7 PALMER ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY
�. Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7" edition Revised
LErMtI
Building Permit Application To Construct, Repair, Renovate Or Demolish a /• =008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numbe . Date-Applied:
Signature:
13uildi g Co 14
mmission 4Mspector of Buildings Date
SECTION 1: SITE INFORMATION
l.k Property Address: k fin 1.2 Assessors Map& Parcel Numbers
I.Ia 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 n) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑ p p y
SECTION 2: PROPERTY OWNERSHIP'
2.l Owne5'of Record:
� �C.IQ �LC\�
Name(Print) Address for Service:
Signature 'relephone
SECTION 3: DESCRIPTION OF PROPOSED WORK:(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work-: r c Ut'\ GY 'dr,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
. Plumbing S L l' `Other Fees: $4 rn��
. Mechanical (BVAC) $ Lis[: � , ,
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ ❑ Paid in Full ❑ Outstanding Balance Due:
0 �4h �c
Y
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Z�
,�hh Cclt�l (-� Licr sv Numbr l?s iration ate
Name of CSI:I lulder ``
C 1,Jr (4wrrv\� $ S1 List CSL l'ype(see below)
Address T' Description
lJ Unrestricted(up W 35,000 Cu. R.)
y•
R Restricted INc2 Family Dwelling
SC nature M Masonry Only
7S-"s8-0`G(1y RC Residential R noting Covering
'Iblephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2, 12egistered Home Improvement Contractor(HIC) li B o
C.
fIIC Company N:une or HIC Registrant Nmne Re istmtion tmlxr
Ga 1p SF Szi1P� /2�'/�Z
Add •ss Q 78".J3�e,_�(i 7y' Fs nation Mate
. ignature '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 Dale
(Signed under the pains and penalties ofperjury)
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and 110.R5, 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 halt7baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
q
b CITY OF S.kL.&N11 ANSSACHUSETTS
LNG DEPART\1MNT
120 W."HLNGTON STREET,3' FLOOR
TEE, (978)74S-9595
E3t.lI•D
FAx(978) 740-9846
KINMEJ r FY DRISCOLL
T'HO.�fAS ST.Ptxxas
ViAYOR
DIRECTOR OF Pt:BLtC PROPERTY/BCtIDlMNG CO%LMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
1n 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:
slnal�
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
dcbnvlf,bw
CITY OF SALEM
�Y
PUBLIC PROPRERTY
DEPARTMENT
.11a::of 1 Y:Int%C%'I I
\1 Nt Mt 12C.WASH1A4;ION S1'V ELT a 5 A I Pet/,Ivf.W.u.1 It GI I nA197J
li.t: 08r7I5-9395 a 1'.%x. 979.74C Ix46
NYurkers' compensation Insurunce Aflldavit: Builders/Contracto rill Elect ricia nil Plunabers
%o litant Information Plcase Print_Le jhl
VamClUtrvnuvvt)rgantratinNlndlvlduall; J .IZ �r't�'✓'c\� ��i����� �-'^�
ddress: /r*"r?V vC( S
Cily,Starc:/.ip; "'r-Ak,. aIS ,C' 11huneo:
.tire vu an employer?Check,the appropriate box: '1'ypa of project(required):
4. ❑ 1 ;art a general contractor and 1 6. New construction
1. I :un a employer with ❑
enl to 'ces full und/ur art-time).• have hired the suh•contractors
p y ( P ?. ❑ Remodeling
2.❑ 1 ;un a soli proprietor or punner-
tilted on the anachcd sheet. r
ship and have no employees These sub-contractors have S. ❑ Demolition
working for my In any capat.ity. %workers{.comp insurance. ...:9,_Q-building udditiun ---- -
5. ❑Wit ur u cnt ration and its
- ------)No-workers cuinp:"insurance- - 10.❑ Electrical repairs or additions
raquircd.) Officers,have uxcrclsed their
3.❑ i ant a homeo%nicr doing all work right of exemption per N101. 11.0 Plumbing repuirs or additions
myself, LNo %workers'comp. c. 132, i 1(4),and we have no 12.❑ Rtwt'rupain
insurance required.) t employees. LNo workers' 13.0 Other
camp, insurance reyuircJ.j
•ney.�nPllwmd that cheeks bu nl Most girt tilt nun the necnon bwtow Blowing Illicit w•wktali wumptnuawn Pulley iul'urmatidL
'Humeliwmn who ndtmit this arlldarit indicating Ilttty ale doing ull Work and ilica hire outside conitarten intul auh,"it an"al'ndowlt inditsuing wink.
C',mlraenww that thvck This back Moot:ntachod an additiurwtl..?wit.hawing IIw ,now of the ruhaonnwion and then tvurkon'catty.Policy tnfwtnanw.
1 inn an emplayer that/t providing workers'compen cation in.turneed far my tatplayedt. Below fs the pu/!ty and/ub.rift
informotian.
Insurance Company Vnme: R c% - ------
Policy At or Sclf•ins. Lic.0: _._ . .._ Expiration Date:
lob Situ Address; I& Ar."� .r N .SG' \ Crtyistate/Zlp:
Attach it copy of Ilw workers' compensatlon pulley declaration page(showing the policy number and ellpiratiun date).
Failure ut secure coverage as required under Scuiun 25A ul'SIGL c. 152 cau lead to the imposition of criminal penalties of a
line op to S1.500.00 and/ur uue•yea imprisomnent, as well m civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 it Jay against the violator. Ile advised that a copy of This slutcmcnt may be lurwarded to the OI'licc of
Inc�p11ga11 m is of die UTA for itimirarce Goveragu• %CI'I Ile ation.
/du hereby terrify under the paial and penofticy a/'perJmy that the iuforrnellon provided above is true mad correct.
Date. al'
oflicial nse anly. Do not Ivrite in this area, to he cumpleled by city or lown o/JiriaL
i
City ur'I'nwm: . . Permit/License 0.
Iwwuiny Aulhurity (circle onc):
I. ItuarJ of Iir:dth I. 161ildiuq Ucp;HHnvnr ]. (:itldfmw Clerk 4. Lluctric l inspector 5. Plumbing lospcctor
6. Olher _
C'.,a Wet 1'c nuts.