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37 PROCTOR ST - BUILDING INSPECTION (2) Tf3- I (A 15 5 The Commonwealth of Massachusetts AL S; VIC S Board of Building Regulations and Standards CITY q / LEM Massachusetts State Building Code, 780 CMR 1614 S P T Nf a2�i7ed Ard 1010 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied' Dt iWing Official(Print Nune). Signator Dat SECTION 1:SITE INFORiyIATION` 1.1 Pro ertNy A Ness:i 1.2 Assessors Slap&Parcel Numbers _ ,�' 7 L la Is this an acce ted street9 yes no Map Number Parcel Number 1.3 'Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq It) Frontage(It) 1.5 Building Setbacks(R) Front Yard Side Yams Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(1V1.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: Outside Flood Zone? Municipal❑ On site disposals stem ClPublic❑ Private❑ al y Check if es❑ - P SECTION2: PROPERTY OWNERSHIP': 2.1 Owner'of Rec rd, SA I p/�7 M hn V"+;i VO6R Il iS time(Print) City,State,ZIP 39 Pi-actor S-�- _ qJR - )11.3= ofav No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK3(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed 1Vork-: m m F Aall 19a, e 17 �. Il au r2chtcl P r w SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) 1. Building S 46 I. Building Permit Fee:$ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Costs(Item 6)x multiplier x 3. Plumbing S ether Fees: S 4. Mechanical (EIVAC) S List: , • /� 5. Mechanical (Fire S Total All Fees:S-- Suppression) Cheek No._Check Amount: Cash Amount:_ 6. Total Project Cust: S 0 61 ❑paid in Full Cl Outstanding Balance Due: oc6h �,)t r-- t ` i SECTION 5: CONSTRUCTION SERVICES 5.1 Construction S/Iupertiisor Lieccuse(CSL) CS 06 a 0.re Q O ,2d(�D1Ye 104-6-r I4 h,S License Number Expiration Date Name of CSL Holder List CSL Type(see below) O L e(L h S T Type Description No. ;md Street �r U Unrestricted(Buildings up l0 35,000 cu. It. Ly/711 Iyl d l �10 R Restricted 1@2 Family Dwelling CttyfFo n,State,ZIP M Masonry RC Roolin Coverin WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Tole hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 13 TA tL I=e PA-4- 1,t1 RS HfC Rc g`y n &umber E9 piru�tion Date f I IC Cuntp;my Name or HIC Registrant Name 5�t{ �� tQ ti S i- Nu.and Street s�0_ /��1 Email address I—Yhh Citvfrown,State ZIP Tele hone SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.QL c.152.4 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 Istuance of the building permit. Signed Affidavit Attached? Yes ..........❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION,TO BE COMPLETED WHEN " OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) 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 contained in#sapplicationjIsirueand accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Wectronic Signature) are NOTES: 1. An Owner who obtains a building permit to do his/her own work,or an owner who[tires an unregistered contractor (not registered in the Home Improvement Contractor(HIC) Program),will nur 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 w"ww.mass. •n� �Information on the Construction Supervisor License can be found at wtvw.ma;s.,-,ov!dos 2. When substantial work is planned,provide the information below: 'rural floor area(sq. ft.) h ,(including garage, finished basementlattics,decks or porch) Gross living area(sq. ft.) Habitable room coma Number of fireplaces Number of bedrooms Number of bathrooms Number of h:dflbaths Type of heating system Number of decks/porches 'Type ofcooling system Enclosed Open 3. "folal Project Square Footage may be subsfiluted far"'rural Project Cost" PROPOSAL and CONTRACT , Free Estimates Fast Courteous Service Vinyl placiment kd!/ation STRUCTURE DEVELOPMENT " Replacement Windows•Goiters _ � ,.. COMPLETE INTERIOR& Mll's`Cell:(781)589-3104 EXTERIOR HOME IMPROVEMENT Ted's Cell:(781)589-4861 EXCAVATION WATER•SEWER Fax:(781)593-0020 PROPOSAL S� tTTE �� �.t y/� .