35 OSGOOD ST - BUILDING INSPECTION (3) A 'rhe Commonwealth of Massachusetts
J Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7m SALEM
edition
Revised J<IRHOly
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1. 2008
One-or
is Tenon or Dwelling
This Section For Official Use Only
Building Permit Nu r Dale Applied: 6s 2
Signature: - 'Jr' i'z-b'1 Z
Buil ng Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property ddr ss: 1.2 Assessors Map& Parcel Number
�a n'x�cr4� 1 XIA
I.I a Is this an accepted street?yes V no Map Number Parcel Number ,..
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) - - Frontage(it)
1.5 Building Setbacks(R)
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:
Zone: Outside Flood Zone? * D
Public IN Private O - — Check if es❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
VY VY'rA Y1O V
Name(Print) Address for Servse: V
UI7��32 S�3n
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) Q
IT
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Alteration(s)' Addition ❑ n`
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': I ZS
(TIN e2ft V)
SECTION J: ESTIMATE .ONSTRI CTIO COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1 Go O I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
O 0 U ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S �
4. Mechanical (11VAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: Q(57 00)0 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
rt5/.�1 Licensed Construction Supervisor(CSL) l7g11 'R G ' iolC>
License Number Expimtiun Date
Name of CSL-IIoIJer L List C'SL'rype(see below) _
iv\�P r Desuri Lion
Address U Unrestricted u to 33,000 Cu.Ft.
R Restricted 1&2 Family Dwellin
Signature M Mason Only
'a (N-16p RC Residemial Routing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
C l d } D I Residential Demolition
3.2 Regbterf�Home mprovement Contractor(HIC) 1 l�31 a,
�i otCln/ a�,o 1r�Pct+y ���t
Registration Number
IIIC Company
olli 06/bolo
Address �—!q" l,��yb, Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION 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:O 'AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S iG OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�-
I as Owner of the subject property hereby
authorize to act on my,behalf, in all matters
relative w thorized by this building permit application. -
nor
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,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 Mal 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 I IO.R6 and 110.115, respectively.
2 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenUamics,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 healing system Number of decks/porches
. Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SM..F.M, AASSSCHUSETI'S
13LML)LNG DErmnilrlT
120 W.%smLNGTor4 STREET, )'a FLOOR
TEL (978) 745-9595
FAX(M) 7O-96"
KI.MBEA"Y DRISCOIl
MAYOR �Iosw ST.PMaRa
DIRECTOR OP PC eLIC PROPERTY/8t:MDLVG CO.%L%0SSI0N Ei
Workers' Compensation Insurance Allldavit: OuiiderslContraetorWElectricianslPlumbers
%nolleant Infflrmada
V21119 (aust�Orgatttreiorbltrkv,du-J): U
Address: Orr& II04_vt BWUIII- U'/t.4 M10t c4
cily/state/zia `Bfc-v Piton w:
,\re you its empleyw9 Check the a propriat boa: Type of project(required):
1.❑ I am a employer with 4. Q 1 am a Vnenl conawtor and 1 b, Q New conscrurdon
employees(full and/or part-time).• have hired the sub eaesremr
2. 1 an a sale proprietor or partner- listed on the d si anschores- : 1. ❑Remodeling
:hip and hove no employee Thee sub-comnemn hew tl. Q Ikmolition
working for me in any capacity. worker'comp.inatusaoe. 9. Q Building addition
INo workers'camp. insurance S. Q We are a corporation and is 10.❑Electrical repair are a SditioM
required.) otYkm have exercised their
).Q 1 am a homeowner doing all work right ofeaemption per MGL 1 I.Q Plumbing repairs or additions
myself.(No workers'comp. G 13Z f 1(4),atd we have no 12.0 Roof repair
insurance required) ► %:rnploy=&(Now rkeW
quire I I.Q Other -
comp+inarrrarhoe rquiretl.J
•Any appatwe 1101 dlaehe bi rl owM alas no tea the M1`40 b1bW A@eieg Lade we tea' pWky inpunyloa.
'16wwuwmm who aWwA iris alllnwie idhariq they an Joint)tit work awl them him aarii ceekecom mum atthmk•new aM bvi1 indioriog sane
i'.we:rote thM Awk this bet mum anachue an 3"600MI AM anwitM do nrr-ten st►eeetedete Ltd thab wutlMR'mrtP pdieyr ttaaor ud m
I one raw employer thor tr prsvl//nR workers'cowpromeden/nsnrts omfor wy eaeplorees. Sebw/s Me p0ft&A41fM s/b
informed#^
Insurance Company Name:
Policy 4 or Self-ins.Lie.hM Expiration Date.
fob Site Addicts: City/StawZip:
Attach a copy of the worken'compansinoa Polley dseWatlan pop(showing Ihs polky number sad espirsdon dNe).
Failure to secure coverage as required under Section 23A of MGL a 132 can led to the imposition of criminal penalties of a
nine up to S 1.500.00 and/or one-year imprisonment.as well as civil penalties is the form of a STOP WORK ORDER and a fine
of up to S270.00 a day atlainst the violator. Its adviwed that a copy of this slatemem maybe forwarded to the Office of
Itw.anyatiuns afilLe MA for insurance covcraga vcriticatuat.
