3 OAK ST - BUILDING INSPECTION (3) �> The Commonwealth of Massachusetts
} Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, Ph edition OF SALEM
6(/ Revised Junnury
7 Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 20011
One-or Two-Family Dwelling
s Section For Official Use Only
Building Permit Number: Date Applied:
Signature: ! r�?j r (z) _
Building Cu tssioner/I I 6ildinp Date
TION 1:SITE INFORMATION
1.1 Property Address: 9 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq il) Frontage(it)
I.5 Building Setbacks(R)
From 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 Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?Check if yesC3 Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
N �{,(
✓�✓/ 'n/K/� ��Ly Addrc�sa for Service:
Si tune Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition Cl
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Speciry:
Brief Description of Proposed Work':
�' �,�y-e bees_ � �pac•e ��.��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials 011icial Use Only
1. Building S S U v I. Building Permit Fee:S Indicate how tee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. OthprFees: S���!!
4. Mechanical (FIVAC) S
5. Mechanical (Fire S
Suppression) Total All Fees:$
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S 3, 3�� ❑Paid in Full ❑Outstanding Balance Due:
� D6S
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed ConstructionSupervbor(CSL) �905-6�
/I,yL//, Oq �— License Number .rpi ion Date
Name ol'CSL•I r luldc List C'SL'rype(see below) W s
o Description
U llnrestricteJWDwell
0 Cu.Ft.
G- R Restricted 1wellinSi naw� M Mason OnRC Residenial RrinTelephone WS Residential SidinSF Residential Smin A liance InstallationD Residential D
5.2 Reg stered Home Improvement Contractor(HIC) / SD 6 1 1
HIC Cum any N...yynne ur IIIC Registrant Name
Registration No er
/,-,)
AJJress'�' V J �7S ,U6 5^ 'xpira� n Date
!0- L
Signature F ' 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.
Signed Affidavit Attached? Yes ......... No...........❑
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 Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 no have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,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 hearing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF S-UI &ti(y ILkSS.XCI-Hi:SEM
Wari iG DEPhRTtENT
120 WAiHCVGTON ST&W, Ya FLOOR.
Tom. (978)745-9595
F.ut(971A 74&9&M
KI\IBE.ALEY DRISCOLL
HAYOIt I1tOtdAi ST.PaRlla
DIt1 WMA OP FL OLIC paoptjtTY/KaDNO CO.%LvnSSION slid
Wurkers' Compensation Insurance ARldsvit: Oteilders/Contractors/ElectrlclansiPlumbers
aunllcant Informatlos ^ Plew)Print Legibly
�/J�
V0111e ItlwtneuOrt,atuaneM1ltlJtntWalY• ` Q r/��- 0A�C'T`J�y�'7`1//� l
Address:
Cify/statelzil C v 4aY=
,ere yen an employer?Cheek the appropriate bear Type of Project(rprlrea
I. 1 am a eanployer with_�_ R. 0 1 ors a general cGaatteat and 1 L 0 New cowasaetion
cmploywo(Rdl and/or part-tine).• have hired the au►cmmacmm
2.0 1 am a sale proprietor Iw partner, lined m tMamsehmd siwet t y 0 Remodeling
.hip and have no cmplayces These sub-comaemn haw P. 0 Demolition
working for mt in say capacity. workers'comp.intonate 9. 0 auiWing addition
(No workers'comp insurance S. 0 We an a corporation and is
regstiraLl
olYkars have ennalnil their 10.0 Elocuical repairs or additions
).0 1 am a homeowner doing ail work risk of eatemprion pen MOL 11 bing repain or additbtn
myself.[No workers'comp. c- 1 52.I10),and we haw no 102 -42suar.poiss
insurancerequired.)r .mployeao.lNeworkers, I3.0Otbw
cornµ ineursnee requisd l
•ear•rpbao iti slew eta ri nwar sire na era Ile Ircuen brew I I lb*wwt w'eaare.+.wary infimmoda L
'I himam o who rubmie IIb raldwk indloaiq Ihq an Men YI weak sate ale him rush raaeaerwe nttmr wdwb a raw dff&.a ineteaion eNL
:C. tow ws tha rbwk this lien setae JON%e a addidww Shen dtawins den now arty w167ewrrryte end th.le wotbam'w"F inky inawwtWen.
/uen saw rwrpkyd rAae tr prmdl/wg tomrRers'cowpawsedrw/waments�ir aq esttpfoyeea oeMr tr the pNlep ew//e1 sGr
informed*&
In,urince Company.Name' Q
Policy M or Self-ins. Lie.e: Expiration Duo:
Jub Sire AtWresa � �� s'T CityiStawZip: old
,knack a copy of the werken'compansawn Policy derlmlbo pop(showing the polky number and expiration dase)6
Failure to secure coverage as required under Staten IJA of MOL a 152 can lead to the imposition of criminal penalties of
fine up to S 1,500.00 and/or one-year imprisomnem,as well as civil penalsice is the farm of a STOP WORK ORDER artd a floe
.If up to S270.00 a day auainst the violator. lie advi.+ai lhet s copy ur this statement may be furovarded to Cho 0121ce of
Iitvvailgatiuna ul'dte MA for insurance cavcrop wriricrtioo.
i de hereby a under the pains andp1mytiew ajper/sq Cher tAe in/arwerfewOnrilr/upaw is true and cwrrd
Z!x 4.4 4 A Dots:
P`urc k
(7/F&i91YIrY/IIy6 DonW Wife in Phil dreg/ebe.utwpirrdby City ortear.n//BirL
City or rune: Pcrmir/Llcemee__. _. _ I
hsuing Aahuniy (circle one):
1. Ituard of 114411111 2. Ruddlnu I)epartmvnt ). Citytrowa Cierk t. electrical ntspeclor S. Plumbing Inspector
6.Other
L,ntract Penae: _ . _ Phone s:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I'.11: M11) ' Mlr, ll
Ile\1l`.%qII%4"'I.'4SI$kfr esmi N.%l.%%i%I 111 J 1.•.Pr•.
I'n:vll..'i}�{a! �f)x:v7t1•NSIs+rl
Construction Debris Disposal Affidavit
(required liar all demolition and rcnovuliun work)
In accortdancu with the sixth edition of the State Building Code, 780 CMR section 111.5 k
Debris,and the provisions of MGL a 40, S 54;
building Permit 0 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
I11. S 150A.
The debris will be transport fed by:
me of hauler)
The debris will be disposed of in
narnt ul aei rty .
I:Iddroa I/r ra.1 Iyl
y signature ur Ixrmir applicant
date
�IassachusetK- Department of Public S:ifcty
t Board of Building Rc�dulaliuns and Standards
Construction Supervisor Specialty License
License: CS SL 100562
Restricted to: RF,WS
DAVID .MOORE
3 OAK STREET
SALEM, MA 01970
o7�L �/1jE Expiration: 911 S12012
('aumi.aivarr _. Tr#: 100562
,� ���
- Odlet of Consumer ARalrs&Business Regulation
IMPIRCIVEMENT CONTRACTOR
ReglstraUo140617 '
-Explradotr3 4f12P2012 Tr9 294008
TypeJA-b9A
CODA ROOFIN(j� '� i
DAVID MOORED-.' � �,
�.
3 OAK ST - 6,. a � _
SALEM,MA 01970
Undersecretary