7 PLYMOUTH ST - BUILDING INSPECTION "the Commonwealth of Massachusetts ID/{/ CITY OF'�Fff
Board of Building Regulations and Standards �y C CFS
VTA
Massachusetts State Building Code, 780 CMR Revi.red AT✓l tI✓?(�(I
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or
This Section For Official Use Only
Building Permit Number. 1715ateApplie
Building Otticial(Print Name). Signature Ql �Ddte
SECTION 1:SITE INFORMATION
1.1 Pr erty Addres 1.2 Assessors Map& Parcel mb
5A 'r!bb -53 d
I.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 lung Information: - r P._^e.tvDlmensions.
G0
Zoning District Proposed Use Lot Area(sq tt) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yams 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 )Isposnl System:
/ Zone: _ Outside Flood Z,ene? Municipal On site disposal system ❑
Public❑" Private❑ Check if "
SECTION2: PROPERTY OWNERSHIP!
2.1 Ownef'pf, Record;,��� 3a C- 7
t7 meme(Print) State,ZIP
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building I( Owner-Occupied ❑ 1 Repairs(s) el Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other M/Specify: �—
Brief Description of Proposed Work=: 0' t--
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ a per, Cd I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
?. Electrical $ fU0 e ❑Total Project Costa(item 6)x multiplier x
3. Plumbing 'S 3 00e? ,4/0 i%9ther Fees: $
4.Mcchmtical (HVAC) S List:
5. Mechanical (Fire S 'Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
G. Tutai Project Cost: S 6 SaC) ❑ Paid in Full ❑Outstanding Balance Due:
mad
SECTION 5: CONSTRUCTION SERVICES
5.1 Constructimi Supervisor License(CSL) CS 065/318' / "a V-d v!:�r
License Number Expiration Dale
f v
Name ol'CSL Holder List CSL'rype(see below)
3? L r-3fi (- KOAr� Type Description
No. and Strect
U Unrestricted Buildin s tie-to 35,000 cu. It.
LyAl&l MA 019 Ot/ R Restricted 13t2 F:uni1 Dwellin
Cityfrown,State,ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
-7f-f-7/5 3X2.3 /Y1ee*0410C<5 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Dale
IIIC Company Name or HIC Registrant Name _
No. and Street Email address
it /Town,State,ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G4 c. 152.0 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........... ❑
SECTION 7a:OWNER AUTHGRIZAT[ON:TO BE COMPLETED.WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize Mlbkot1° GInU rS s8 �tC ,el e rn
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
WAS i/1S1wl
Print Ow er's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
A-4 Y� - ll15- 111
Print Owner's or Authorized Agcnt's Name(Electronic Signature) Date
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(H(C) Program),will got have access to the arbitration
program or guaranty, fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at
www mass goy v'oca Information on the Construction Supervisor License can be found at www.mas.sov'�
2. When substantial work is planned,provide the information below:
Total fluor area(sq. tI.) 'A -,,(including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rype of heating system Number of decks/porches
Type of cooling system Enclosed Open_
3. "Total Project Square Footage"may be substimred for"Turd Project Cost"
I
Unrestricted- Buildings of any use group which
contain less than 35,000 cubic feet (991tn;)of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code Is cause for revocation of this license.
Far DVS licensing information visit: www.Mass.Gov/DVS
Massachusetts - Department of Public Safety
Board of Building Regulations and Standards
Construction Supenisor
License: CS'084318 ,
MICHAEL E CHALMERS,- -
37 LeBEL RD
Lynn MA 01904 7fig` R
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OTYOF SALEM, MASSACHUSEM
T+ r� BUILDING DEPARTMENT
t« 120 WASIRNGTON STREET,31D FLOOR
TEL. (978)745-9595
F
KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THomAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONSMSIONER
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 c40, 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 deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
er;c' 2—
(name of hauler)
The debris will be disposed of in:
(name of facility)
/00 Tuyv-�.�Pl G(z Stiv vs W- 01�4�
(address of facility)
Signature of applicant
Date
° Q-1-Y OF S:U ELNI, NLASSACHUSETI-S
BL•LM IN,G DEPIRTsW-NT
120 WASHNGTON STREET, 3'o FLOOR
TFL (978) 745-9595
F.Ax(978) 740-9W
KINIB Rt FY DR]SCOL L
i;MAYOR THont is ST.PIEM
DIRECTOR OF PUBLIC PROPERTY/BumDr%,G CONNISSIONER
Workers' Compensation Insurance AfTidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informat[nn /1 ponn^, Q� ` Please Print Leetbly
V;Ilnc lHueineaOrganiratin u'Individuat):L6ftAUCY-4 SANS 11 L1/i S
Address: SN � CIneS��Jb 5-� G I t [�
City/State/Zip: �.- V,\i,\ K-k UYI00 Phone #: �(1 ��`I ' S�Ob
Arc you an employer?Check the appropriate box: Type of project(required):
1.9I am a cm to er with 4, ❑'i am a general contractor and t
P Y 6. ❑New construction
elllployees(full and/or part-time).* have hired the sub-contractors
2.❑ lain a sole proprietor or partner. listed on the attached sheet. I 7. (a Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working"ti>r mu in any capacity. workers'comp. insurance. y, ❑ Building addition
1No worker/cmnp. insurance - 3. ❑ We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.❑ i am a homeowner doing all work right of exemption per MC
11.❑ Plumbing repairs or additions
myself. (No workers'comp. c. 132, §1(4),and we have no 12.❑ Roofrepairs
insurance required.) t employees. [No workers' j;,❑Other
l'Ulllp. IIlSUrsR[C n`tlajr, j
'Any applicant due checks box rl nnwl also rill uul the%.,lion below showing their workers'compensation policy inturmatlom
'I Inm.owm"who submit this stArbwit indicating they am doing all work and than hire Outride Mulctars mull submit a new aMdavit indtuting such.
$toms curs Out cheek this box must mtachal an addittutul shml showing the awns of the subventsanon and their waken'comp.put icy infurmaiion.
I ant urr ernplay er that is pruvidbig workers'compenrarton btsurance for my employers. Belmv Is the policy and Jub rite
iuformalinn. e7�
Insutance(:notpariy Naine: Q l ' m _ Uil�lt l 1 Io VLJV�CiIY�•p co!^ � AV
Policy 4 ur Sclf-iiis..7 Lie.H:V�G - 106-(,6I1 60&— O ILt A Expiration Date:i/y/t�ws/
Job Site Address; l f ) V l.,G U Th Sk City/Stab:/Zip: �le✓,'4A O I"1/7l/,t
Attach a cagy of the workers'compensation policy declaration page(showing thepolicy number and expiration date).
Failure to secure coverage as required under Section 21Aot'MGL c. 152 can lead to the imposition oferiminal penalties of
line up to S1,300.00 und/ur ale-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a line
orup to s230-00 a Jay against the violator lie advised that a copy of this statement may be furwarded to the Oftiea of
In vestigatiuns of the DLL for insurance coverage vcrilicaliun.
/du hereby certify larder the pains and penalties ujperjury that the b1foromtlars provided ubJuve is true surd correct
PhDam:
Official use Only. Ou Dar write in this Orem, to be completer/by city ur town o/Jit•fut
City or fawn: _ _- -- Permitn.lceme q
Issuing Asat hurily (circle one):
1. hoard sal lleakh Z. Building Vella,intent J.Citytfuwn Clerk J. Electrical Lupcctur 5. Plinubing Inspector I
6. Other
Contact Person:... —_ .. Phone 3: i