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19 PICKMAN RD - BUILDING INSPECTION (3)
�00 C'������@ /%��� � 7he Cummonwcahh of Massachuscns Town of � � �I .+ r Boud of Bwldmg Regulauons and SundarJ� �� � �? J �iruachwens Swu Bwlding CoJe, 780 CMR. 7'"edmon BudJm�Dept � r� BwWmg Pemmt ADp�icuion To Cunstruc�, Repa�r. Renov�ie Or DemoGsh � � Onr-ui T��u-fwrnh D�rrlhng This Sauon fov O � �d Use Onl BwWin� Pertml Numbcc D e Iled: a `�6'�Q Siynaiun: ""�"" Buddm�Comm�s�ioner/Inspa�a of BuJdmp , SECTION 1:SIT� 1 o erion 1.1 Pr�penr A re : �.7 �uaon M�y� P�rcel Numpen sj . I.1 a Is�Ai�an acce ted�treel"ya no Map Number Pvicel Number . 1..1 Zonin�InfarmaUos: I.� Property Dlmm�lonr. � Zonm{Du�nct Proposed Uu LM Art�(sq II) Front�`e 1�) 1.3 Bulldin�Selb�clu(f1) From Yud Side Yardf Rer Yad 0.eauvad Provided Requirtd Rovided Requircd Provided � I.f W�ter Suppy:IM.G.I c.00,SSq 1.7 Flaod loet IntormHloe: 1.!Sew�{e Dbpoul Syftem: Publie O Priv�u O Zonr. _ Ouuida Fioad Zone1 Mwicipd O Oe�i�s dispo�l�y�eem O Cheek if �O SECTION i: P(IOPER7Y OWIrERSHIP� 1.1 Oweer� f eeord: "lj� /G iy�,9n 4�'dLl '/ 0 � N.����� ,,�,.�a��' 3.�� 3 8/� . sipuw. re�epnon. SECTION l: DESCRIPT�OIV OF PROPmSED WORK�(cAak�U th�t�pply) New Conewction O Exia�ins BuildinQ O Owner-Ocaupied O Rep�ira(s) O AltentioMs) O Addition O Demalition O Accesaory Bld�.O Number of Uniu_ Othm O Speairy� Bnef Dexnption of Proposed Work�: �5 -7 q o✓,�p/��� r � SECTIOIV 1:ESTIMATED COIVSTRUCTIOIV COSTS E�timaud Coen: OAleld Uu Oolr lum Lsbor and Matariila - 1. Buddm� f �� I. Bwldinp Pvmi�Per. f Indiute how ke n detertnincd: O Sundard CiryiTo.n Applica�ion Fea 2 Elaanc�l f O Toul Proja�Cos�'�Item 61�mul�iplier ■ ) Plum�ins f � d 2. O�her Fees: f 1. �lrchamul IHVAC) S Lis�: t Nahamcal iFire s Toul All Fces: f Su nsswn Check �o. Check Amounl: Cuh Amoune_ A To�d Project Cos[ S �a �� O Pad m Full O Ouuundmg Balance Dur �� �� � ° SECTIOIV S: COIVSTRUCTIOIV SERYICES S.I Licrnud Comtructlon Supeni�or�CSI.) �. • • L�.rn.e NumRr E.pu�uon D�u !�,yae ul CSL IIpIJer � Ln�CSL ir0�Ix�e Alo�rl .. • ,_,,� AJlna i� Defcn �on � U Unres�nc�td u �o!l,000 Cu. FI. I R Reiincted I�2 Fomd O.ellm � �i�MIYf! M .Nawn Uel RC Res�denual Roofin forenn Trky�one WS ResiJemial WmdorandSidm � SF Rr�idenusl Sohd Fuel Bumm A 6�nce Insull�hon D ResiJen�ul Demoluian S.7 Re{I�urM Home Improremeet Contr�etor�HIC) HIC Cmmp�ny Name a HIC Re�otrw Name Repsvaum Number I AdNef� Eapirnion D�Is Si�nmut Telephone I SECTIOIV i:WORKERS•COMPENSATION INSUAANC6 AFFIDAVIT(M.G.1..e. 132.� ]SC(6)) Wodcen Compeneation Irounnce�Rd�vit must be completM md submitted with�hia applica�ion. Failurc to provide I ihia�Rd�vi�will rcault in �he denial of the luuance of ihe buildino permit. �, Si�{ned ARIJ�vil AuacheJ? Ya.......... O No...........O SECTIOIV 7�:OWNER AUTHORIZATION TO BB COMPLETED WHEIV OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I. �5 -1 . u Owner of�he eubjcct property hercby awhoriu to acl an my beh�lf,in all mattm rclauve W work authwiud Dy thi�buildinQ pertni�appliution. Si ofOwner D�u I� SECTION 7b:OWIVfR�OR AUTHORIZED ACENT DECLARATION �. , +e Owner or Awhorized Agent hercby declare thal�he sutemenb and information on ihe forc�oinQ applic�lion are We and accunte,w�he beat of my knowledae and belulf. Rin�Nun� Si�{nuure of Owner ar Awhorized A`ent D�u I Si ned under�he sm�ud nsltia of IVOTE3: I. An Owner who obiaina a buildin�pertnit lo do hiyher own work,a an owna who hirca an unreQisured contnctor (no�rcQistered in�he Home Improvemen�Contrutor�HIC)Pro�nm►,will'g h�ve xces�ro ihe ubiiniion pro`ram a�uann�y fund unJer M.Q L. c. I a2A. O�her imponant mformauon an the HIC Pro�ram and Con�uuciion Supervisw Licensin�(CSL)can b� found in 780 CMR Reoulslioro I 10 R6 and I IO.RS.