10 PLEASANT ST - BUILDING INSPECTION The Commonwcalth of Massachuscits Town of
J �J Board of Building Regulations and Standards lommeow
Massachusetts State Building Code.780 CMR. Ta edition Budding Dept
Budding Permit Application To Construct. Repair. Renovate Or Demolish a toondoo
One.or Tuo-fwnrlt Divel6ng
This Section For Official Use Only
Building Permit Num r: Date Applied: q
„"tttJJJ Signature: y _ O-IDS-/ J lb
Building Commissioner/Inspector of Suit mga Date
SECTION 1:SITE INFORMATION
1.1 Pr rty Address* 1.1 Assssson Map& Parcel Numbers
I.la Is this an accepted street'?yes no Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage IR)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
/ Zono: _ Outside Flood Zone? Munieipsl�On sin disposal system C
Public t7 Private O Check i(
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow 'of Record: ,� �f�e D �A6 11 e�'
wr
Address for Service:
Name(Print) ------��--
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(cheek a8 that apply)
New Construction Existing Building Owner-Occupied Repairs($) O Alteration(@) Addition O
Demolition Accessory Bldg.O Number of niu Other O Specify:
Brief Description of Proposed Works: w
SECTION g: ESTIMATED CONSTRUCTION COSTS
Estimated Costa: ORIeW Use Only
Item Labor and Materials
1. Budding f �GY�U 1. Building Permit Fee: f Indicate how let is determined:
O Standard City/Town Application Fee
2 Electrical f �� O Total Project Cost'(Item 6)x multiplier x
Plumbing f 2. Other Fees: f
1. Mechanical iHVAC) f List:
s Nechanrcal (fire S Total All Fees.f
Su ression
Check No. _Check Amount: Cash Amount:_
h Total Project Cost. f /�Oj �'� 0 Paid in Full ❑Outstanding Balance Due'
. pia
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) /05A
,ZkAarl R sm lY l L,ccn.e Number E/ drat n Dale
N•#w ol�plJer Au Li.l CSL Type I><r h,law) (i1
y 5 . Saugus 0 U(o
A a T Description
U I Unrestricted(up to 35.000 Cu. R
0. Restricted 1!2 FamilyDwetlin
Signamr M Masonry Only
W/ -Uy RC Residential Rooting Covering
Telephone wS Residential Window and Sidmill
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
3.2 Registered Home Improvement Contractor(HIC)
,i
HIC Company Name or HIC Registrant Name Registration Number
Address� Alyhe ar Expiration Date
Signslure Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL 12SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this andavii will result in the denial of the Issuance of the building permit.
Signed Allidavit Attached' Yes.......... No...........0
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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
7SE ON 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
I, ,as Owner or Authorized Agent hereby declare
that the staloKents and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. /
c6�dr�/ _Slvi/
Print Nam
Signature of Owner a Authorized Agent Date
(Sigived under the pains and penalties of
NOTES:
I. 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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations 110,1116 and 110 RS,respectively.
2. When substantial work is planned,provide the information below-
Total floors area(Sq. FL) (including garage, finished basemenVanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
,Number of fireplaces Vumber of bedrooms
.Number of bathrooms Vumber of halfbaths
Tvpe of healing system Number o(Jeckst porches
Tspeof cooling system Enclosed Open
I "Total Project Square Funiage"may he suhsfituted for-'Total Project Co.i'
CITY OF SALEM
YA
PUBLIC PROPRERTY
DEPARTMENT
)I`.�, n I_'0�'.�;III\t�:UN$1'NGET �Sd1141,�1.\;iAr I❑ ;I 1 L:I'r _
978-7409846
Construction Debris Disposal Af idavit
(required fur 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 1a is issued with the condition that the debris resulting from
roperly licensed waste disposal facility as defined by MGL c
this work shall he disposed of in a p
Ill. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
_—.__.
(n:une of aci tly)
(address of facility)
J
s
taturc of permit applicant
,late
14
CITY OF S.U..E.`I, NLASSACHL;SETTS
BL'ILDtNG DEP.l mmioT
/r 120 WAsmvi;TON STREET. r FtOOR
a/ TEL (978) 745-9595
FAX(978) 740.9M
Kj%fBEUEY DRISCOL L
MAYOR Tw"U ST.PMRIti
DIREcroitorPLBLICPROPERTY/SV DLNGCOaL%USSIONER
Workers' Compensation Insurance A(Ildavit: Builders/Contractors/ElectriciansiPlumbers
Annlleant Information �/ /- �j / Please Print eedAlar
Nalneltlwnw,rOrtm,ruionlm4v1dual): .
Address: —1/D /'fiai✓�
City/State/bp: OM,)6 rhonam. 2V- 94J-0y72
,bee you as emplaysr!Cbaek the appropriate box:
I.❑ 1 am•employer with 4. ❑ I am a grntxal coal seta Type of project(required):and I b, ew construction
�unployee(toll and/or pan-time).• have hired the subcon tree n e
2.(0 1 am a soil pmprietar Ju pannen listed an the attached Area : 7. Remodeling
.hip and have no amployee Thee subcontractors have 8. O Demolition
wetting for me in any capacity. workers'comp.immunea 9. OuiWiry addition
(No workers'comp ra insunce re S. O We a a corporation and is
required.) of ,"n have examsed their Io.O Electrical repairs or additions
1.❑ 1 am a homeowner Joins all wort right ofe)[amption per MOL 1 I.O Plumbing repairs or additions
myself.(%a workers'comp. c- 152,91(4).and we have no 12.01taof repairs
insurance required.]t employes.[No workers. 1),O Other,
COMP,insurancerequined.j
•Any appurar char mores brs al mutt alwr as attr trio o.otloa b doo dirwiag ode wand..'cattpworbar polity inbunwda►
't Lvtwuwtrs who submit tole amdovir indiotlae they an doing all sax sae Jan him worries aetromm areas"boil a new,affidavit indfrr ow it.
" ►
lwmavan that whack taia boa muia aeathad an addtiund Jra Jawing ow mina at nu,alkserrarlatr spun dust wMIM ,ramp•policy ii aattwtiaw
i star atr employer that Is proridinjr workers'coarpresedon insarmateejar err tarpGryaax Seim 4 the pNkr oaI/a1 silo
inforatefbia
In.surunce Company Name:
Palicy N or Self-ins. Lie. N: Expiration Date:
Job Sire Address: City/Statd2ip:
%"sea a Copy of the wsrkgn'compensation poUry decteraUee pap(Showingthe poldry number and a:pinMoa date).
Fuilum to secure covers4e L required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of s
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a Bee
of up to S230.00 a day against the violator. lie advi.*W that a copy of this statement may be rurwurded to the ODTce of
I it vealn gatiumof due MA for insurance coverage ,c6l'1caliQL
1,10 hereby cerrijy r e prind a/Nis ojper/mry that the injorarattow provided uAavr is rrxe sad cerreet
" t gala: cI•-�-/a
.
Offlriei nee Y/tiy. Do ref Write is this arre,to be ra/np/tW by tvtr or rows o/Jfr•%L
City or fawn: YrrmiN.lecnse N J
luuingAuthonly (circle one):
Ilvollb 2. Rudiling Department I Cltyirowa Clerk J. Electrical Inspector S. Plumbing Ins
6. 1)Ihrr
Phoat N•