10 PEARL ST - BUILDING INSPECTION (4) I'he Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
b b SALEM
Massachusetts State Building Code, 780 CMR Revised.tfar?011
a.
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Drelling
This Section For Official Use Only
Building Permit Number: Date A no 1 d:
Building Official(Print Name) Siglfature Date
SECTION l:SITE INFORMATION
1.1 Property AJJress: 1.2 Assessors Nlap&r Parcel Numbers
L la Is this an accepted street?yes`1 _ no Map Number Parcel Number
i
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks III)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provide)
1.6 Water Supply:(M.G.L c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public El Private❑ Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
N:une(Print) City.State,Z.IP �
No.and Street 'relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work-; ^S\,L. •C-pew 1,,'�Ac�.o.�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 1. Building Permit Fee: E Indicate how fee is determined:
'. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x _
3. Plumbing S 2. Other Fees: S
4. \Iceh:....cat lf-I\'AC) 3 List:_
5. Mechanical ((Fire 5 - -
Su m mression1 Total All Fees: S
Check No. Check Amount: Cash amotmt: —_ -
G. To al Project Cost: S � ❑ Paid in Full 0 Outstanding Balance Due: ---
r
SECTION 5: CONSTROCTION SERVICES
5.1 Construction Supervisor License(CSL)
�e-�r �.
�, ) \ � 5����_-- - License Nunther Ilcpira(% Dale
Numc of GSI. I folder
List CSL Type Isec below) _
No. and Street Type Description
U Ihvcslricled Buildings no to 35,000 cu. 11.)
R Restricted L@2 Family Dwelling
Otyf'oon,Slate,7.140 M Maion
ry
RC Rooting C'o%erin
W'S Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address U Dentnlitimh
5.2 Registered Home Impprovement Contractor(HIC)
�� �^ •,�`A"'� I egistrati"Not, Fspiru ion Date
I IIC C' an) Numc or 1IIC Re gisranl Nmne
No.arid Street Email address
Ci /Town, Staff t ,Zee IP "relc hone
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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERI 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 thishis an is true an accurate to the best of my knowledge and understanding.
Print Ottner's or Authorized Agee s Name(Electronic Signature) Date
NOTES:
I. ;\n Owner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor -
not
registered in the Home Improvement Contractor(HIC) Program),will riot have access to the arbitration
program or guaranty fund under M.G.L. c. I q'_A.Other important information on the HIC Program can be found at
y~t npp,g,rc t_gc,i Information on the Construction Supervisor License can be found at t��y ty.ni:us.goh"gllh;
2. When substantial work is planned, provide the information below:
'Focal fluor area(sq. ft.) (including garage, finished basement'attics,decks or porch t
Gross living area(sq. 11.) Habitable room count
Number of fireplaces___,_____ Number of bedrooms
Number ofbathroonts _ _ _ Number of half'baths _
I pe of heating system _ ___-- _-- Number of decks;porches
1)pe orcooling System Enclosed Open _---- _
1. ''told Project Square Footage-may be Substituted flor-rotal project Cost"
CITY OF S,U-&NI, AUASS.ACHUSETTS
BLIIDLVG DEP.IRT?tENT
110 W-UHNGTON STREET, Y4 FLOOR
FAX(978) 740-9846
KIJ®F_RLfiY DRI3COLL
MAYOR nows ST.PMRU
DIRECTOR OP PLxic PROPERTY/9t: DLYG CONNISSIONER
Construction Debris Disposal At'fldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions of MGL a 40, S 54;
Building Permit M is issued with the condition that the debris resulting from
[his work shall be disposed of in a pro
l 1, S I SOA. perly licensed waste disposal facility as defined by MGL c
The debris will be transported by:
(name orhauler)
The debris will be disposed of in :
(name of facility)
A�
(ad ress or f-36111y) w�
eiyn,ilure orpermit applicant
rid e
Information and Instructions
s Jet c4ul as" every Ina.+on in the scrvcce of another umler.lily �untnct of hire.
