6 PICKMAN RD - BUILDING INSPECTION a� The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
p 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 Appli
Building Otlicial(Print.Nai el Signature a2—
SECTION 1:SITE INFORMATION
I.I.Properpty,AdJresso 1.2 Assessors Map& Parcel Numbers
—14
L I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(tl)
1.5 Building Setbacks(ft) _
Front Yard Side Yards Rev Yard N
Required Provided Required Provided Required �ovideq
Om
1.6 Water Supply:(NLG.L c.4Q§at) 1.7 Flood "L.nne Information: LS Sewage Disposal Sys�: Drn
Public❑ Private❑ Zone: _ Outside['food Zone?
Check ifyes❑ Ntunicipal ❑ On site disposal system
SECTION 2: PROPERTY OWNERSHIP[
2.1 O_wDnertofyyjjecord: /I n
t/Ll f r7rtrl) 1/1 b'l) I�P �eU�lt t rn
Name(Print) City,State,ZIP U1
No. and Street 'telephone Grail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repa ) ❑ 1 Addition ❑
Demolition 91Accessory Bldg. ❑ Number of Units Other ❑ Specity:
Brief Description of Prorpused Work'' p���p��-T Z,i,
_aZ_f�>gfiL� f lI-A 1 r P N w C
SECTION 4: ESTIiNIATED CONSTRUCTION COSTS
Item 4EstiniatedOfficial Use Only
s)I. Building 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical ❑Standard City/town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3. Plumbing ? Other Fees: S4. Mechanical (I IVAC) List:
5. Mechanical (Fire $
Suppression) 'total All Fees: $_
r �0G Check No. Check Amount Cash Amount:
6. Total 1 roject Cost $ ❑ Paid in Full ❑Outstanding Balance Due:
SOvT Ttj CO lJG GZ P C T�YL l'j
y
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /G/ / // !�
7MIC6j jg Ky �(� (� License Number lspiratior Date
Na to of CSL Holder v
/{ et�x �S J List CSI..Type(see below)
No.and Street J 7 T Description
IM r l 0 / C tl Unrestricted2 Fa t(Buildings u el ing cu. ft.)
City/1'own,State,"LIP
Restricted I&2 Fannil Dwelling
M Masonry
RC Raitin Coverin
WS Window and Siding
c SF Solid Fuel Fuming Appliances
�7
4,7 -62 I Insulation
Telephone Email address D Demolition
5.2 Rstered Home lm roverrlentContractor(HIC) ��St/S S
Clllhll l HIC Registration Number E on Date
I�CUumy�D y�N� �rF�I�C_Rcgistrmu Name
and Street Email address-
City/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
![his 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
t c* OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
.1,as Ow er of the subject property,hereby authorize Z(AA14 Ky �--f 6&� )
.to act m omy behalf,in all matters relative to work authorized by this building permit application.
D4Sp &P ✓ rl e-' 7 �J
Print Owner's Name(Electronic Signature) ate
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 in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorised Agents Name(EleYtronic Signature) Du[e
NOTES:
I. Au Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the.Florae 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
evww.nrtss.gov/ocu Information on the Construction Supervisor License can be found at www.nnass.uov/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. fl.) Habitable room count
Number of fireplaces Number of bedrooms _
Number of bathrooms_ Number of half/baths _
Type of hcalimo system _ _ Number of decks/porches _
Type ofcooling system Enclosed) Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF SiUEM, NWs.1cHL'SET s
/ Y
j 4 - BUILDING DEPARTMEINT
\ 9s ��r•l 130 W.isHLNGTON STREET, 3'a FLOOR
., TEL (978) 745-9595
F.tx(978) 740-9846
KI\tBERLF_Y DRISCOLL
"AAYOR THon(A.s ST.PiERm
DIRECTOR OF PUBLIC PROPERTY/OIYI.DING CMMISSIO:iER
Workers' Cmnpensation Insurance AiTidavit: Builders/Contractors/Etectrlcians/Plumber9
A a ificant Information Please Print Le ihl
V;I111C (HusinesnOrganirulion,InJividu:J): (�GQC ��Dr-�O 'Vj�..�
Address: Y . �• �1�X L
City/State/Zip: �9k)(XtSvlj lll D/923 Phoney:
Are you can employer'!Check the appropriate box:
Type of prnJect(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and
employees(full and/or part-time).' have hired the sub-contractors 6• ❑New construction
1 am a sole proprietor car partner• listed on the attached sheet. I 7. ❑Remodeling
>tip and have no employees These sub-contractors have 8. [] Demolition
working for me in any capacity. workers'comp.insurance. 9. Building addition
(No workeri comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑Electrical repairs or additions
J.❑ I ant 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.❑ Rnof mpairs
insurance required.) t employees. (No workers' 13.❑Other
cutup. insurance required.)
