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16 NURSERY ST - BUILDING INSPECTION The Commonwcalth of Massachuscits UI of Board of Budding Regulations and Standards *Mzi Massachuscits State Building Code, 780 CNIR, 7'"edition Building NOW Building Permit Application To Construct, Repair, Renovate Or Demolish a One- or Ttco-Fir ulP Duelh-- This Section Flar Official Use uiyy Building Permit Num r: Date• ed' Signature: J o 13 O Building Commissioner/Inspector of Butldt Date SECTIOIqY SitE INFORMATION 1.1 Pro rty Address: 5. 1.2 Assessors Me & Pare Numb r (la 215 1.Is Is this an accepted strect?Yes—fief no Map Number T Parcel Number 1.3 Zoning Information: ^ I. o erty Dim dons: R �p / ut.-r- I r g Zoning District Proposed Use Lci A Na sq fl It Frontage((1) 65 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Informs'on: 1.8 Sewage Disposal System: On site aI Zone: _ Outside Flood Zone? Munici disposal system O Public�( Private O Check if esO P �o Y SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner' Na rin0 Address for Service: � RZS' 7419 &C ?�3 Signature f Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction O Existing Building O Owner-Occupied Repairs(s) O I Alteration(s) Addition O Demolition O I Accessory Bldg. O Number of Units_ Other O Specify: Brief Description of Proposed Wo '• 'C Q LO its ! cz r SE ION 4: ESTIMA ED CONSThUCTIblit COSTS Item Estimated Costs: ORlelal Use Only Labor and Materials 1. Building s ;3p p06,0 0 1 1. Building Permit Fee: f Indicate how fee is determined: O Standard City/Town Application Fee 2 Electncal f '�„©�®,w O Total Project Cost'(Item 6)x multiplier x J Plumbing f 3000 O d 2. Other Fees: f 4. %1 chanical (HVAC) f CJ o® , ©� List: t Nechamcai (Fire f Total All Fees: f Su res.ston /� Check No. _Check Amount: Cash Amount:_ 6 Total Project Cost: S 3 6, 1; B 0 Paid in Full 0 Ouutandmg Balance Due: r SECTIONS: CONSTRUCTION SERVICES 5.1 Licensed Construction Supers isor(CSL) �r r � �,� ys3� !o e lr Li.enw NumRr Esp Iuo Jl' e,-fiLr,i CSL Type(are below) /ce� T Descri no r A ss �.A� M q o t c X� U Unrestricted u to 13,000 fu. Ft C �fV� R Restricted 1A2 Family Dwelhn !i nalYfcey r� Co �ySyl I Masonry Only q 2 O /s C .%�Co O RC Residential Roofin Covenn Tone WS Residential Window and Sdm SF I Residential Solid Fuel Burning Appliance Installation D Residential Demolition 3.2 Registered Home Improvement Contractor(HIC) Cllveye ;� HIC Company Name or HIC Registrant Name c guva N mber (,(��0 V Address /'L a s.� Expiration Data Signarure Telephone aoco SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.J 2SC(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 Aftdavil Attached? Yes.......... No...........O SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CCONTRACTORr APPLIES FORBUILDING PERMIT I, I t1 D i h.CL !� 1 � F , !n C t� IV' n o the subject property hereby authorize im -IaAcLel t3CA VIN IP V to act on my behalf,in all matters relative to work authorized by this building permit application. , p /0-'�`I-� Si nature of wrier Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION 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. G Print Name y SignatureAf MneiFoAAulhorized Agent Date (Siblited under the pains and penalties of perjury NOTES: Eon Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor t registered in the Home Improvement Contractor(HIC)Program), will gg have access to the arbitration gram or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and nstruction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I OA6 and 110.RS, respectively. en substantial work is planned,provide the information belowoon area(Sq. Ft.) (including garage, finished basement/amics,decks or porch) ving area(Sq. Ft.) Habitable room count of fireplaces Number of