4 NURSERY ST - BUILDING INSPECTION i
OThe Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
19 Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
F
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tiro-Fmnih•Dwelling
n For Official Use Only
Building Permit um r: Date Applied:
Signature:
w dig o iss ne/ s t ui ldings Date I
SECTION 1: SITE INFORMATION
I.1toperty Address: 1.2 Assessors Map dr Parcel Numbers
N SOH Sr
1.1 a Is this an acceple street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
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:
Publi Private ❑ Zone: _ Outside Flood Zone? Municipat&On site disposal system ❑
S� Check if yesCl
SECTION 2: PROPERTY OWNERSHIP'
1 Owner'of ecgrd: C
va vd Inc Iy✓Y C w u .) �- -5e (r, m
Nam (Print) Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Buildin Owner-Occupied-O I Repairs(s) ❑ Alteration(s)-6'I Addition ❑
FMcchanical
on Accessory Bldg.O Number of Units Other ❑ Specify:
scri,PLion of Proposed Work': i v i e Y rO<
} � J0 hreQryc�nn S a � Q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Labor and Materials
g f J t �p o 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
cal f J - O 0 Cl Total Project Cost'(item 6)x multiplier x
ng S a,Cb® 2. Other Fees: f
ical (HVAC) S List:
5. .Mechanical (Fire
Suppression) S Total All Fees: S
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S SJ Oo n 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES !
5.1 Licensed Construction Supervisor(CSLillesidential
G(' � CI �•� Q ' o
1\.(�L\1'Y\M Cv \ 1 1 Z `)�Ccmber Expiration Date
N.4mc of C L. I Alder i'� �, ype(see Mew) v
I—,--
. ( �� C, Description
Add`es Unrestricted u to 35,000 Cu. Ft.
Restricted 1&1 FamilyDwelling
Sig attire ,Mason Only
17 Z I' 7�0` g0� 2 Residential Roofin Covering
Telephone Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Reg i tered HPTe(tmprovement ContraCtgr(HIC) f �+ ' t, -7
�� A 1@ `CT'1 S'�'�.I C��� JJ� >.Q✓J CPS _1r1 l
HCC ✓cL.` � Registraton Number
I (1N �� c � . nS-b I7-ILI � lO
Address � 01196S iration Date
79 /-7C'� _ 8'0 l2_ Ex p
Signature Telephone
SE IO 6: WORKE 'COMP NSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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......... No...........
13
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR Cl ONTRACTOR APPLIES FOR BUILDING PERMIT
1. 6-or k
J a-rd , &,,.1 d �, e__._ , as Owner of the subject property hereby
authorize -r .r-�R d to act on my behalf,in all matters
relative to work authibrized by this building permit application.
Si nature of Owner Date
SECTION 7b: O/W' NERt OlR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the sta merits and information on the foregoing application are true and accurate, to the best of my knowledge and
be If. I
'Z
Print Name
Oil
Signature o Owner or ut ortzed g t Date
(Signed under the pains and enalties of r u
NOTES:
r2. When
n 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 P�have access to the arbitration
rogram or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
onstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.RS, respectively.
substantial work is planned, provide the information below:
floors area(Sq. Ft.) 1SD" — 17 O U (including garage, finished basemenbanicdecks 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 5 FeG.m v l � Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage" may he substituted for 'Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
SKr . DEPAR'I'LiENT
I I I J'9.•J;. l;•,; . I %X ',.1 '4: '1i L.
Construction Debris Disposal Affidavit
ocoluiwd lbr all demolition and rcnovalion work)
In accordance W ith the sixth edition of the State Building Code, 780 C NIR section 11 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N 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
I 11, S 150A.
The debris will betransportcd by:et
Cev\�cccl JV j roS 'a_� 1 ► �4'd en r t V �
(name of harder)
Ilse debris will be disposed ofin
(nJlnr ul IJelhty)
- Iaddrra. uI'lacdirol
I 'nJ we nmt apphi nt
CITY OF S.U.EM, .LASSACHL;SETTS
BUILDING DEPARTNIE,NT
120 WASHINGTON STREET, r FLOOR
TEL (978) 745-9595
FAX(978) 74048U
iCt.,fBFRIEY DRISCOLL THols 1sSTYIERRB
MAYOR
DIRECTOR OF PCBLIC PROPERTY/Hl'QDLYC CONLMISSiONiElt
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Vamt: (dusine>LOrsaniratiominJsp (se-
city/state/zip. vteuJ): I TZ � Or$�
Q � r✓C+ t U` t, ,/ C t3 1 �n
Address: � r'C
- 0 ,i d C i r C
I�V r(, (1!�," ^ tf\�r O[ one N: -7 t [--7 FO - IF6 q 2—
ire you to employer'Cheek the appropriate box: Type of project(required):
L Li 1 am a employer with n_ 4. ❑ 1 am a general contrwhor and 1 6. ❑New construction
employees(full and/or pan-dme).• have hired the subcontractor r�
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet : yxl femaleling
:hip and have no employees - These subcontractor have 3. ❑ Demolition
working for me in any capacity. rker'comp.insurtim 9. ❑ Building addition
[No worker' comp. insurance S.. We are a corporation and its ME] Electrical repair or additions
required,] ot'ftcers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152.§I(4),and we have no 12.0 Roof repairs
insurance required.]t cmptoyeea. [No worker' 13.❑Other
comp. insurance required.]
-Any applicant their chub has rl must also fill We the Wiliest below showing their worken'st'"en onk,policy informstlon.
'I Lvtwuwrsen who sulonit this affidavit indicating they ace doing all work and than him otmide otesomion mint e.hmil anew afrlslovit indkming suck
:C.mtms:toa shot cheek this beet more anachod an aadittural rhea showing the name of is subeosanaon and their woAwi oanp.paucy informauoo,
l am an employer that is providlnir workers'compere radan Insurance for my employee& Below/i the policy and Job yffe
informations.In.urance Company Name: Mass
IQ SS wk P 7�
�e,4 r15
avC_\J1- aoug8467 _387
Policy Nor Self-ins. Lic, N: - Expiration Date:• r
Job Site Address: M"'�S 'Oyq City/State/Zip: JR (e -fl l w�� a 9 "70
.mach a copy of the worker'compensation policy declaration page(showing the policy number and expiration date).
Failure to sccurc coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Ik advised that a copy of this statement may be forwarded to the Office of
Invcsugationa of the DIA for insurance coverage verification.
I do hereby Certify under the ins n err es of p Ju that the information provided above is true and correct.
:n•r t tr gates �I�10,
iOfficial useauly. Donor write in this area, to be cunrpleted by t by or town a/Jkiust
City or Tuwn: Permitif.iceme N__
6suing Authurily (circle une): —
L Itwrd of Health 2. Building Dep;rrtment 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other _ _.
Cneuct Person: __ __ ___ ___ Phone N•