1 PERSHING RD - BUILDING INSPECTION (3) r
Y.
The Commonwealth of Massachusetts
ql, Board of Building Regulations and Standards CITY OF
( Massachusetts State Building Code, 780 CMR SALEM
!� Revised Mar 2011
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 Applied:-..
t IL 3 i
Building Official(Print Name) Signature" ` - Date
SECTIONl: STPE'INFORMATION .
� LI Prop y Add ess: 1.2 Assessors Map&Parcel Numbers
/24 A644
1.1a Is this an accepted street?ye no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard -
Required Provided RequiredProvided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public lil�private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2; PROPERTYOWNERSHIP'
2.1 Owner'of Record:
&J Dy 11A6�TP - +�m�t ty.$ Ai r t i PSI I� c�19�p
Name(Print) City StateZIP
(�Oiti rssa
� l PEP�utl�rr tzh 4,�I-i rnA rt?_mos.trIo-rwuv\tsP_Wwt�.�ot'1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION.OF PROPOSED W RK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) $1 Alteration(s)- Addition 0
Demolition ❑ Accessory Bldg. ❑ Number of Units / Other ❑ Specify:
Brief Description of Proposed Work Z:
"_ 10 C144!2 OVAYAAh-
SECTION 4d ESTTMAT D'CONSTRUCTION COSTS
Estimated Costs: "
Item Official Use Only
Labor and Materials
1.Building $ J 1. Building Permit Fee: $ Indicate how'fee isrdetertrtined:
❑Standard City!Pown Application Fee
2.Electrical $ i+ -
❑Total Project Cost(Item 6)z multiplier= ' 'x
3.Plumbing $ 2, Other Fees: $
4.Mechanical (HVAC) $ Ltst:
5.Mechanical (Fire $
'
Suppression) Total A1l Fees: $
Check No. Check Amount: Cash Amount. "
6. Total Project Cost: $ 000. OO ❑paid in Full' ❑Outstanding Balance Due:
n1>\1l_� l21 'l
SECTION 5:1 'CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
`� ��ooyaN
Name�P hiAlp 1p fR I c uZe fiense Number Expiration Date
olde'
M List CSL Type(see below)
S7 Ind raQA.F Sl I I T Description
No.and Street
W A N ,aUUnrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP `, M Masonry
P p.Q £A LH CM-Q 6, /t I I - / u R S Window
Covering
Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improve`m�ent Contractor(HIC) 15 R p 6 1 1„—',a � -
)0 /6 0? CA CL��t U tic HIC Registration Number Expiration Date
HIC Comp 99 7 an Name or HIC Registr t Name
N�trci.. r_� SSU LQ S� P 46R Cf1LEmail E-ar/dre5ss CrI7P I
Ci Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.Llc. 152. § 25C(o)
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 /�,��,�r�J(d F}�.
to act on bcliehalf,in all matters r ative rk authorized by this building permiiit apply ation.
(,P l�. -w-ar t
Print Owner's Na (E ctronic rgnature) Date
SECTION 76:OWNER'OR'AUTHORIZED AGENT DECT ARATION
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 Agent's Name(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 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.eov/oea Information on the Construction Supervisor License can be found at www.mass.eov/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"
T Q-I-Y OF S,,UE.NI, %L-1SS.ICHUSETTS
BLILDwG DEPARTME.\T
120 WASHLNGTON STREET, aro FLOOR
�asar TEL (978) 745-9595
F.kx(978) 740.9846
}v.\BERf FYDRISCOLL 7HOnfAsST.PiE.ans
%NLAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDINIG CO\LMl5SfONER
Workers' Compensation Insurance Affidavit: Builders/Contrue tors/Electrlci2ns/Plumbers
Applicant Informatinn Please Print Lee[bly
NainC lilusiness,Organ irahowl ndividual): 4AA AJ P
Address: '? /� 4tAg,— �,Q,;TL
City/State/Zip: // Phone N: �J_� if-_ y 4 [ 9 s `/
r
e you an employer!Check the appropriate box: Type of project(required):
I am a em Io er with , a• ❑ I;un a general contractor and 1 6P Y ❑Nc onstruction
employees(full and/or pan-time).• have hired the sub-contractors
lama sole proprietor or partner- listed on the attached+hoer. t 7• emodeling
;hip and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. y, ❑ Building addition
INo workeri comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and We have no 12.❑ Roof repairs
insurance required.) } employees.[No workers' 13.0 Other
comp. insurance required.)
-Any uppliuun Jut checks box 11 meal also fill out the Suction below showing their workers'cumpensaion pulley inflarnalfon.
'I Iommwnsrs who whmit this attld•+vit indicating Ibey ate doing all work and then hire uutsido comracttm most submit a new affidavit indiolina such.
:(%loi wlen Thin cheek Ibis bus most alachur an additiund sheet showing the narne of the subwonuactore and Ihelr wnrken'comp.pulley information.
I ant an eurpluyer that is pretvidbig workers'cuniprasadun Inrurarace for my emplayees. Below Is rhe polfry and job aIle
hr/of uturfnis.
Insurance Company Name:
Policy U or Scl Gills. Lic.d: Expiration Date:
Job Site Address: e L City/State/Zip:
Attach a copy of the worlters'compansatioa pulacy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition ofcriminal penalties of a
line up to 51,500.00 und/or one-year imprisnnmcnt,as well as civil penalties in the farm of a STOP WORK ORDER and aline
of up to S250.00 a day against the violator. Be advised that a copy of This statement may be furwarded to the Office of
Investigations ofthe DIA for insurance coverage verification. -
/do hereby c erdfy rnntder the pabhs and penalrlec ujperjui y that the br/arruur/un provided ubuve is true and correct.
ii•�n uurc' 4'! _� � Dam: kA- 3—
Phoned:
--P I ,d: S a
6
Of/iciul use only. Oo our write in this arra, to be caarp/tled by city or tabun o/atria[
City nr I'uwn: _ ,- Pcrmit/IJcensc p
........
Issuing Aulhurily (circle enc): ---- --
1. hoard of health 2. iluildlnq 0cpartntent 3.Citylfulsn Clerk J. F.fectriul Inspector 5. Plumbing Imepecmr
b. Other
I
Contact Pertno: Phone r'
CITY OF SALEM, MASSACHUSETTS
BunDiNG DEPARTMENT
120 WASHINGTON SmEET,31D FLOOR
nL. (978)745-9595
FAX(978)740.9846
KIMBERLEY DWSCOLI.
MAYOR TrIomm ST.PIERRE
DIRECTOR of PUBLICPROPERTYAULMING GDMNIISSIONER
Construction Debris Disposal Affidavit
(required forall 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 # z 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:
(name of facility)
(address of facility)
Signature of applicant
Date