�I•ta;.tchuseus ucnerul Laws chaytcr I i2 teywrcy all emplo)en to provide ,vurkers eutnpansanun tar their ct ofhi ees•
I•,tr:u.uu w I'll. ,tuluta, an esilp - N
vproas or nnphcd• orat Of wnnen•" of an two or more
�n ;,nplupar t+dclined U"an individual, partnenhip,assueianoo.�irporesetual ves ufor ithel,la decea cJ empluycr,:V f t
wnt enterpnsa,and italu,ini{this Weis P tom tmployces. However the
.�t the G,regumd engu.cd m a 1 a,menhtp,ssoewaoo or other legal.nosy,employing a of the
ccmver or trustee ul'.lit iudiv,du4l, p
mcnt be deemed to be an c,npluyer."
none to do maintanunca,cunatruction or repair work un ouch dv inl{houw
owner of a dwelling house having not more than three apa�'ents and who resides thereto,ur the Occupants
,Iwethny house of another who employ."tt thereto
shall not because of such employ
or,,,t the.rounds or building app
'SC 6 also status that '.very state or local licensing agency shall widthuld 1M issuance or
gh
%li.L chapter i 152, e O required."
rrnswul of a Ilcense or permit to uyuats s buslneu or to eon uYa� wlth the slnsuIn ranes ccorersasiraq@r any
en roduad ;cclptabl edvld*nher the ommonwcaith not any of its political subdivisions shall
Applicant "Ile has not p
cd
jidJlUuwlly, `IGL chapter I S., 1-s
sneer into any cumract for the parfomlance of public work until ucepetble evidence of cuntyliustce w ith the uuura
reyuinments of this chapter haw been pre, to the cmuracting authorit
Applicants cheeki IS the boxes that apply to your situation and,if
address and phone nu nber(s)along with their A mplcatats)tither
Of
Please till out the workers' compensation affidavit completely,by LLP)with no it
other than the
necessary,supply sub-eontractor(s) num@Is),
have
to carry workars' davit may
be submitted to the Department Of Industrial
insurance Limited Liability Companies(LLC)or dins.Limited Liability Painsuranceif an LLC or LLP-
inembars or purmats, are not required
employees,a policy is required 8s advised that this atfidavit tray aliment of
,�Ip be aura to sldA line data skis uil)fdrnol tlte1elZvp�vit should
accidents far contlrmation of insurance covcraee c"fiancha law ur if you lift required to obsta u workers'
he rowmed to the city or town ou Irrveaanytquestionsf re4 dings a license is tieing requested.
industrial Accidents. Should y uttment st the nutntsar Ilsted below. Self-insured companies should enter their
Compensation policy,please call the Dap
self-insurance license number on this a pro riate Inc.
l
City or rowe Omelals
Please he surc that the affidavit is complete and printed Icdtbly. This Department has provided a space at this slim
bean
licanL
Of this al'fiJavit fur you to till out in the.vent this ORice of Invesu.cd;t%1 re onlusubmitntact uune�tTlduvd'itth dicatin Current
I'laaac be surc to till in the permiulicense nullba�oNtln any ech will leven yd'ts n relat on y u on In addition,an applicant
vit lie
that mutt submil multiple PennitllNtal,ntads?,1ob Sit@ AddretC this applicant+houW write"all locations in l' Y
policy information of necessary)'
be rovidcd to'he
tusvnl•"•�copy I'(tile ut7lduvit that has boon officially sanslluj or ermm is of licenses.d by ltA eawty�atlidavt r town ,just be tilled out each
a license or permit not related to any business or commercial venture
applicant as py I proof ti et a valid at is on rite t'or Nrturc p
)ear. %Vhcre a home owner or citizen is obtaining
for your a. .lad license or permit toburn le
t i a svaa cteJ sail perms is NOT reyuired to wmplata this uftit)a a huge•ny yuuuons.