«speciively. 2. WAen subsuNisl work is planned.pronJe ihe mfarmauon below� Toul Ooon aru(Sq. FI.) Imcluding gange, finished baxmenUatlic�,deckt or porch) ��� Grov livin�area�Sq. R.► H�biuble room caum � :�'umber o(fireplxes Vumbtr of bnlroomt \umber o(ba�Arooms V u mber o(hal f.ba�h� Tvpe ofhemng�ysum Vumber ofJecky porchn r,��„r,�i��,�Ys��m Enclo.ed Open 1 ��Ta�al Pro�ecl Sywre Fuoiagd'm�y he.uh.mweJ for�'ioul Pro�ect Co.Y' CITY OF S.�VrE.�i PUBLIC PROPERTY DEPAR'I'�1E1VT ' �1�u�NM/'IY L . I �/wvW ��WA9UM[.ZOPI Si1F.iT�S�lslL WwSA06�3t11S AI��O . �i v-4ns�sss•f..�c r��aeaw HO,NEOW�IEA LICENSE E7KE.�IPTION Ptew hi.t D,�, a—�6�, i ,ab� �� ,�k�� �2 ��1���, xome ownea wd�ea. s �c m:� �( Home Oaoer Telephon� T�8 33���P/a Presant Mailin�Add�ea� ��^�-c_ The eurs�ent exempdon of"Homeownas"wa�extmded w inciude own�-oceupied dweUing�ottwo Unit�or la�and W aUow nuh homaownen to engage an individual for hin w�o.doa�ot poasa�a Gcense,provided that the owma acv ar aupatvieor. DEFIIVTfION OP HOI�+AWNER Penon(s) who oan�s parcel o[land on which h�/ahe raida or intendr w raide.on which there i�, or is intended W ba, a one or two family dwellint. attached or detached strucnua accessory W auch use and/or.fnm sWstura, A per�on who comtrucb moro than one homa in a two yar period ahall not be coasidered s hom�wna. Suc6 "homaownar"shall submit to the Buildin�Otifcial,on a torm aecrytable w tha Building OEtteiai, tha! hdshe be raponaible for all auc6 work performed uadar the Building Pamit The undmi�ed ,.homeownd'a�suma reaponaibiliry for compiianee with the State Buildin�Code and otha applicabla by-law� and regulationi. I The undmigned "homeownd'certifia that hdshe undmtands the City of Salem I Buildin� Departrnent minimum irupation procedurd and requiremrnq and thu hdshe •�vill comply with said praedura and requireme ts. � HO�tEOWYERS SiGYATL'RE ,\PPROVAL OF BUILDf.YG [�iSPECTOR See other side for staee cade "� CITY OE S.1I.E.`t, �L�SS.-1CHi:SETTS BL'RDL�(G DEP1ATlE�iT � ' 1�O W.��FIL�IGTON SIAEET, Y°F1..00R . , 'I�s_ (97� 7i5-9595 F.�x(97� 7iQ9&16 ���E�Y DRISCOLL �fAYOA ( Moaus Sr.P��us DIIIECTOI OF`Vl'HLtC PIIOPEATY/8l'QDLVG CO�L�RSSIOVER � Wurken' Compensatlon In�urance Aftidrvit: DuilderslContractonlElectriclrnilPlumben A � Ileant Inform�tlon PI a Prin Le � .V�iTlt �Bu�irkv�Or�amntiorolnJrv�dual): � . Addre'ss: �g I �G�+�^�i+i I� J CitylSatc/Zip: ��i��^'� �5 Phonc q: / � �3�� 3��,�- � ,1�e you r�employ�rT CAeek the app►opriate bos: Type of project(requlre�: I.0 I am a employa with 4. Q I;un a gencral contractor and I employea(full and/or pan-ume)•' hava hired Ju subcontracmn 6. �New conytruedou i 2.O I am a sole pmpriewr or panner- listed on �he attached yhae� � 7. ❑Remakling ,hip;u�J huve nu employea Theae subconteaeton have tl. � Demolitioa wohing for me in rny capaciry. workm'comp.inaurauce, 9. �Duilding addidon I �No worken'comµ insunnca S. Q We aro a corpomrioa and iu 10.0 Elatrical rcpaio or addicions r�quireJ.] � . , oPlicas have eureixd their J.