6 NURSERY ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Town of
Board of Budding Regulations and Standards �01
Massachusetts State Budding Code. 780 CNIR. 7'4 edition Budding Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a MEN&
One. or Tyco-Fun a egrng
This Sectio For O sal Use Onl
Budding Permit Number: Da lied'
Signature: �1
Building Commissioner/Inspee of Bui dings
LZ
SECTION 1: E INFORMATION
1.1 Property Address: �� 1.2 Assessors Map d Parcel Numbers
(� Lit SP..itA
Map Number Parcel Number
1.1 a Is this an uc ted tree''.r Yea ✓ no
I Zoning Information: 1.4 Property Dimensions:
Zoning DistrictProposed Use Lot Area(sq it) Fromage(It)
13 Building;Setbacks(R)
Side Yards Rear Yard
Front Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:(M.G.I.C.40,134) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Cheek it veso
SECTION 2: PROPERTY l O�WtNERSHIP'
Ll Owoer'o�Re fill / _ 1 i_/' ¢1 A (, tv U/S�{c.(
Y< ..M.M �tiFF CKO1� ZL7t-r
Name( nt) Address for Service:
7$1 — -710 - SU`( Z 4Q2
tp:anxt Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Constitution O Existing Building O Owner-Occupied O Repain(s) O Alteration(a) O Addition O
Demolition O Accessory Bldg. O Number of Units_ I Other O Specily:
On De ion of Proposed Work
('Tvr wM..elt g 'tit 12rep�w4 0 � a� renr�e
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item t Labor and Materials
I. Building f I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Eleencal f O Total Project Cost'(Item 6)x multiplier x
Plumbing f 2. Other Fees: fj
a. Mechanical (HVAC) f List:
t Mechanical (Fire f Total All Fees: S—
Suppresiionj
Check No. _Check Amount: Cash Amount:_
h Total Project Cost. f O Paid in Full O Outsundmg Balance Duey
.2�
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supers isor ICSI.)
Licen%c NYniblr Expiration Date
Nyoe ut CSL ItylJer Let CSL Type I cc hrlow)
► v
A JJress Type Descn non
U I Unrestricted u to 35•000 Cu. Ft.
R Restricted Ii62 Family Dwelling
5rynainre
N Masonry Only
RC Residential Roofin Covering
Telephone wS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
kthis
Company Name or HIC Registrant Name Registration Number
ss
Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. I52.1 2SC(6))
rs Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
?davit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........O No...........O
SECTION 7a.OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. as Owner of the subject property hereby
authorize to act on my behalf.in all matters
relative to work authorized by this building permit application.
Signature of Owner Dan
SECTION 7b:OWNER'Oft AUTHORIZED AGENT DECLARATION
1, as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application arc true and accurate. to the best of my knowledge and
behalf
i arm
Signature of Owner or Authorizeda-Agent Date
(Signed under the gains and penalties of
NOTES:
1. An Owner who obtains a building permit to do his/her own work.o►'an owner who hires an unregistered contractor
(not registered in the Home Improvement Contractor(HIC)Program), will gg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 790 CMR.Regulations 110 R6 and I MRS.respectively.
2. When substantial work is planned. provide the information below-
Total floors area(Sq. Ft) (including garage. finished basement/anics.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 ofheaung system Number of deck s/porches
Ty pe ufcooling system Enclostd Open
t "Total Protect Square Footage"may he.uh.tituied for Total Prolcct Cost"
CITY OF SA Y. N(
PUBLIC PROPERTY
DEPARTMENT
u.u�asaY ouraaL 130 WASUPOG aN SMOM•S•uK%UZM0&Sff s 01"
M r.s-7+sss+s . t:.uc 975.7+aesw
HOMEOWNER LICENSE EXE.MMON
Pion" "I
Dar. 11 a o
Job Location �o �j tNS Sr
Home Owner Address u v g-U�
Home Owner Telephone — M/k O 16 63
present Mailing Addrew i- /1k=Lid UA r L , n
The current exemption of"Homeowners"was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who does not possm a license.Provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNMt
Persen(s) who owns a parcel of land on which bWsba resides or intends to reside, on
which there is. or is intended to be.a one or two family dwelling. attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one hone in a two year period shall not be considered a homeowner. Such
homeowner"shall submit to the Building Official.on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit
The undersigned "homeowner" assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeownw"certifies that he/she understands the City of Salem
Building Department minimwn inspection procedures and requirements and that he/she
-mill comply with said procedures and requirements.
