9 PICKMAN RD - BUILDING INSPECTION SECTION 5: CONSTRUCTION SERVICES /
5.1 nsed Construction rvisor(CSL) ��jj Zcf d c•
License Number Lxpir:uion ate
Nance tit CSL�- Holder List CSL Type (see below)
T, e Descn pion
i Unrestricted(u)to 35.000 Cu. No
r c�—
R I Restricted LYc_ F:umily Dw clliue
Signet re y 9-L/"�3� M Masonry Only
RC Residential Routine Covcr'me
Telephone WS Residential W nduw and Sid ate
SF Rrsidenual Solid Purl ftummu :A>>Imncc Inscdluuun
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) �� f
Registration Number
f IC Company fName or HIC�aS e, biamd'r� �2 D�
AJdre�� flz (��������� E.epiratiot Date
Signs 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
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... No ...........
11
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
[,
to act on my behalf. in all matters
authorize
relative to work authorized by this building permit application.
Date
Signature of Owner
SECTION 7b: OWNERt OR AUTHORIZED AGENT DECLARATION
, as Owner or Authorized Agent hereby declare
I,
ing application are true and accurate, to the best of my knowledge and
that the statements and information on the forego
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the 2ains and 2enalties of 2er u ) 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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and 110.R5, respectively.
2. When substantial work is- planned, provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Habitable room count
Gross living area (Sq. Ft.)
Number of fireplaces Number of bedrooms
Number of bathrooms Number of ec
Type of heating system Number of d deckks/ porches
so
Enclosed Open
Type of cooling system
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
The Commonwealth of Massachusetts
Board of Building Regulations and Standards I"OR
Massachusetts State Building Code, 780 CMR, 7"'edition MUNI�'ll':�LI'1'1
w USk:
Building Permit Application To Construct, Repair, Renovate Or Demolish a Re rised Januut
One-or Tivo-Faunily Duelling /. '008
This Section For Official Use Only
Building Permit "` er: �— Dat Applied: R /0
Signature: ` ° � / �i
Building Commi.sioner/ Inspector of BLtiddin Date
SECTION 1: SITE INFORMATION
1.1 Proper ,a%ddress: 1.2 Assessors Nla & Parcel Numbers
�Ul1ylUM oeG{ P
I.1a Is this an accepted street? yes no Map Number Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 1't) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided 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 to Private❑ Zone: _ Outside Flood Zone? � /
Check if yes❑ Municipal MIOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.i-;Ver'ofR rprd:
J ee,�r/
Name(Print) Address ror Service:
Signature 'relephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': Ca4 5 b lelf c 4z— U/AEG
/If/ O///S�In a/-Gv n,h•:�clh ->< �.�.�fii �ja
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item r0a
: Official Use Only
(Lals) y
1. Building $ d I. Building Permit Fee: $ Indicate haw fee is determined�. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost' (Item 6) x multiplier ,x3. Plumbing $ 2. Other Fees: $4. Mechanical (HVAC) $ List5. Mechanical (Fire
Su ression) $ Total All Fees: $Check No. Check Amount Cush Amount
6. Total Project Cost: $ ❑ Paid in Full ❑ Outstanding Balance Due:
�y /OqO r
Vrr 1
CTTY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
>,lwruar txtmtauu
llvrtta tlC gy&"%G40t *M r a SAUCK Wksm as wrls 019TJ
Tw MAS. 016 o R.va:W11,740.9"
Workwil' Compe"oden tasursoea AQIdavltt Solidera/CentraeosryEkxMdsmsn%mbors
Aoalicant Informailos Please hime t 41atnsm
r^
%420W uwnyO.pairatiorin4v.h.lY.__ f/O.w��/L y g-/"///ir i",-,
Addt�_ i LYf ,) /P,5
city/snme/zip: A4 [lion.a:
%r--o yyoou au ompbyw?Cheek the appreprim bass
I.0'Jam a employer with 4. [31 am a p agea conVacgot aW 1 •. C °pprolaet(rMdr :
ettwkwest(fu11 savor punt-dam).r have hired the waeuturactors
0 .