/de hereby certify met r rho priws un Pere/Net of perjury that tAw in/armadem provided ubove is true and a antea
I I) : �° a
� 8 .3 -(, 7y c �J , KI
Pht+ne A:
O/JJrir1 use sad). Oo not write in 1A&arts.to be etnep/rld by dry w rown n/fh•iet i
� C'iry or town:
I+tuing.\ulAunty (circle tine).,
I Iluird of Ilralrh 2. Ruilding Deparrmcm ). C'ily/town Clerk 4. Electrical Itrepeclor S. Plumbing Inapeetor
6. thher
l .nl act Penan: _ _ _ Phone r'
,A CITY OF SALEM
PUBLIC PROPRERTY
�N
•.� DEPARTMENT
I.0 WA+111.\L:O.V)I'll kl"r 0 S•11I\I, II J I ,+.W _
fFI:471.74}-9595 tr 1'.%X:778-74019446
Construction Debris Disposal Affidavit
(required I'ur ull deniontion cold renovation work)
In accordance with the sixill edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p . _ 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
1 11. S 150A.
The debris will be transported by:
mama of Iwuler)
1'he debris will be disposed of in :
(numa OF a�n�
laddraxaul'Iacllily)
+Ignalure of Ixrmil�pplicaM
,lata
Id„i.dl,:a
------------
Huard of Budding Regulanons and Sland.lydr.
1 SAir]
HOME IMP)IOVEMENT CONTRACTOR
` Registrptiont, 116312
Expiration. 6/6/2010 . Tr# 269653 ;
Type; Individual
MICHAEL OSSORNE 1
MICHAEL OSBORNE j.
EVEKY MA 01915 1dn i���oa n
a . . ;.. \1ass:ichusetts- Department of Public Safety`
Board of Building; Rl'g;U181111n5 andS[undards
-- Constfuction,Supervisor License.
License: CS 92158
Restricted to: 00
MICHAEL H OSBORNE
,a
30 DOLLOFF AVE
BEVERLY, MA 01915'
Expiration: 9/8=10
e. . Tr#; 3376 -
Page # - of-- --pages
N1 ;ch�-gel u�bocne Cs#o`�,�, IS�
�ve�ly MA o iq I>
LG
Proposal Submitted To: Job Name Job d
3S U 00
Address Job Location
Date Date of Plans
Phone k Fax N Architect
We hereby submit specifications and estimates for: C l eQn 'WS+I n Ck4 Ck, Re G 1 Who 2k I Sal a15 �ZdCGo�/�'fi,
weal lS ,P(�me (�c, nd , L�1S{q 1 � �c>t, r new dec+n (a l
owlets In ectil (oort-I rt�MCA,nii rt t a Vi,lq QGIIC, RCS Ceilin� ' bbI
jnS�,,,U lieW
CrS�Gil new elcc�(;cC6 �n out wi 4 )A -�ococ, n rc1I
flew `�� �IGvC eve( wheCe excel+- 1�`d400�1S, �5l-all new c�e5 hea+�r 1 n
J,II new Six ?Gnel G�aocS.
k �
new ic) 4 Cc�un _\ -Iop _ � bnli _1�ew >> n�te
if s}c�li new h�� t xa eS t�ea�et an hicc� �Icn -1(1s}Gll rfew Lk6 Ix,v hcnG
Oxcd {,-yN en};ve 4-k;rd gull6(D{)n )icJ cct;e �;J�' 34cK 5lo(a�e
-rn�+Gil rlew Ixx(c In oa cud oor 1locui LinoliUrr in
�fl�IClll �eW S�ICQI �}QtCCGS� �"4'>[t} C,J111 I've Q(,{�C�1CiSeC{ ly Ot,�(1C'.(.Zt�}QII 11eW U�oj(G�C'(�
3.aa amp elec�Cical SeCvIC��-Irr)Gll of w �cAl on` 9Ak-VIC(O� house . LvfAnII S
Ile
u fTV_k7� tr-Ank5 cn Z(ki oS ,c-)Gi }xyrh�, �,�SEY�n 'new �lec��;cc,l ''>e(vtte �n 4h;rL� i I coy.
We propose hereby to furnish material and labor—complete in accordance with the above specifications for the sum of:
q _Qi1}y SJcn �l` ckXASclfli)f 01-1c Dollars
with payments to be made as follows:�rnGU i n 7� )O �1�I�g l��.jl(2_�N
Iry morntlon or deviation from above cpeciAcatlons T!nlvlirg gam rnstc will he Rocpectfully/�
executed only upon written order, and will become an extra charge over and
above the estimate.All agreements contingent upon Strikes,accidents,or delays submitted -
beyond our control. Note—this proposal may be withdrawn by us if not accepted withir.
v 7-_ z52�50 D gf)00 i #:1 Rcceptance of ropo5aI f
The above prices,specifications and conditions are satisfactory and are Signature ---.---.---
hereby accepted You are authorized to do the work as specified.
Payrnens will be made as outlined above.
i
Date of Acceptance_____._--- Signature
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