III plca+etJu not hcsictilI to buns %%u l all 4 to thank you ill aJv•mc,. caopantinn and shuulJ y
ncc U.parunenrs addte+a, rolephunc and Eli numbeQ
The CornetnweAlt)1 Of MLttaeAUsetts
Depament of Industrial Accidents
Office of Ievestl¢ationa
600 WaStdrigton Street
9o3ton, MA 02111
fel. p 617-727-00 ext 02 of 1-877-MASSAFE
617 7
www.Mass.&ov/die
CITY OF SALEM
PUBLIC PROPRERTY
S° DEPARTMENT
\I tlr yl
!C lanlrn..rnu.\ilxw. a in(1'w, M.t1A.p.u1 a I nJl'q�
Ihl• vi•)IS',3'13 ra 1:" wN."4C•n.IM
Workers'11,11
s' Cu ..it-- tlon Inwrunce ,Uflddvit: Uuilders/Cuntractun/Electrlcians/Plumben
l 1 illcant In urfndllo
PI d.� Int le 'hl
VJ1T1C I Ihran ktr;IWAMunii1w Ind,v a luu4:
�tldruss:
City,Stare./ip-
I'hunr
.\ry)uI/an v ugl toy or"!Cheek the appr0yrlate box:
I 1,❑ 1 a111 a umpluyur with
un • d Q I ;un of project(ruqulreJ);
1pl mcumraefor and f inurparlfiate).• huve hireJ the.ruh•euntracfurs r'- ❑New cunstrucliun
-'•Q I and a tale prnprictllr ar partner• limed on the anachcJ sheet : 1. Q RomalelinE
.vhip and have no mnpluyees These subcontractors haw iwrkiny the no;in any capacity, workers'comp, mewonee. St. Clnerrolition
I NO workers'camp. iusuranh 3. Q We are o crhporstion and its 9. ❑ Ouddind aJditiun
10 ruquiruJ.j otftccrs have ueereiruJ their 10•0 Electrical repairs or additions
Vial a homcarrllut Juind all work right of uaenlplfun per M(iL 11.0 Istumbing rcpoirs or addition
Inyscit IKo tvnrken'camp. C. 132,J I(s),anJ we hove no
iaxurancu rcquired.1 r :Inpluyees. INe workers' 12•Q Rluul'tepairs
crnnp innurancw rcyuind.J I J•Q Utlfar
%"y.,,plrrad ill's J.."ob b'U'0I nuN:Jw lilt rn,l rM wman 4hlr Jwrrrt r
'I I.,n..nrrrrun ah11"Anvil Ibis olAJarll indluline Ill".p Jain x hvir wwYus'rwrrlMs4dlua Iwlisy urriutrrwiln►
'(-,Hrlr%lr,n row t,1pY'e this box nllw alr;hid ea rddtli x dl tvura rtld rhnl Alp awrids comrnsbp w+
urwl.hurl Jluwine the natty of the pa'cew/ rs1 whne a nrw�mJrvil inJiuYia
/alrr Ulf rely/oyer fhw if prvvJd/ne 1vorAeri'rurnpenrndon hr.rarnnce/0r my rrn ,nd tAer uvrkws•rnty pdwy relbontoo vnwl,
infurfnWluas. pl J dra Br/ulr Jr Ihi pu/lry and/u1 aile
Invurancu Company Nalne:�__
I'ulicy 4 ur Scir•ins. Lic.a!
Eapirallan Dave:_
lob Silo �\dJres.r:
\Itach ifcu C'uya5later"Llp:
py ur the rvorksre c nnpu,ld%:run pulley Jvcluratlun pug@(showing the Polley uuntbar and ucparatlua dule).
r(.1"llun: w 11 1110 cuvers,ye•u required under 3ecliun_'3A ul'.►IGL e. 132 eau lead to the imposition of criminal yenalties o/a
u rip Ii SLSflO,rlq Jnll/ur uae•year unprivnnmcnt, Js well Ja civil Iwnahtca in tho lunn ar'a STOP WORK URGER anJo fine
ai up ra i?10.rM a Jay rg;linal the v6rlJlar. Ile advl.wd thin i copy uflhly,lafulnwn may bu Iurw uJrJ lu the Ullice ,r
Iilt iall�Jllr,tb of the IJI.\ cot ur.ur.u'cd :uvcrJge 1 atliufum.
/du/a•rchy.crri/'y turdv the paint uuJ prnnlrier u�prr/nry rhrr die in unnrr/on/' proriJrd u0uve it rrlre mild c0rrvrt
71 --
uq,un/y. /1d nor mrbr i urcu, ru he1'n rrn: _uthurify (cPernit/l.lacnverJ RrJ1U1 I lcpw..trot . (:itl. rarvu CIcrk J, l••Iccfric.11 Ins ,cvfuri,I Plumbing Intycclor
'tr,utr. '