34 OUTLOOK AVE - BUILDING INSPECTION (2) i,
The Cummonweallh of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Budding Code. 780 CMR. 7*edition Building Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a �
one-or As
one- Durlbng
1 This Section For Official Use Onl
BudJing Permit Num Date Applied: 3 >L
Signature:
Balwo Commusi / In t of Buildings Dui
SECTION 1:SITE INFORMATION
1.1 Iro Address: 1.2 Assessors Map• Parcel NumbersY 6Uzlz.
1.la Is this an ace ted street? es ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sit illFrontage IR)
1.3 Building Setbacks(It)
From Yard Side Yards Rear Yard
Required Provided Required 7 Provided Requirtd Provided
1.6 Water Supply:(M.G.L c.e6,154) 1.7 Flood Zone Infornodon: 1.8 Sewage Disposal System:
Zone; _ Outside Flood Zorn Municipal O On sits disposal system O
Public O Private O Check if
��1wsr qq SECTION 2: PROPERTY OWNERSHIP'
I C Llr`ff r2li1S 3`{ GuTI—uvK AJf— , 51A-( MAMA
We (print) Address;for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(Cheek a0 thst apply)
Ncw Cons lion O Existing Building 91 Owner-Occupied 13 1 Rgmirs(s) Alteration(.) O Addition O
Demolition O Accessory Bldg.O Number of Units—/ I Other O Specify:
BriefDescriptiogofProposad Work : ST2ilo GKr.57(uuL /sOi toA 5
GPL !C� a �-r/Ei2 SNM/,EG�/32R/✓tb '- APR/� ✓�. G ASL//�G3
..no
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: O(�)sl Use Only
$47
Labor and Materials
g f n I. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
al 3 O Total"set Costa(Item 6)x multiplier a
g S 2. Other Fees: S V Vnical IHVAC) S Lisl:cai (Fire S Total All Fees. SnCheck No. _Check Amount: Cash Amount:_
roject Cost S Gd 6d O Paid in Full O Outstanding Balance Due
SECTION S: CONSTRUCTION SERVICES
9.1 Licensed Construction Supervisor ICSL►
IJ,' JolGlq 2l0 /�
4 i
f gii) 1,p�r'�C4*)Zl f- Litenve.Mumber E, i/un Date
Ntror�ul�'-CsS�L• HplJrr q Lis('SL Type fKv below)�_
.122 4 nL4�E- (Arj is Al RD
Descn wit
AtAA r/I IOC Unreici e 1 amityto O0 Cu. FtReftnaed IAI Famd DrelhnRefidrnual Roofin CovennTelephone Residential Window and SidmResidential Solid Fuel Bumm A bane InstallationResidential Demolition
S.2 Registered Home Improvement Contractor(HIC)
�Yksitnrd✓J rt77 &KALA?AeA-ejeS /6L7-3V
HIC Campat Name or HIC Registrant N Registration Number
w T � ^A-XiAA
Assets
+ .•rj3/-/(�f3% Ea in( Dap
Sigtuttae Teleph;w,—i
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL 1 2SC(6))
Workers Compensation Insurance aMdevit must be completed and submiRed with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
Signal AMobivil Attached? Yore.......... 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
aulhorin to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si of Owner Dap
SECTION 7b:OWNER'Oft AUTHORIZED AGENT DECLARATION
1, /4/IJ asOwner or Authorized Agent hereby declare
I
the statements and information on the foregoing application are true and accurste,to the best of my knowledge and
behalf.
G tAlZr�
Print main +
Signature of Dionne or Alahooracia Atillial Dap
Si under the young and penalties of
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
Ina registered in the Home Improvement Contractor(HIC)Program).will 99 have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important informaton on the HIC Program and
Construction Supervisor Licensing ICSL)can be found in 790 CMR Regulations 110 1116 and 110 RS.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 man 1 Sq. F1.1 Habitable room count
.Number of fireplaces Vumber of bedrooms
`umber of bathrooms Number of half.baths
Tvpeofhealing tystens Number ofJeckvporches
rypeofeooungtyuem Enclowd Open
I 'Total Protecl S4uare Footage"may he.uh.titnted for 'Total Prolcct Coa"
CITY OF SALEM
PU
BLIC PROPRERTY
DEPARTMENT
I'FI:V7t•74 •)i95 1'.\Y:978-740-7846 .
