26 NORTHEY ST - BUILDING INSPECTION -� C Li -72
cr�t The Commonwealth of Massachusetts INSPECT10"NL S R CITY OF
Board of Building Regulations and Smndards Q� EM
Massachusetts State Building Code, 780 CMq �U OEC 3b Re4islur 2011
Building Permit Application To Construct, Repair, Renovate(�r Demolish a
One-or Two-Family Dwelling
This Section For Official Use Onl
Building Permit Number: Date A plied:
building Official(Print Name). Signature- Date
SECTION 1:SITE INFORMAT1( N'
1.1 Pro p er A dres : 1.2 Assessors Map&Parcel Numbers
9u, 11//Jje 5T
I.I a Is this an accepted treet?yes !.
� no Map Number Parcel Number
'r 1.3 Zoning Information: 1.4 Property Dimensions:
I Zoning District Proposed Use Lot Area(sq 11) Frontage III)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone. Information: 1.8 Sewage DDisposal System:
Public d Private❑ Zone: _ Outside Flood Zone? Municipal ET On site disposal system ❑
Check if ycsCl
SECTION2. PROPERTY OWNERSHIP,
2.1 Owner'of Record:
-TiraSe_J< MA ol�jt��
iT�me(Print) City,Slate,ZIP
v l a z'-' Owl 78/d��-3So
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: T11
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ �p I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x
J. Plumbing S 'PQther Fees: .S
4.Mechanical (lIVAC) S Lisle.
5. Mechanical (Fire S total All Fees:$
Su ression)
Check No._Check Amount: Cash Amount:_
6.Tutai Project Cost: .S /�o, SUO da Cl Paid in Full ❑Outstanding Balance Due:
9
Cl�Ll — —2
7
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) n_ _CIS 7
License Number Expiration Date
Nanre of CSL Holder List CSL Type(see below) u-
/ Type - Description
Nu.;aid Street -
Unrestricted(Buildings LIP-to 35,000 cu. It.)
rJe/ /Y/r4 d% O R Restricted 1&2 Family Dwelling
Ci lfown,State,ZIP M Miserly
RC Roofing Covering
`y- WS Window and Siding
SF Solid Fuel Bruning Appliances
I Insulation
'rele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) '. qy� _S_
-1 P CO )"<r _ HIC Registration Number Expiration Dade
HIC C Tpa n one or 111C Registrant Name
act l�ari>,,� sT
No.and Street Email address
Eaffidavit
nto oi90 y 7Bl -STi9 —t62I1
ate ZIP Tele hone
N 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.§ 25C(6)),
pensation Insurance affidavit must be completed and submitted with this application. Failure to provide
ill result in the denial of the Issuance of the building permit.
vit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION,TO BE COMPLETED WHEN.: ,,:
OWNER'S AGENT OR CONTRACTOR AIiPLIES FOR BUILDING PE"IIT
I,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.
Print Owner's Narne(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.
Print Owner's or Authorized Agcnt'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
(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. I42A. Other important information on the HIC Program can be found at
www.mass.�o� v'o=a Information on the Construction Supervisor License can be found at wwwK.nta�
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) ' .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. it.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number ofhelflbaths
'type of heating system Number of decks/porches
"I'ypeotcoolingsystenr Enclosed Open_
3. "total Project Square Footage"may be substituted for"rued Project Cost"
CITY OF SALEM, NWSACHUSETTS
Bt:I nwr,DEPART>I&NT
3 ) t 120 WASNLNGTON STREET. 3"'FLOOR
71EL (978) 745-9595
F.tir(978) 74M846
KI)IB RrFYDRISCOLL
r - TIgoh(ASST.PIEH B
DIAECTUA OF PUBLIC PROPERTY/01:1LDrsG CO\L\f155tONER
Workers' Comlkifisation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Annficant Informatinn Please Print Legibly
V;1111t (IlupinassOrganiratinn Individu;lq: �i��LFry /Af�iJ� �r)J.ST
Address: c>?is ✓cW,)_JA, ST
City/State/Zip: - a. tnA- of o Phone N: `7ql- S99 —
Are you an employer?Check the appropriate box: Type of project(required):
I.•0' I'am a employer with 4. 0 I am a general contractor and t
- 6. ❑New construction
entpiayees(full and/or pan-lime).* have hired the subcontractors
2.0 I aor a sole proprietor or partner- Misted on The attacked sheet.f 7. glemodeling
ship and have no employees These sub-contractors have V. 0 Demolition
working for me in any capacity. workers'camp.insurance. 9, 0 Building addition
I No workers*comp. insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of axempiion per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152,y 1(4),and we have no 12.0 Roof repairs
insurance required.) t employees.(No workers'
comp. inwmneercquired.j I3.❑Other
-Any applicant Ihas uhculis box al must also ail out me scctiva below showing their woden'compensation porky intimation.
