22 PICKMAN RD - BUILDING INSPECTION ` The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 201/
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Buildin it um r: PP
uild' g Off cial( 'nt Narne) i true Da e
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
D GR�
1.1 a Is this an accepted street?yes ry no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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:
Zone: _ Outside Flood Zone? Municipal �On site disposal stem ❑
Public L9' Private❑ Check if yes❑ P P system
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner o ecord:
I Jnni(�+__.,LtN f G�fS/af? L g rn /7fs9- 01170
Name(Print) City,State,ZIP
P;-Ck-0,4y-1 90fid ( 617 ) 912- (.7 'i4
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building lir Owner-Occupied IB' Repairs(s) El-I Alteration(s) Q-1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': I -
1(2
L
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1. Building $ 1 S� ao 0 ,du 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
�� V ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ 0 List:
5.Mechanical (Fire $ y�
Suppression) W Total All Fees:$
o t Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ /6, Soo ' 0 Paid in Full 0 Outstanding Balance Due:
r SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) rs
(.lJr {/ ,o, ��nc�! License Number pimtio E Date
Name of CSL Holder List CSL Type(see below) U I,
� 43 r l r4 A Sl-p��- Type Description
No.and Street
/ o U Unrestricted(Buildings u to 35,000 cu.ft.
C
- n -o /7/)Af 0/ R Restricted l&2 Family Dwelling
City/rows,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
// SFI Solid Fuel Burning Appliances
4tS j'08-(00N� �Do Y7�o✓17`rr9G'7�F� �' I Insulation
Telephone Email address I Loll . D Demolition
5.2 Registered Home Improvement Contractor(HIC) Z-7
wr,1161Yh F /I "A HIC Registration Num t ber xpi o
HIC Company Name or HIC Registry t Nam !_ ,
�r rt� ��—)Qy$A_�.-C¢ /OOa11P1rQ"1521A,+rA-'T_ i/1✓"i7.!')d1
No_aAd Street �T Email address �i/,
Ci /Town,Sta e,ZIP Tele 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 ..........er' 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 A)l //, r W C. /h ( /)
r
to act on my behalf,in all matter live to work authorized by ththhis/building
^permit application.
et9.-Jd Z7 20r3
Print Owner's Name(Electronic Signature)7b,>L-k E C' JJ to y - 7Z., G.(3y' 0.[2 Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contaiaW in this a lien i and accurate to a best of my knowedge and understanding.
'nt Owner's or Authorized Agent's Name(Electron" Signature F)�,.�..tcl 5. ('yf`o.(r _�'`. �,L�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. og v/oca Information on the Construction Supervisor License can be found at www.mass. ovg /dos
2. When substantial work is planned,provide the information below:
Total floor area(sq.ft.) (including garage,finished basementlattics,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"
CITY OF SALEM, N'LkSSACHL'SETTS
Buti=Nr,DEP.kRT\ NT
N+ 120 W.kSHNGTON STREET,P FLooR.
+tiK o T FL (978) 745-9595
FAx(978) 740-9846
{ONIBFRT FY DRISCOLL
MAYOR DIRECTOR
ST.FtHRRH
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSLSIiSSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by: I k
(name
The debris will be disposed of in
(name of facility)
�SL--9 _ oc�. ie-
(address of facility)
signature of permit appl ant
date
Jcbri9aiLdx
CITY OF S:1LE1 f jANSSACHUSETTS
Sull-OLNG DEPARTM &NT
a s! = 3 120 W.ItSHLYGTON STREET,3"FLOOR
TEL (978) 745-9595
Fmt(973) 7.40-98-44
KIJfBERLEY DRISCOL-L TH01LlsST.PiERRB
MAYOR
DIRECTOR OF PUBLIC PROPERTY/Bl;lI17LYG CONLMISSIONEA
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Letzibly
Name tnusima &Organi:atiomtndividual):
Address: �
City/State/Zip: Sta G i,, m ✓3_ _ G14-)0 Phone#: 27r &OL —i�o qS—
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. Gg'fam a general contractor and 1 6. ❑Now construction
employees(full and/or part-Lima).• have hired the subcontractors
2.❑ lain it sole proprietor or partner- listed on the attached sheet.t 7. [B-RLr odeling
ship and have no employees These subcontractors have 8. ❑Demolition
working.for me in any capacity. workers'camp.insurance. 9, ❑Building addition
[No workers'comp.insurance 5.'❑ We are a corporation and its
required.)
officers have exercised their 10.❑-Etbctrical repairs or additions
3.❑ i am homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,$1(4).and we have no 12.❑Roof repairs
Insurance required.]t employees.[No workers'
comp:insurance required.).
13.❑Other
•Any upplicum than chucks box 11 muss also rill out the section below showing thole worker'compensattun polley imasmadom
'I hvneownera who submit this adidavit indicating they an doing all work and then hint outside centimeters must submit a new alndavil indhcssing such.
:(:untrscwn that cheek this box mud ausehod an addiaurwlehod showing the rums of the suhNnlleebn and their woken'comp.pulley information.
fain on eoployer thatis pravfdlttg worker'compensation lnsaranee for my erstployee% Below/s tbs policy and Job sits
inforararlan. /Insurance Company`lame: �_
:tgs �Q'
Policy 4 or SelRins. Lic. 0: II-- Expiration Date:
JulsSittsAddress: ZZ PtA42114vl. S�r � City/Statrizip: 70
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to sccuro coverage as required under Section 25A of bIGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S t,500.00 unlVor one-year imprisonmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a line
urup to S250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
hrvesligutimts ul'the DiA for insurance covtmga verilicaliun.
t flu hereby certify under the putts rd peaallles of perfury riot the inforurution provided above is/rue and correct.
)era• T— O I
Phone 3:
(IJ/iciu!use auJy. Do not write irr dris arery to be completed by city or town afj1rial
I
CityorTuwn: _.-.__ Permit/i.Icense..0
lesuing,%tahurity(circle one):
1. Uourd of ilcalth 2. Building Department 3.Cilp town Clerk 1. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: ... _—.. -- Phona lh