Construction Debris Disposal Affidavit
(required fur all demolition and renovatiun 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. 5 150A.
The debris will be transported by:
—
umme of hauler)
The debris will be disposed of in
� rrAY W6ex �
(came olfacdmy)
N a y c i• PfmxW %a
taddress of facility) _
ignature of Ix n i applicant
date
-t CITY OF & .&M. NLkSSACHUSEM
9t:ILDLYG DEPAIMIE.vT
110 WASHLNGTON STREET, 3'a FLOOR
TEL (978) 745-9595
FAx(978) 740.9SM
KI.BERIEY DR15C011.
T
�(AYOR Homu ST.PmRM
DIRECTOR OF PCgLIC PROPERTY/RL•IIDLNG CONLMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclanal Plumbers
Applicant information Please Print Lcelblr
VatTClBusinr.rOrymrarionlnJrvduall:������ Cr-T / �01>��ALT0ILS
Address: .SJr P. L(1^1,riyT ST *�"4-
city/Statdzip: AA60,04 MA- 0/9Go Phone* 979-53/-/Geoi
.1 reeyyou to empleyaT Check the appropriate bes: Type of project(required):
1131 1 am a employer with!� a. Q 1 am a general contractor and 1 6. ❑Now construction
cmployt:es(full and/or par-time):• have hired the sub-contractors
2.Q 1 am a sale proprietor or partnu- listed on the attached.sheet i y [Yl KemadeIing
.hip and have no employcm Theca sub-contractors have V. Q Demolition
working for me in any capacity, workers'comp.insurance, 9. Q Building addition
[No workers' comp insurance S. Q We are a eoquirslion and its 10.0 Electrical repair a additions
required.) oft=have exercised their
3.Q 1 am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself.[Na workeri comp. c. 152.410).and we have no 12.URoor repairs
insurance required.] r employcao.[No workers' I7.❑Other
comp insurance required.)
-Any aPPucam Chat alMM ba el row air no eta the .arkan'tawnaPa*w m puliry Infim"Wnt►
't barwawnaa Who%WwW this aAldrvi indiorina alter am doiM all work and der him amide contractors maw.1took s new aMthwir indi.&S ask.
=t'.marsmn the teach this br maw anaclW as additianal Jima showing the over of tle arkava ra"M ad their waimm'tort/.pali v iarwnmtlaw
/rat an employer that b prsvidlair workers'rompennulan Insurer.for MY earpleyeest Below/s/Ae pwky redm afar
informadon.
Inwrrnce Company Name: )_(atit?ry /Nl/r1/h1L
Policy for Self-ins. Lie.M: ',6 ,616q&P Expiration Date to
Job Site Addresr—9 y 10UA_4 a1C A-tJE, 2310MUtrJ S i City/StatettZip: S-�+ esI A
.%ttach a copy of the workers'compensation Palley daclantioa pap(showing the policy number end expiration afnte)L
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
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 Ilas
of up to S250.00 a day against the violator. Ila advimd that a copy,of this statement maybe furw•rrded to the oince of
In%cilittiations oftits n1A forinsurance coverage verification,
/do hereby rani) urlGtio�s r�
ndeer,the peens and penalties o/par/nry that the in/ormarloa provided above is true and correea
,;wlmurr_ Z/lLt/
Phunr:A• -jai- 6-3/_/(,Pj l TTT
O/J!i its!sae mdy no raw writ.in this area,tr be.mnplNd by city or rotvn./JkirL
I
Cary or fawn: Permit/l.icense M__,
i
Issuing.\uthorty (circle unt):
I. Iluard of Ileulth 2. 9uddlnti Deparlmcnt ). cil,trown Clerk 1. Electrical Inspector S. Plumbing Impactor
6. Other
l„nlact Pcnon: _ Plane a.