HOMEOWNERS SIGNATURE `
APPROVAL OF BUILWNG INSPECTOR
See other side for state code
Ma4sachusetts- Department of Puhlic Safety
Board of Building Regulations and Standards
Construction Supervisor License
License: CS 391W
Restricted to: 00
RAYMOND H FITZGERALD
2 ORCHID CIR
BURLINGTON, MA01803
Expiration: 9/29Q011
('ounnisvionrr TrB: 6136
�e '�owhxaw�ea� o�✓utraeaa�eraslQ '
Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR
'19 � -IM;.�
Registratiotth. 161897
Expiration- :'f2/9/2010 Trill 278731
Type private Corporation
S .1
FITZGERALD CONS--TRUIGfitO ,S�ERVICES INC.
F RAYMOND FITZG�RA`LJ�
2 ORCHARD Cl jP
BURLINGTON MA 01803 ,ldmiaistrutor
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
}p..•1,,n I ie V('.\il IIXG;l!N S t NECT 0 S.\I P\1,
TH:97 8-'45.9i95 I°.\x:978-74D.10M
Construction Debris Disposal Al idavit
(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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
CL 1J v\ 2A
oor,4tn G
n�-0.1 /t2f
(name ofnauler)
The debris will be disposed of in
___ (name ul aci tty)
(address of(acil(ty)
.ignalure of permit applicant
11k � 09
date
CITY OF & .E.�[, NvL-kSSACHUSE-M
BL'D.DLNG DEPARTMENT
120 WASHLNGTON STREET, 3m FLOOR
TEL. (971) 74S-9595
F.tx(978) 740-984
IC],IggRLEY DRISCOLL
MAYORT one ST.Pmam
DIRECTOR OF PUBLIC PROPERTY/11UMM443 CONDf2SSIONFA
Workers' Compensation Insurance Afndavit: guilders/Contractors/ElectrlclansiPlumbers
lnnlicant Information �Please Print Leaibir
Name (Busher 0rwnttatiomindrvtdual): Ft�,6��� IC C�� t tan mid CPs c
Address: .Pl— CI r_Cj e__
l c� 3
city/state/zip. 3.,d I:nA-�6 r% Phone#- 7 Ff t - -719 - o 4/-2—
Are you to employer?Cheek the appropriate box: Type of project(required)•
1. 1 am a employer with 4. ❑ 1 am a general contractor and 1
employees(full and/or p -time).• have hired the subcontractors 6. ❑New construction
2.❑ I am a sole proprietor or partner- listed an the attached sheet : 7..,431remodeling
>hip and have no employees Them subcontractors have a. Demolition
workingfor me in an capacity. workers'comp.insunnoe
Y P tY• 9. C] Building addition
(No workers'comp. insurance S. ❑ We are a corporation and its 10.0 Electrical repairs or additions
required.) officers have exercised their
).❑ i am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.f 1(4),aml we have no 12.E Roof repairs
insurance required.)t employees. LNo workers' i tQ er �-
comp, insurance required.j
Any applicant that checker ball Of mull also N uuo the rclion below slowing their vorkere'cor pmwaf a policy inrmttLloac
'I hettewraaa who sutenit that allldwvit indicuing they atv doins all work arse thes hit*cloiAe coetrncaen must nhmit a new affidavit indkaaiaq such.
:c.,Mmim Also clack this but mud attached an addltiawl ahem dewing the name of tiler aA.t*mrame,a and their wptwro'cones.policy i*rYrrtl M L
Ian as employer that b previdlnB workers'romproom don buururea for try emplOY"S Below/s/he pellq aw//oI star
Insurance Company Name:
Policy All or Self-ins. Livc.1ll: Expiration Date: -
Job Site Address: �e I"yv'se. City/StatrJZip:nc� (ervtr W,
,%ttach a copy of the workers'compensation policy declaration pap(showing the policy number and expiration date)6
Failure to secure coverage as required under Section 23A of MGL C. 132 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•fiat
Of up to S250.00 a day against the violator. Its advistxl that a copy of this slatement may be forwarded to the OtYce of
(IriYallgallUala Uf 1he DIA for Insurable coverage velhcation.
1,10 hereby terrify milder the prowsa/n��d(�pena/h/yes aIfPeerj_ury that the informselaw provided above is true mild currtea
`immure_ r1 t Lt— ✓�.J�'� � I)ot¢: .1 L � t� /�--t
Phoned: -7T1_� �-
D/flcial use otdy. Do not write in this urea, to bt Completed by c'iry or tows u/f a-id
Cory or fawn: Pcrmit/Llcense M
Issuing.wharily (circle une):
I. Iluard of Ileallh 2. Building Department 5.Cilytfown Clerk 4. Electrical Inspccto► 5. Plumbing Inspector
6. Other
lmiflicl Person. ._. __ Phone N: