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4 PEARL ST - BPA-18-546 f n The Commonwealth of Massachuscns y/ Town of Board o(Bmlding Regulations and Standards �� Massachusetts State Building Code. 780 CMR. Ts edition Building Dept Building Permit Application To Construct. Repair. Renovate Or Demolish a !k loodem One.or Tuu-Puiruh Duwlfing Mims CF Official Use Only Building Permit N mber: e Applied: Signature: Building Conor d InDns FORMATION I.1 Pro nyAddr� : ssesson Map& Pseeel Num&N�bcr a b this an uce fed street''yn no Number P e IJ Zoning Information: 1.4 Property Dimensions: Z,ADO Zoning District Proposed Use Eot Area(sq it) Frontage Ifl) 1.5 Building Setbacks(ft) Front Yard Side Yards Rev Yard Required Provided Required Provided Required Provided 1.6 Water Supply:I c.40.134) 1.7 Flood Zone Infor mallon: 1.8 Servege Disposal System: Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0 Public 0 Privan O Check if s0 p SECTION 2: PROPERTY OWNERSHIP' hh 2.1 Owner'p,JtIJ Sec G,l/r 1V4L 0/ V Name IPrint) Address for Service: 9�8 -Sya- �i�SS Signature Telephone SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction 0 Repairs(s) O Alteration(s) O 1 Addition 0 Demolition O Accessory Bldg.0 Number of Unit_ Other V Specify: kfLyw5 Brief Description of Proposed Work': V I h IcS SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Cost: Official Use Only Item i Labor and Materials I. Building S 1. Building Permit Fee: S Indicate how fee is determined: 0 Standard CityrTown Application Fee 2 Electrical S O Total Project Cosl'(Item 6)as multiplier a J Plumbing S 2. Other Fees: S 4. Mechanical IHVAC) S List: s Mechanical iFire S Total All Fees: S Su remon Check No. _Check Amount: Cash Amount:_ 6 Told Project Cost S ' a 00 Vo ❑Pad in Full 0 Oumandmg Balance Due r f � SECTION S: CONSTRUCTION SERVICES 5.1 Licensed Construction Supersisor lCSL) l!�15 Zz P L � Zm!/ Lwcnva Number E.puitton Dire N.troe ut('SL• Ilpldr Lta('SL Type(Kv below) Tvoe I Description /��'�``KKK"•fyff U Unnxuicted u to)5,000Cu Fl R Restricted 1!2 Family 0%el6n Sianimre M Maturity Qnl 170 711 Q�� � RC Residential Roofin Covering Telephone W S Residential Window and Siding SF I Residential Solid Fuel Burning Appliance Installation D I Residential Demolition 5.2 Registered Ho/me lmpr�lveme4t Contractor(HIC) ��� �� F'iaydah ! i��� IVi/C.T�i�OH HIC C yName or HI -Registrant Naa Registration tslraation N um ST, sic MAI- � Ar 77F 76Y 6S16 �E er pinion tie Si Telephone'19 7,�,7 SECTION 6:W RS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.t. 152./ ISC(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 Aflidavit AnschaP Yes.......... O No...........O SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1, ��Skm 1 l , as Owner of the subject property hereby autharim 5 V ( o I bldpuch�Ll to act on my behalf,in all rrui relative tow A au 'zed by this building permit application. z1 /811() Si arum rter Date SECTION 7b:OWNER"OR AUTHORIZED AGENT DECLARATION I, ,as Owner or Authorized Agent hereby declare that the statements and information on the foregoing application arc true and accurate,to the best of my knowledge and behalf. Print None Signature of Owner or Authorized Agent Date (Somined under the pains and penalties o(perjury) 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 ad 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 110 R6 and 110 respectively. 2. When substantial work is planned,provide the information below, Total Moon area(Sq. li (including garage, finished basement/attics.decks or porch) Gross living area(Sq. Ff.) Habitable room count Number of fireplaces Vumber of bedrooms Number of bathrooms Number of half baths Type officiating system Number of decks/porches Typeofcoo(mgsystem Enc(o.ed Open 1 "Total Pralect Square Footage"may he.uh%muted for 'Total Project Cost' Sou o&M og egn ddAr,durds Constructlop Supervisor License ' UCOM. CS 98826 Euplre0o�t1%5/2011 TO 98826 r.. f . R an MARK JOHNSO� PO BOX 288' WENHAM,MA 01984�`�'` '� Commissioner �-��� a CITY OF S U.E.`I, ,L-kSSACHUSETTS BL'BDLNG DEP.IRTIENT 120 WASHLNGTON STREET, )aa FLOOR T L (978) 74S.9595 FAX(978) 740-98M K1NlBFar FY DRISCOLL T MAYOR Ho&L%s ST.P1Em DIRECTOR OF PUBLIC PROPERTY/81:aDLNG CO\LMlSSl0NEIt Workers' Compensation Insurance Atijdavit: Builders/Contractors/Electr(clans/Plumbers ADr)Ilcant Information Please Print Legibly VaITe (Busirwv.Orgytiratioru lnthvrtlwd): '!-iayUj //-� Address: V l"� S I . g / City/StateMp: E $5 a IYA (7 L Y._ Phone N: 17©p-760 'b5-16 Are as employer'Check the appropriate box: Type of project(required): I.fm m a employer with_Q 4. ❑ 1 am,a general contractor and I employees(full and/or part-time).* have hired the subaattretor 6. ❑New construction 2. 1 am a sole proprietor ar parer- listed an the attached shed : 7• ❑Remodeling ship and have no employees Then subcontractors have g. ❑ Demolition working for me in any capacity. worker'comp.insurance. 9. ❑ Building addition [No workers'comp. insurance S. ❑ We are a corporation and in 10.❑ Electrical repair or additions officers have exercised their 3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No worker'comp. C. 152.4l(4),and we have no 12.0 Roof repairs insurance required.)t employees. [No workers' 13.❑Other COMP. insurance required.j •Any upplicare[test chocas boa/1 mums aba fin tot the secsion eclat showing their verkea'cwrgenaenitxt policy itrWsmadot. 'I heteswnree who submit this atttdark indicting they are doing all work and then him outside cnntractom awes submit a new altldevil indicaing ruck =(%.1mesom then chink this lest mud atacht d an addicted shows showing de,noes,of tits su►mmmosom and thalt workem'comp.policy insern elon. I use an employer that 6 providing workers'compouadon Insaroaar for my employees Below/s the pallry and Job rise informulion. Insurance Company Name: Policy 4 or Self-ins. Lie. H: Expiration Date: Job Site Address: City/StatWZip: .%ttmck a copy of the workers'compensation policy deciaralbs page(showing the policy number and explradom date). Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of fine up to 51,500.00 and/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. lie advised that a copy of this statement may be forwarded to the Office of I I1�'Ca1lgallUna a for insurance coverage verification. I da her certify and the ns it 1olt11 jperI th t the heformaNatr provided ubov is try r mild correct �7 p Dan : l� Phu A: l 0 O 11 use wufy, no, wrile in this areas to be.unspleted by city or town )If cimL iCity or Tuwn: _ Prrmit/Llccme hsuing Authority (circle tine): - -- I. Board of lleahh 2. Building Department 3. Cilylrown Clerk a. Electrical Inspector 5. Plumbing Inspector 6.thher luntact Person: _ _ _ __. __ Phone At: •� s CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT -.I\I L^ H I h.1 1-KN 0i I \I`.1 I'll I_'C\>('.1 it II\li'I i1,M$rN ELT •�.\I P\t, ��.\�i.\I I Il N 1 i+.I'I . tEl:'17t.7� '/i9$ 1'\x:7716740-4846 Construction Debris Disposal Affidavit (required I'ur all demolition :Ind renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit q _ 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 t It. S 150A. The debris will be transported by: CO3( Co (name of hauler) l'he debris will be disposed of in (mama uf�`a�,ty) DD (Ilddrtm of laClllty) ignature of 1x ,it applicant date