me the No assists awmagrr sums rulsob a new Mae*6wiew.6 .L
<'."twone star'bark 1W bw nwe awslne a 3"liwwl at"dawiq Aw nwar of tke aOaarmrwa re 1hek sloe'awaF Ptiq'a�wWara
/awes en ewpYyer rAN d prat!/Iw;wwRwis'towprwmMe/wianwcr/rtr eq ray/oyeru aNer 6 tMioa/hyr war//si sGt
in/orsed" _
In..surance Company Name: yC 42/
Policy fur Self-ins.Lie.M khe, Expiration Date POI
!sib Site Addnse / City/SlatrQip:
.\crack a copy of the workers'compeamadom peuey dorlantlae pap(shawing the pNh y arsbor atsd esplratloe der$
Faihrre to%"urs coverage as required under Section 2JA of NGL c. 132 can Ind to the imposition of criminal penalties do
fine up to S I.J00.00 and/or one-year imprisonment as well as civil penahis is an ram of it STOP WORK ORDER and a One
.tf up to S2J0.00 a day apisinm the violator. Ile adviwxl that a copy of this statement may be rurwurded to the 0171ce of
Invcsoymiuna al'dte MA for insurance covcralps v%voikalwo.
/le hereby enrif velar he piw uw1 rh o On/try rAN tAw in�Nwerlaw Onri/d be uw rwf a wrrd
Dole! X;zalv
sly 7e-
OJJ/eisl ale mdJt Oo nor write in this weep te ste.urwp/ire/by city a sewn n//h•ir!
City or fuwn: YrrmiN.ltenst tr
h,uing.\mhunly(circle sine►:
I. Guard of IlralrA !. RuddlnY I/apartrttcnt J. City/roan Clerk t. Electrical Inspector S. Plumbing Inspector
/. t)ohe►
l.,.nleel Penton: - _ Phones:
,S CITY OF SALEM
PUBLIC PROPRERTY
0fiF DEPARTMENT
.I'.U:' N I�1 '•Nlr�'•I I
�.NIIL\L:�IN5I*$LET*5-%11]f,�1.\+i.\I I11 H I ..I'1•.
TFI:971-743-939S .r.\x:979.743-9446
Construction Debris Disposal Affidavit
(required I'ur 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 1,ertnit q 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
I11. S 150A.
The debris will be transported by:
.,I -1 11i / ih
t)lank of hauler)
The debris will be disposed of in
(n:uneut xi Ity
i
tuddrei4oflicility) ��-
f
/ Signature of lxrmit applicant
�Llo 0
Jate