�I I,am a,hom`euweerdoin�all wori�' riyht of eaemption pu MGL I I.Q Plumbing rcpain or additiom myself.(No worken'comp. c. 132,§I(4),and we have no �Z,Q Roof eep�irs insunnce requircd.]t �mplayees. (No workew' I3.Q O�ha comµ inwnnce mquired.J •Any applicanl Ihr cAwb Daa II muY alw fill wt IM�oclim bclow nAo�ie�Iluir Workea'cpnpmu,Gr�p�liry i�urmLlon. �1 Lwneuw�an who�u6ni1 Me iflldwk indlotin�ihry�n doiny all weAt and ihm hin ouqide rnntroerpf�mu1�uMnil�new a1R�hvi1 irdierip wc► � I -f.mum.yon�MI cheek�Au bm�mwl anxAed ae aJdi�iwal+hen showin�tlr iwne o(Ilr a►eoelnebn and iAeM�ruA4m'camy.puliry infwmouo�. I /un�aw employti rhot bProvid/n,�worke romp�nmdoa Jnirroncr jar my emp/uyee�. Bdow/i iht poltty ned fob xlq I injormution. In.urrncn Cumpany Vame: � Policy M ur Self-im.Lio. p: Eaepin�ian Date: Job Sirc AdJrcu: Ciry/SntNZip: ,�ttrc6 a copy of t6a worYrn'campea��tb�poUey dalantlan p��phowln��tu pollcy oumMr�nd e:plrulo�dah} Failura to xcuce covenge u mquircd unikr Ssction 23A of MGL e. 132 can lead to the imposition of criminsl penalriea of� fine up to S I,S00.00�m!/or one-year impriaonment,as well as civil penrlties in 1he form uf a STOP WORK ORDER and a fine of up eo 5?30.00 r J�y agains� ihe violaror. Ile adviavl�ha[a cupy uf this�atemen�may be 1'urwarded to the Olfice of Inv.ahg��iurui�il'iho DIA for insunnce covcr�ga vuiticaliva � /do Jrereby e�nijy u��di hr prin�J rnud/s er/ury rhal thi injamarlaw pravideJ ubow i.f n!qt und cuneet �i,•n�unrC: I)ute• _ � 'lvf/v Phune�: . . . � iO�eiu!u,e o�Jy. Do��ot wriu in�hir rreu,..ra bs.unrplered by eiry or rowe oJflrruL � I I City or 7uwn: � _. __ PcrmiN.kemeN__. � hsuing.\whuri�r lcircle unc): -- I I. IfwrJ uf IIr�Uh 2. Auildln�Depnr�m.nt J.Cily/fown Clerk J. Elntrical fiupntor 5. Plumbinq (n+peefor � � 6.Oihrr. l,�ut�ct Pcrson: _ . . —. --- Phant p• ��� CITY OF SALEM ,� PUBLIC PROPRERTY �„ ,��i " �r�,,,�/ DEPARTMENT o,��, �.I\II:� XI hl !•Nlv �'I I .\I`.l i tll �]��Y�.\ii ll\f.:<1�I�l N LL T 1}.\I I`\I.S�.Ni\{ I II il I i�:��l'- �I'CI:478-'�i 9;y5 � 1'\`(:718�i at�'18i6 Construction Debris Disposal Affidavit (rcyuirrJ 1'ur all denwlitiun��J rcnuvatiun wurk) In accurdmicc with thc sixtli eJition of thc State Duilding Code, 730 CbIR scction I 1 I.5 Debris, and the provisiuns uF MGL c 40. S 54; Duilding Permit !� _ is issued with the condition that thz dcbris resulting &om this wurk shall be disposcd of in a properly licensed wa.ste disposal facility as dafined by MGL c I l l. S I51)A. - il The debris will be transportcd by: �I J��� � �n ' �nomcoChaular) I 'I'lie Jebris will be disposed of'in : (name u� aci iry) �;�ddress uf I�ciliiyl , gnamm of�xrmit ppli a -� �J�� �i��r .�rhii.,ir,s�;" - ----- ,_._. _.�__,___.__�___._.._---V----�___.._--�- _�_��____________�.�^____�_ 4I . . . , t�1✓dl.�'P�R�-�C�..�4-M.p'� =P�r13�. _ � �� — �,,,;;,� .�: � �- _ _r _ � � - c,�.-ccK�n )J� -- . I � � � s��-o�iu0 g �� , �� - . � � .�,r� — — � - ' � I . � . v i i . _' nrir�r--- � � i i o i .�'n,: I � �,s �. _ /.I . , - � � . ' . \ (\(�p � . ��� , - � . . � � � . I � .. \ �. ' � V/ ~ \ ii3ei �` . . 11 '. � _ 1 i{ . .- - . a1'� I 1111 JIJC 1 �� t ' I . I . ._�L"��CJ`• y 4 7 111�11i-� I . I \ \ u-v' ��'# . 5����1�_�OV`l\� •.\ � 8�_�.� ��T1.�i �Liii i � lla n`T`Tr — i �X��� "K�9c.Ri��. . � �� � � A `� � �(.(�NOpy�G . � ' � � . 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