2.0 1 am a sole proprietor or partner- listed as ft attached sheet 1 7. lies
ship sad have no ompbyow Thies sub-conommes haw Y 0 Damolitim
Walking forms in any capacity. werken'Comp inpuonoa, q, ❑ �additistm
f rat►warkem'tamp insurance J. 0 We an a corporation col(a
rCquirmLl oflleaa haw exercised thew !0.0 E4etrical repair or addtiom
3.0 1 am a homeowner Joins all work right Orudraptimt per h4GL 1 l.❑Plumbins repairs or aJJitions
myself.(Ko workers'comp. a 132.+l(4L and we have no 12.❑Roof repaid
lnsuract re quived.l► :mPloyeea.[No workars' Is.O Other
e°'"p insurattar nquirud.l
•A,a 40buid Nat elrAta me a .mat aim All"der ra&ae hulaw Jowly Nair wartmt'algaaostbs paliwy marertioL
1%Wkv*1am who Submit Nip dtldwk bdbmd%wry an defy oa WM std 460 hlrt ama1Y saaaormrr attar wink a saw a1Rd.it tadladiy a"
-C mason Not ohms Nis Om cart atadard at add oomw AM.bowing tbo teem of do as►wraues"ad Nor wwkm'ew}polk7 w6nw im
I aar aw roopt'oyer that Ar prov/dfwR WMArra'reaprwnaalew Intnroncef4w wry aap/oyert Below/a the B awJ
iw+ 'Y xft
Insurance Company Vanw.
Policy a ur 9elf--ins L9w. Eapirduon Data:
Jub Sine A1k4esr: / //'rG�� (12�77y �/� cayobtatazlp. e-wo ��f0
.%rtach a copy of the workers'compeasatioa policy dtclaratloa pap(showing the policy number and expiration date),
I'ai lure m xxure coverage as requited under SCclioa 25A of MGL c. 152 cast lead to the imposition of criminal imaWtia ofs
fin.up at 51.5110.00 and/or one-yea imprisnamcm.as well as civil penakias is the form Ora STOP WORK ORDER and a fine
"fup to S250.00 a Jay again"1110 violator. Ile advised that a copy urthis statement moy be t'urwwardad w the Oi ice of
:-1% is+auto of dw DIA for im,urarce;ov.ndt:rctiFicattun.
/Ja hen by cefuro too psi ao yen h/rs a0eduq that din Ia/orAadea prov&W aloes As 170 and comet
Ci.•:rt r. r•• �/ y. 2 l� 6y
f CILIS �
OQ7def err ow/p Ib watt rrr/rg/a rho ares6 m tie cowpAyd ly eA)F ar Atwa oQ4•/dL
City or Town _ PermiV1.1cease 0
Issuing Authority (circle onc)t — —
1. Ilmard of llralth 2. pudding Ikpartmcot 1. City/fowa Clerk J. Electrical Inspector S. Plumbing Inspector
4 Other
Gmilaet Person: Phone q
Information and Instructions
to It Gcneral Laws chapter 132 mpLim all employees toPro'
�Setvice uf�f calve hw ��tt(or dbrif�byeetAr . ._.
Nnuons to this",itvu.a a em/by+se is delimd b a.-AVQsy PenOO
tta Othim
e%press or imp6C..sa1 or writta►'
anooaeioa.osrpawsias of other Eva easily.er any two ar tetra
AA do~is deft d as"at+idieidral pmtttwabip► legal rcpnaattesive of a decessd employer.or the
of the foregoing engaged i°,a JeieR���'ad isebtdb+g tb�. However the
roawiver at mssee etas Btdvidtsd.Ptrmsesisw astoam°°a at a" legal saltily.entPloyWUPW
overt eta dttreFBeg bane hvieg eat mess thee space apwbtsoa sd whr taeidee or w e'so eh dwelling at
owns ire lactose of atrtlrer to do maietmsoca c.r.►r"ctim of repair bolus
or Orber'WAldh PPS lbaeb Shea set bommi s of lash empleym"be doomed to be an employer."
