5 PAUL AVE - BUILDING INSPECTION (2) The Commonwealth of MassacfflMVED
OF
Board of BuildingRe ula sSERViCES CITY M
I � Massachusetts State B�ildi� ode, 78�0 Is SALEM
n dI Revised Shur 201 r
r\^�` Building Permit Application To Construct, RpVr jMnftte&&Ah a
i 1J� One-or Two-Family Dwelling
1 This Section For Offici l Use Only
n Building Permit Number: Dat .Applieds
Building Official(Print Name), Signatu� _ Dotal
SECTION IL•SITE INFORMATION:
1.1 P7 erty.�ddLress: F, C 1.2 Assessors Map&Parcel Numbers
1.1 a Is[his an 4accepted street?yes 110 Map Number Parcel Number
1.3 'Zoning information: 1.4 Property Dimensions:
"Coning District Proposed Use Lot Area(sit It) Frontage(R)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provide) Required Provided Required Provided
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? Municipal O On site disposal system ❑
Check if yesC3
SECTION 2: PROPERTYOWNERSRIP) /j)
2.1 9�1 �r1lG /N
t��hma PH� City,State,ZIP y]�
G S riv Elf- /1�lkE Chec1� EAddition
No.mid Street Telephone Emil AddrSECTION 3: DESCRIPTION OF PROPOSEDWORW(check all that apply)New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work": 77f 00 ,al-1 Z*ZAA'�--
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ o3 .E2 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
I. Electrical $ ❑Total Project Cost"(Item 6)x multiplier x
3. Plumbing P9therFees: S
a.Niechanical (HVAC) $ 1900 a, OV List:
5. Mechanical (Fire S
Suppression) "total All Fees:S
Cheek No._Check Amount: Cash Amount:_
6.Tutai Project Cost: S% )S v3 ❑Paid in Full ❑Outstanding Balance Due:
11
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor L' cnse(CSL) I . -of
J._
G / ,�,� l/ icense Number Expiration Date
Name of CSL Holder / List CSL'rype(see below)
Type Description
No.and$(reel U Unrcstr wd ffluildin s up to 35,000 cu. 11.)
R Restricted I&2 F;unil Dwelling
Cityfro n,State,ZIP IDI Mason
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Duming Appliances
Cr�c�� at0 "
U G 1 Insulation
'icic hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) —LGiG
i✓ �I�(�"� HIC Registration Number Expiration ale
HIC Co any pp9 r HI�SRegistrant Name
1 No.mid cet f �jl=d� �— Email add
Ci own State ZIP TA hone
r SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.4 2SC(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 ..........O No...........❑
SECTION 7atOWNERAUTHORIZAT,ION:TOBE COMPLETED.WHEM i '
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
I,as Owner of the subject property, ieb outhori
t tZoWK41
atter a ork authorized by this building permit application.
Print Owners KantV(Electronic Si a re) DurC
SECTION 71b: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 in this application is true and accurate to the best of my knowledge and understanding.
Print owner's or Authorized i\gent's Namc(Electronic Signature) Date
NOTES:
1. 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 nor have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
Fv%vw mass.eov:'oca Information on the Construction Supervisor License can be found at wwtv.muss.��ov:'dns
2. When substantial work is planned,provide the information below:
Total fluor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) Habitable room court
Number of fireplaces Number of bedrooms
Number of bathrooms Number of h;df/baths
rype or heating system Number of decks/porches
"type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted I'or"Tot:J Project Cost"
QTY OF SALEM, MASSACHUSEM
BUILDING DEPARTMENT
120 WASHNGTON STREET,3'DFLooR
TEL(978)745-9595
KRaERLEYDRISCOLL FAX(978)74 M46
MAYOR THomAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUII.DING ODivII OSIONER
Construction Debris Disposal Affidavit
(required-for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
A2
(name of facility)
(ad ress of facility)
gnat re of plicant
Date
1�
�G
Y° CITY OF S:1L.EM, N.Wsika4uSETTS
BL'mnwin,DEPARTIENT
130 1Y/AsH4N4TON STREET, 3w F100R
�eaar
TEL (978) 745-9595
F.LX(978) 740-9846
K).NIBERIEY DRISCOLL
"'VL'1YOR Ti4o&w ST.PIERm
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LIILSSIONER
Workers' Correpensation Insurance Af efavit: Builders/Contractors/Electricians/Plumbers
Applicant Information �r /1 Maw Print Legibly
V;IIT1C Inusit,rssOrganiratinro'Individual): � )o Qwj ekLcy-,
Address: ,4� r-
City/State/Zip: 14 Iq Phone Jf:
Arc you can employer!Checkkpproprlate bust: Types of project(required):
I.Ia I am a employer with��_ 4, 0 I am a general contractor and 1
employees(full and/or part-time)." have hired the sub-contractors
6' ❑New construction
2.0 lam a sole proprietor or partner- listed on the attached sheet% 7. 0 Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working tier me in any capacity. workers'camp.insurance. )- 0 Building addition
I No workers'camp. insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
J.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(10 workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insuraneo required.) I employees.(No workers' 17,0 0ehar
comp.insurance requin lij
'Any applie:un dvu checks bun/I must also rill out the section below,showing their worlien'compensation puliry infmmaaon.
is Inmvuwi%"who wbmit this atnrhvii indicating they m doing all wwkand then bite Dasidecanlnmma opal submit a new amJavir indicating such
$lnutxtuo shut ehwk this kos mint aoachar an additiunul nheel'hawing the name of the subaromnclm and Ihelr worken'comp.policy infutmolinn.
f unr can employer chat/s providing ivorkers'c'ons.eensadon lnlurarleejor my enrplayees. Be/uly is the policy and jab site
hs/atination.
Insurance Company Naine:
Policy 4 or Self-ills. Lic.d: �L Expiration Date: �''Z -3 �d/S
Job Site Address: �G l Cily/State/Zip: .�
A teach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failuru to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 und/ar one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a line
of up to S2S0.00 a day against the violator. Ile advised that a copy of this statement may bu furwarded to she oracc of
Inve,ligasionsofihe Dl rorinsurancccovemgeverilicatiun.
l du hereby cerli �tdf rhr p na nJ prrtolde u rrjury that she injunnutlon prurldeJ ubuvr iv true and c'orrrra
Dam.
-
P , 1. _
F
ly. Ou our min in r/i(r urru,rube curuplrfedby citycarIusun n/Jle'!uL: _ PermidLlcense Alrily(circle one):allh 2. Iluilding Departweut .1.Cilyfrnwn Clerk 4. Electrical Inspector 5. Plnntbing Inpector
Cualact Person:___..___ Phone;r: I