68 PIERPONT ST - BUILDING INSPECTION --- -- — T-
ic ('ot nnn,nas ca It h ul Mas,ac hu Netts f( IR
et liirard rtl ItwlJing Krculatiuns anJ Standards \il Nit II' \1 I I 1
Massachusx•tts Slate llulldint: Code. 780(AIR. 71" edition
I �I
Iuilding Per III,t Applicanon To Con SoLIct. Repair. Renitaate )I DCIIiolIsit a R, I
\ (hit•- r ,-/':Muth lh Alin\' — 1
\ I l'hu .' 'd1 m Fru Ofhclal t he Only
BwlJut_ Pcrnm Number Dme Applied: ---
$ - U. V •�
i ;ign.uule ....--=- - --- ---- - ------ --- - - -
liuiWmE C uIllul , uneU Irma• wr III I r i u IN Uatr
CTIO, 1: SITE INFORNIA'HION
I Pruperh Addr s: sf 1.2 Assessols flap & Purccl Numbers
I la I, Ihls all accepted elra•e17 rd>___ nr Map lumber _ i'.u,.l ,Nuinhri --
1.3 1_onS°°g-information: 1.4 Property Dimensions: t
_—
__ _
Lnugg Ut,viri-- P!:;Ine.ed W m Area I I _ 1.ruata�r :it;
1.5 Building Setbacks (ft)
Frmu Yard .Side Yards Rear Yard
Rcyuircd Provided Required Prurided Reyuiied Pi :ded
I
1.6 Water Supply: (M.G.L c 40, §Sy) 1.7 Flood Zone Informatlon: 1.8 Sewage Disposal System:
zone: _ Outside Fl4>trd Zune:' Ylumei al ❑ On ,ne diN>tnal ,a,tc nt ❑
Public ❑ Pn,ate ❑ Check if yes0 P
SECTION 2: PROPERTY OWNERSHIP'
2A Owneer'of Record: �. a q
/> �' e �H�
Nalne i P u t) n Address for Service: Q�--7 6.O
/77$- 5 7 2 `3 ) ----- -
jStgnatti e Telephone
rSECTION 3: DESCRIPTION OF PROPOSED WORK=(Check all that apply)
—
j DNe - -
T
\Jdnnnt
❑❑ x 1ew Cuntru Oid ❑ R ❑ \Ilermnni,) ❑C
ulim Access( I v 8ld . ❑ I Nwnber oI Units_ Other ❑ Specify
Brief Descripwm tit Proposed Work
n s mks 3_ j) - --
I
SECTION J: ESTINIATED CONSTRUCTION COSTS
j
Estimated Cr,ts: Official Use Only __. .Item (Lahorand Materials) _
I Buildln¢ 5 I. Building Permit fee: 5- Indicate It,:%% toe i, dole!uuncd:
` ❑ Standard City,"Fimn Applicanrm Free
I Fleetncal ❑ row Project Cost' I Item 6) s multiplier _ s
1. Plurnbmg '�� '_ Other Fees: 'S
1. Ntechamial !14\ \C) 5 Lt,t ---_-_.- ----
i. Mechanical 'Fire --- - - ------ --
�u )arc„Iu,i fuel All Fee,:heck No Nor __('heck Amount, (:nh \uiowit
o total Project Cost �5r L/J O ❑ P.ud III Full O Ouistandinz B,i Lime Ihlc
HOLp UNT/L
AU& 2.p
SECTION 5: CONSTRI CHON SFR% ICFS
1; 1 Licensed Construction Super�kor 1041
sl, ll,,Ijcl
"I f SI, kI,v 'Ce h,lo"I
---------- ......
I
R KelloMcd IN- Fanu 1, lh',.Ihilt
R( r It,
I c1cph"'Ic —Id-�-!-d-t,
S.-Fjl 7
FL—L,
.2 Registered Home Improvement Contractor (MC)
HIC Compall% N'lile or HIC Rcgistjjjit Name [tcgl,ujlwlt N.....hrr
I Npl-,11'il Date
Signature Icellilmle
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (: I.G.L. c. 152. § 25061)
Workers Compensation Insurance altidavit trust be c,mipleted and uhmillecl with this ipplcar,,,w F,olale 11! po,nJje
this attida%it will result in the denial ill the Issuance of the building permit.
Signed Attidavit Attached? Yes .......... 0 No ,
SECTION 7a: OWNER AUTHORIZATION TO HE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
v -rh,
as Owner of the property hereby
111ho',ze :o ut.tlm Fil-, he bait, Ir .11: Ina(lels
ze!::Ioe IL3 %\ork authorized by this building permirapplicattion.
Signature ut Owner Date
SECTION 7b: O"NFR' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized \,,,en( hereby Jecime
that the starements and in6ormarionon the foregoing application sue (rue and accurate, to the best or rnv knowledge and
behalf.
Print Name
S1111latUreol Owner or Authoo/eclAgent Dire
S;,!ried under the pains and penalties of perjury)
NOTES:
I. An Owner who obtains a building permit to do his/her own work. or an owner who Imes all LInICLl,ico2d1 LI-1111,Ict"I
run registered in the Home lrnprovernent Conlrac(or (MC) program). will not have access to the urhm,mi,m
program or guaranty hind under M.G.A.. c 142A Other important intitmanonon the MU PrnLi.mi and
('Onsllticllon Supervisor Licensing (CS1.) can be found in 780 CNIR Regulations I M R6 ind 1 10 R5.
Whin substantial work is planned, provide the infi,rmanon below.
F,nal tloors area 1 Sq. Fri including garage, firti,hed de,ksor 1,,.i,h,
mea (Sq Fr.) Kihirahle ni,m count
Nuiriberct nicplaceN Number ,t hedn„,in,
,Nlimhei m hailho,,,nis Nuti&crot halt
I\pe 4 heatifly, s.,tern NImhet ,-t Jc,k,, 1), 1 he,
I\I,e o ,,,dmg ,,,tern .,Qd
..tonal Pr,yCLI Square Fos ,rage' ril'IN he uh,ntuled tl,f F'o'd 1,n1jCI:1 (',,,t
1
�i
•' CITY OF SALEM
PUBLIC PROPRERTY
• w l :.
< ^ DEPARTMENT
..,
I I I 't'S '4i 139; ♦ I tX. 'i-78-V_ 'I.i L.
Construction Debris Disposal Affidavit
(required for all dcmolition and renovation work)
fit accordance Kith the sixth edition of the State Building Code, 780 Ch1R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
(his 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:
1 name uC hauler
The debris will be disposed of'in
(namr ul 1JL1111y) -
Iaddres, ul gwlitvl i
,ignatw/eJo f/p/:mat,apphrant
Jatc
CITY OF SALLM
,jars PUBLIC PROPRERTY
��:•� DEPARTMENT
III v'S 'J • 1 \\'. 7 r.v.V: 1i L,
Construction Debris Disposal Affidavit
(rc\luired lirr all demolition and renovation work)
In accordance ith the sixth edition of the State Building Code, 780 CN1R section 1 1 1.5
Dcbris, and the provisions of.b1GL c 40, S 54;
BUildin5 Permit it is issued with the condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c
l 11. S 150A.
The debris will be nanssp�orted by:
1 name of hatdcr)
fhe debris will be disposed of in
(nalne ut lacility)
(addreas of lacditvl
ignatmc of I cnnn ,yq>hcant
late