at an the Foaa& s
htGC ehaptef 132.123C(6)also sow spat"elegy Stab w IetY aeedstt sgseey shad wWbON tM bteeeaee K
-caved d•geests1 Spa is b opeteb a bet:tssm K b toest+tatt btYW V Is tM esauosweaW fes Say
or ovideen of compgasb with,do Is ee st rae coverage rs%tstsrd.
st shall
sppYse wbe bee star produced esaptebM
AJdisiaadly.Mdl chow 3=.�of��unW acceptabis evidraa f emaPl�with ril itrtrarw
enter�a�s at t chyroer be"base Prassnod to the eoneeednf etrbadSy"
Appgitttem
please all out the wWk@W carrPsossttaa afidavit eotnPan dy by checking boxers thawith
apply rt your(s)O tea as4 if
neeemeey.sttpPty onalitleyesto-ttb eaatreerot(s)w�slti addeeas(os)ttd pbtase number(s)altos with their canilkaas(s)�than the
C ies(LL.C)of Limited LlebiNq Po*�Ps(fin with m
insurance. Limited Liability oespan ituutamee, It an L[.0 or L,CP doer haw
me lmbae ors policy
imiLasaadvwo�d rid tube of submitted to the Department of Industrial
inp Yeas. o(ietntrsnee Alp be sun b alp sad date the aaldevhL The affidavit should
Accidents for cmaUmstice or liumse is being requested, eat the Department of
be returned to this a town that the application flat the Permit
industrial Accidess. Should you have any questions regarding the law of i(you ace requited w obtain a uwld enter their
orkerse
cotnpas ation policy.please call the as the number listed below. Sag-iasumd compeer
ies sho:self inwnaoe license rumober on the liar.
City er Tsar Oatltlells
It
t t The Department has Provided a spree at the balm&
cax P be sure drat the affidavit is complete and printed g bl!'
o tiro at'fitlsvit for you to fill out in the event the Office of Investigations has to contact you regarding the appliearm
!'lcatw be acre to till is the parmitllicense number which will be used as a reference number.mi ne nad•icion,vil n api; ant
urrent
list must submit multiple permiulieetsu applkarions in any given year.need only
policy information l multiple
Perm )and under"Job She Address"did applicant should write"all tocatfom is_(city of
officially stamped or arked by the airy or town may be provided to the
townJ."A copy of dw of idevit that has been
applicant as proof that a vapid affidavit is ors file for Mture permits at licenses. A new affidavit must be filled out esti
yam. What a halts uwtrr or citixes is obteiaiAS a license or permit tot related to any business or commercisl ventum
(i.e. s dog license err pantit to burs leaves site.)mid person is NOT required to complete this affldsviL
Chu Otii:c of Investigations would life to thank y.w in aJvunce for your,00pention and should you have any questions.
01cL ae Ju nut hesitate to give us ;'call
The Dcpsrmrnt's address. telephone and fax number.
The Commonwealth ottManachtlsetta
Department of hkkLs W Amidwits
00"of favadzuk"
600 Waebillom Street
Sodom MA 02111
TeL 0 617-7274900 ext 406 or 1-877-MASSAFE
Pali 617-727-7749
.t:v ia:d 5-26-05 www.mm.gov/dia
Crry Op sic
PUBLIC PROPRERTY
DEPARTMENT
•.veal af' a>•a`IL
S L\U• 1 C WAfi CW.QW f UfiT•�ti t�1L�vlta:r •a 11 a i.�
Tn.�7 •t1.VQ sta.le)aw
Coastruedas Debris Dtsposaft Affidavit
(rettuirol Ibc an.isnalwas and rlstsovad"wont)
In xcordaaes with the shdt edidiea otdw Stars Building Cods.7W Cl►lt sacd" 111.3
Debris,sod tw provisions of MGL a sq!Sll
gwidall Fmmk d _ is lased with tw eonditiaa that tw debris resulting fhara
this*at shall be disposed of in a pWpWly lieanssd wests disposal fboility as defined by`LGL e
I11. f 15"
The debris will be uunsportad by:
_ Al�1 -s ak/j2
fhsdebris will tw disposed afin :
19A.J -It
(a:.rtta�f Pa:lGty)
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