•Any appiicaan Out check,but 41 must also rill'Jul the ecctiun Wow,howing their worker'cumpemmion policy im;,rmation,
'I lomunwm"who submit this affidavit indicating they arc doing all work and then hire outside Voatmc ors maul,ohmit a new airldavil indicating such.
�C'mumatun Out chvsk this box must anachal can addiliurcal-hect showing ow mono or the,ubaontrcton and their wnrken'comp.policy inrurmmien,
l unt un enrpluyer brat it providing workers'eunrpeusatlun insurance for my erttplayees. Baluw is the policy and fob slid
injnrnmlinn.Insurance Cunlpany Nmne: � r�`�j
_ I wlem it i it�se r I'(t^�
Policy it car Srl(-ism. Lic. N; 7G�7� 0 7J/ ��
Expiration Date:
!cab Site Address: �l Lu(—lM4W City/State/Zip: �I
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
F'ailuru to sccuru coverage as required under Section 25A of bfGL c. 152 can lead to the imposition ofcriminal penalties of a
line up to S1,500.00 und/or one-year impri.annmen4 as wall as civil penalties in the form of a STOP WORK ORDER and a line
of up to 5250.00 a day against the violator. Ile advised that a copy of this.statement may be rumarded to the 011ice of
fnvv,tigotiuns of'the DIA for insurance coverage verifiealiun. -
/du hereby certify lender!/ pains can u des ajperjury Mar the hifurinurlon proyided above is-True and correct.
Si••n 1 rc nn / '7 Data: 7 �
I'Fonc 'J'
Oflicial use atrly. Oa not write ire lhis area, lobe cotupleted by city ur lown njfciat
City nr'I'mvn: PermftR.IccmcM_----.____ ._._—_.. . ._
Issuing Aut purity (circle one): -- i 1. Board of Ile-alih 2. fluilding Department 1.(.'ily/fawn Clerk 4. Electrical Inspecfur S. Phuubing luapcctor
6. Other
Cunfact Person: . Phone
QTY OF SALEM, MASSAQHUSEM
< ` BUILDIN
G DEPARTMENT
120 WASHINGTON STREET,31D FLOOR
\nvs TEL. (978) 745-9595
F
KIMBERLEY DRISCOLL FAX(978) 740-9846
MAYOR MiCMAS STTIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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:
(name of facility)
(address of facility)
S' " ature of applicant
ate
f '
1
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supenisor
License: CS-106626
ZACHARY FELWUS
304 MAPLE STREET
Danvers MA 01913 -
`/ -• �� - " "�ss Expiration
Commissioner 04/11/201fi
. lr � '.� ( Lie�Aar 'y'�omac�ufoeda
-Office of Consumer Affairs&Business Regulation
19ME IMPROVEMENT CONTRACTOR
_egistrauon: 075456 Type:
xpiration 5/13f20154- Individual
_ ZACHARY fELLOAR'
ZACHARY FELLOW 1
i 3 ROOSEVLLT AVE "`
''BEVERLY,MA 01915 Undersecretary.