'I lomeuwm"who submit this aflldwit indicating They m doing all work and then hit*outside contractors mmt submit a runs alltdavil indicating such.
$'.nilmium that Omit Ibis bux mml anachd in additiunal shml showing It,name ofthe subtontnetore and their wndmn'romp.pulley Infurinalion.
I sans an emptuyer that is providing Ivorkers'conriaeusadoa bssurauce for my employees, Belo iv is Ibs poNry and job site
irrjnrotutlnn.
insurance Company Name: 11441A
Policy iJ or Self-his. Lic.d: n&.1/� �i.ai3 Expiration Date: y—10 — 7�
Jub Site Address:o�& AINIT-heJ S-T City/Stute/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and explratlon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
line up to S1,500.00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S2M.00 a day against ilia violator. Ile advised that a copy of this statement may be forwarded to the Office of
hl1'Cfllgall UlLY Uf lI1C MA ror Insurance coverage vertlic shun.
/du hereby crrrify r oiler Uln pulns/and penirlrlcs of perjury rhor rbe injunuurlars provided ubrwa it true and corrrre
Phonc d:
Official wr only. Da not write in this area,to be completed by city ur town offleial
City nr Town:
Issuing Authority(circle one): -_— --
I. Heard of lleallh 2. Building Depaitulew I.fiiylrnwn Clerk J. F.lectrirsl lmpcctur 5. Plumbing luepeciar I
6. Other
I
Contact I'cnnn: _ Phan. 7: ,
CITY OF SALEK MASSAMUSETTS
BUILDINGDEPARTAENT
120 WASFBNGTON STREET,3w FLoaR
TEL.(978)745-9595
KBEERLEYDRISCOU FAX(978)740-9846
MAYOR THomAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING OCAWSSIONER
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
/2LI44,/7' ConIST. Dum4 ofZJCK
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
N
Date
e. k
« � qsr 44e!
.
/A#
z t �l�. \% »
< :s v »s �
V1LLJF#kl
[ a¥tem
as
iM.7\ \
i �yn
< 6 n,er / .
��® .
Page No. of .. Pages
WM TRAHANT JR. CONSTRUCTION, INC. ql C
215 Verona Street
LYNN, MASSACHUSETTS 01904 q
(781) 844-4551
Cell 7,51 M1-350,
PROPOS UBMI7rED TO PHONE DATE
7gI 63) -07a5
STREET r�4 Lm ,}{ JOB NAME
CITY,STATE and IP CODE V llJJ �'J A�1 JOB LOCATION
h'►�+b1e d M�,0)9 ab nb s� s41ern 11 .
'ARCHITECT DATE OF PLANS JOB PHONE
We hereby submit specifications and estimates for:
....... ....... ...
3 //
lA-d ......J Ac t-Ula4fa-, fCJG�d..
n ......... .....................
3 ..... l.d.Ur 4n. y.. ! M. a«.t.��. � l_r►rn .......
......... ................_ ............... ............ ��(�"}G1n7�� 1 ...................?
............. Ao-a-a-SIC....................../,r ... G�uy,f�2....Gq-G..l ......
S2...... 3 11
......c��.� �� .....� P ,.�, f N4i ci��.......
6. .SArl all _4e,,(✓ ....�aw ✓� a uJ ......
.._..................................
............................ I L
t44 ... Szr Co{^Yl2YS
.....
PVCIn/4{er5
Or FrOpOSC hereby to furnish material and labor—complete in accordance with above specifications, for the sum of:
Payment to be made as follows: 11 dollars($ /v rod
d ).
Uv 46 GIC 9 3 Q 6
All material is aranteed to be ass cilied. All work to 6e completed in a workmanlike
manner according to standard practices.Any alteration or deviation from above specifications ' Authorized
involving extra costs will be executed only upon written orders,and will beccme'en extra Signature
'charge over and above the estimate. All agreements contingent upon strikes, accidents
or delays beyond our control.Owner to carry fire,tornado and other necessary insurance. Note:This proposal may be - 2
Our workers are fully covered by Workman's Compensation Insurance, withdrawn by us if not accepted within J d days.
—7
�►ereptttnre of proposal —The above prices, specifications
and conditions are satisfactory and are hereby accepted. You are authorized Signature
to do the work as specified. Payment will be made as outlined above.
Date of Acceptance: OQ+ 1 q Signature*2