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24 PARK ST - BUILDING INSPECTION 10 The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF A r Massachusetts State Building Code, 780 CMR SALEMRevised Mar10!/ yt; Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date appVk. 3 Building Official(Print Name) S' nature Uat SECTION l: SITE INF ATION 1.1 Property Address: 1.2 Assessors Map&c Parcel Numbers I.1a Is this an accepted street9 yes_ no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq tt) Frontage(tt) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required ProviJcd 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public Private❑ Zone: _ Outside Flood Zone'? Check il'yes❑ Municipal ®'On site disposal system ❑ SECTION 2: PROPERTY OWNERSI►IP' 2.1 Owner'of Re$Prd: r 7o�J, - CWIr- MA 6Z12. Name(Print) City,State,ZIP 2 Dt�k l- 5 _._ 791 -4208-305 Nu.and Street Telephonc Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply) New Construction ❑ Existing Building❑ Owner-a^ecupied ❑ Repairs(s) V Alteration(s) ❑ Addition ❑ Demolition t4r Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work`: Qe,Move._J _�2vz( e:c+e cs,- — dReK SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ %SD0 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier xx 3. Plumbing $ 2. Other Fees: $ / pi t 4. Mechanical (IIVAC) $ List: c ��� 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: S 1,560 ❑ Paid in Full ❑Outstanding Balance Due: L mom 5I2% RZT--.0L1 Qru SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) y A2 � CS- lo3z �Yb 0149115 C y vL2 Pr 2-y License Number Expilatiorf Date f Name of C L Holder , f List CSL Type(see below) V No.and Street Type Description S M A OV e( 7U U Unrestricted(Buildings u to 35,000 cu.ft.)R Restricted 1&2 Family Dwelling City/Town,State,ZIP M Mason ry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances y'78 -3$7-8°0� S of t�yy9 `L1 i°•�S lJ .�. I Insulation Telephone I Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) Q` ^p \ HIC Registration Number ExpiraC n Date HIC Com ry N.vne or HI Registrant Name 9r zwt 51c 92K No d Street Email ddress S� a Cit /Town, State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize t�$� to act on my behalf, in all matters relative to work authorized by this buihling permit application. Juiws C, 5 is iN Print Owner's Name(Electronic Signature) I Date SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained ydiin this application is true and accurate to the best of my knowledge and understanding. Print Ownerer' oAuthorized A it's Name(Electronic Signature) Date 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 can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 2. When substantial work is planned,provide the information below: Total Floor 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 heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 1 n CITY OF S:U.EMJI itiL1SS.ICHUSETTS t ©CILOLNG DEPART\LENT 1 '0 CV:ISHCYGTON STREET 3°FL OOR TLL (978) 745-9595 F.CX(973) 740-984S K!J®ER LEY DRISCOI.L N LAYO1 -n-tOaLAs ST.PtERM DmECTOR OF PGBLIC PROPERTY/HCILDLNG CO\L%tISSIO�\jER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section l t 1.5 Debris, and the provisions of tL1GL c 40, S 54; Building Permit ik is issued with the condition that the debris resulting from this work shall be l l 1, S I SOA. disposed of in a properly licensed waste disposal facility as defined by tMGL c The debris will be transported by: y y (name urhauler) The debris will(be disposed of in Q (flame of r1illty) (address Of racility) sign' re ufparmit applicant CITY OF SAL.EM, NL-1SSACHL'SETTS BUILDING DEPARTMENT 120 WASHLNGTON STREET, 3'n FLOOR r �f TEL_ (978) 745-9595 F.Ax(978) 740-9846 KI.NiBHRLEY DRISCOLL AMR THOMAS ST.PIHRRE DIRECTOR OF PUBLIC PROPERTY/BUII.DLNG CO\LMISSIONER W'nrkers' Cornpensation Insurance Afiidavit: Builders/Contractort/Electricians/Plumbers Applicant Information Please Print Legibly n IV;II11C(IrusinussOrganirarinm'Individual): r "4�ew- \'l;y—�) Address: 4/ /9, �er Sk City/State/Zip: '3`i" ' P Gi 47 Phone tt: �/7E 'f3'�7—$�6 ai Are you an employer!Check the appropriate box: 'type of protect(required): I.❑ 1 am a employer with 4, ❑ lam a general contractor and 1 6. ❑New construction e oployees(full and/or part-time).' have hired the subcontractors 2. mn a soie proprietor or partner-. listed on the attached sheet.t 7. ❑Remodeling ship and have no employees These sub-contractors have 8. [] Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition [No workers'camp. insurance 5. ❑ we are a corporation and its required.] officers have exercised their to.❑ Electrical repairs or additions 7.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repuire or additions myself. (No workers'sump. C. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t employees. (No workers' f},[] Other camp.insurance required.) •Any applicant that chucks box at most also fill out the section bdowshowing their workca'compensmion policy inrbrmaaon. '1 h.' C'Mmns wha submit this affidavit indicating Ihcy arc doing all work and then hire outside conimcn rs mint submit a new affidavit indicating such. <'nurwtura Ihul check this box msut anoch x!an additiorml.heel showing dw mmne of the subeonaactort and their workem'comp,policy infomtation. I une an employer that is providing)porkers'conspensadon insurance for my employees. Below is the policy and Job sirs iuforntution. Insurance Company Name: �'m Dvc ivcJt r�e Ti,"o r Policy 4 or Self-inns. Lie. d: b nn(s D Li '9 Z _ Expiration Date: t^� Job Site Address: tm e- ic- S•J . City/Slate/Zip:_ 5 e� Lf 014 'T 0 - Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of kfGL c. 152 can lead to the imposition ofcriminal penalties of a line up to S1.500,00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 a day against the violator. 13e advised that a copy of this statement may Ln: forwarded to (he OI'lice or Invesligutions ofthe DIA for insurance coverage verification. /do hereby certify under the pains curd penahfes of perjury that the it jonna ion provided above is true and correct S " t,nlre �/*'t— Date: Phone Of)irial use only. Ou not write in this area, tube conspleted by city ur town gjiciaL City or Town: _.._._- .__ Permit/I.fccnsc k Issuing Authority(circle une): 1. Board of Health 2. Building Depurnucut 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Insspeclor 6.Other Contact Person: _.. Phone 7: I