bedrooms of bathrooms Number of halfbaths hearing system Number ofdeckst porches cooling system Enclo,ed Open tal Project Square Footage"may he.uh,tilulcd for Total Project Cost' CITY OF S.1I.E.N1, , LxsSACHUSETTS BL'RDIING DEPARTNILNT • 120 WASHIINGTON STREET, 3w FLOOR TEL (978) 745-9595 FAX(978) 730-98U K1�lBERLEY DRISCOLL MAYOR THo&w ST.PmM DIRECTOR OF PLOLIC PROPERTY/at:IIDLVG Co%013SSIONER Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name (ousinv,Orgarairationlndsvtdual): r"� �G 1 � � l � . �OL V v11 Address: 3 60 Come—'e" City/State/Zitr �/n V-e✓' S ►y1 A- Phone a:T9'7 S' (ova -Co ( S 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 I w have hired the sub-contractors 6. ❑New construction employees(full and/or pan-time). y� 2� 1 am a sole proprietor ar partner- listed on the attached sheet : ?• ,cal Remodeling :hip and have no employees These sub-contractors have a. ❑ Demolition - working for me in any capacity, workers'comp.insurance. 9. ❑ Building addition I No workers' comp. insurance S. ❑ We ate a corporation and its IO.�Electrical repair or additions required.) officers have exercised their 3.El am a homeowner doing all wont right of exemption per MOL I t.�,Plumbing repairs or additions myself.[No workers'comp. c. 152.§1(4),and we have no I2.0 Roof repairs insurance required.)t employees. [No workers' 13.❑Other comp. insurance required.] 11 -Any applicant that Ch"JUI Dos Of must also fill out the seelim below showing their worker'cornpmudiln policy infunnAeloo, '11, n cswnas who submit this aMtbvlt indicting Ihcy an doing all work and then him amide emtrnceon nwa suhesil a new anidavil indication suck j :C.n~,nm iha cheek this haw muse adecked an a,Wiliond,hsn showing the rams o<IIM auheomneters and ikek wohan'comp.policy ink n uwm. I um an employer that hr providing•workers'compensation Insurance for my employees Below ls the poilry attd/ob sin information. Insurance Company Name: Policy N or Self-ins. Lie.N: Expiration Date: Job Site Address: City/State/Zip: ,%rack a copy of the workers'compensation policy deelaraflon page(showing the policy number and expiration date Failure to secure coverage as required under Section 25A of MGL e. 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 5250.00 a day against the violator. I)e advised(hats copy of this statement maybe forwarded to the Offrce of Inv.•otlgatians al'the DIA for insurance coverage verification. I do hereby aertiffyyrw/underr ttjhe pains and penuldes of peelery that the informmloa provided above is true and correct. n Date: Phone d� 17S �D rl. 2 n iDfrecial use only. Do nor wrile in thin area, to be,urrrpleted by city or town o/JlciaL i City or ruwn: eermitil.lcense Issuing.whority (circle one): -1. Board of Ilealth 2. Building Department 3. C'ity/town Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other L ontact Person: _ _ ._, __ Phone N' CITY OF SALEM , i PUBLIC PROPRERTY DEPARTMENT S�,I�. NLF.,I•R,,,.i•11. - �t`., R 120 WAS IIM;I'ONSCRUT #SA I'M. 'ViAsliV lit it I I<JI`,%� fel,9711a4 9ws . Pax:978a40-9846 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 c 40, 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 disposal facility as defined by MGL c 111, S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in .- (name of facility) ' RA-- .33 Gr efn1 �c-5v" (address of t'acilit 53)--`� �g sigt ature of permit applicant 0� Lo --r date Jch u�!(Cu< 07 �o�lu llau Board of Building Regulatiode and Standards Conatmcdon Supmvtaor License f + u, Liee-CS 48385 -2 I2{10 Tri 18725 r ExpiraBort�= . i MICHAEL W BARNET' '. 98 GREENST DANVERS,MA 01923 - Commissioner DNT OFOF IiUBLIC SAFEly I Hoisting Engineer License , 11220 Number-"HE ac\, '! - 0 10 Tr.no. 16678 ea Restdcted..� �. 1 B ICHAELw M 98GREENST DAM/ERS, MA 01923�-' COMM stoner