-� Py,ONE -99-M � DATE STREET -h4ly , 1 JOB NAME CIITTY,STATE ND ZIP CODE .. JOB.L CATION ARCHITECT DATE 9FPLANS JOB PHONE We hereby submit specifications and estimates for: 5 Lam. S !All N1-3 ZAJ Z 42 Q/1 T 106 r 11,4- Lr o4 v Ohl O/ 4 � ` O , S YC' /4 S _ o Lj c r CC A s We.Propast hereby to furnish material and labor—complete in accordance with the above specifications for the sum of: jV Payment to be made as follows: J L - An material is guaranteed to be as specified.All work to bs completed in a workmanlike manner according to standard practices.Any allocation or davietion from above specifications involving ems Authorized was will be executed only upon written orders,and will became an some charge over and above me Signature estimate.All agreements contingent upon strikes,accidents or delays beyond our control.Owner to carry Fire,tornado and other necessary insurance.Our workers am fully Covered by Workmen's Note: s ntra t may be Y�t� - compensmion cc Insurance. withdraw by us if not swept within days. ACCEPTANCE OF CONTRACT-The above prices,specifications and I' conditions are satisfactory and are hereby accepted.You are authorized to do Signature�_!,�i "�+ � \ �\� •k)y��/�� the work as specified.Payments will be made as outlined above. L- Date of Acceptance: �( ! � �-)1 Signature -' ' aCI-I'Y OF SALEM, l�'WSACHUSETTS Run=DEPART>IEINT 12O WASHLNGTON STREET, 3m FLOOR TEL (978) 745-9595 F.ir(978) 740.9846 K1.,tBERLHY DRISCOLL T Hobimi ST.PtEM s:HpYOR DIRECTOR OF PUBLIC PROPERTY/BCQ.DIVG CONL\IISS(OVER %Vorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anplicant Information Please Print LeeibIV / t NainC IBusinrss(drganiration.'Individual): ��LD U1 Y C' P�t f`! l�/7�� Address: ©C CQ,A S 7` City/State/Zip: L✓na A4 d/q02- Phoned: 99/— Are y an employer"'Check the appropriate bar Type of project(required): I. 1 am a era to er with .3 4• ❑ I am a general contractor and I P Y 6. ❑New construction employees(full and/or part-time).* have hired the subcontractors 2.❑ I ant a sole proprietor or partner- listed on theattached sheet. ( 7. ❑Remodeling ship and have.no employees, - These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. Building addition [No workers'comp. insurance S. ❑ We are a corporation and its rcgwrcJ.] officers have exercised their 10.❑Electrical repair or additions 3.❑ I am a homeowner doing all work right of exemption per MGL i LC] Plumbing repairs or additions myself.(No workers'comp. c. 152, §1(4),and we have no 12.❑Roof repairs insurance required.l t employees. (No workers' IJ.❑Other /�iro� parc/a - comp.insurance required.) -Any applicmtl out checks but If must also rill out Its accliva below showing their wodrn'compensation policy infimmarbn. 'I lomcuwwrs who submit this amdnvit indicating they are doing all work and then hire ualside Munic'm mml mhmit a new allldavit indicting such, , Cnnmaun that chick Ibis box most atuchal on addidurwl xhocl shuwing the name at the s ibwonlraclon and their worken'comp.policy infurmalion. /ant un eutpluyer drat is pruvldiii Ivorkers'cumpensatiun inrarmtcefor my employees lteluw is tha polky and jub site information. Insurance Connpany Name: ��SS 1/)/ S Policy iJ or Self-ins. Lie.4: Expiration Date: Job Site Address: 39 l r a r 57- City/Statcaip: SA-Z errs In A r Altacb a copy of the workers'compensation policy declaration page(showing the policy number and explratlon date). Faituru to secure coverage as required under Section 23A ofMGL c. 152 can Icad to the impositian ofcriminal penalties ofa fine up to S1,500.00 und/arone-year imprisonment,as well as civil penalties in the fans of a STOP WORK ORDER and aline of op to S2i000 a Jay against rile violator. Ile advised that a copy of this statement may be furwardcd to the OI'lice of Invesliganiuns ol'Ihe MA for insurance coverage verification. " / to hereby ce�nn�ins ai of u/11 ufp Jury that Ilse infunrmNos provided above is true and correct si'vi.1 life: Phone d: f Official use only. Da not write.in this area, to be completed by city or town off clUL • I Ciry nr l'own: _ ._ Pcrmiul.lcomc III Llsuiag Aulhurily(circle one): -- 1. Board All'Ile-Alf 2. Building Delta,inwat .i.('itylrnwn Clerk J. Electrical lnspedur 5. Plumbing inspector 6. Office � Contact l'e rtnn:_._ _ Thane ;t: _ i 'QTy OF SALEM, MASSAMUSEM 'fr. fjl BUILDING DEPARTMENT a 120 WASHINGTON STREET 31D FLOOR TEL. (978) 745-9595 F KIMBERLEY DRIS�LL FAX(978)740-9846 MAYOR THomAS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMSSIONER 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: 11r)e..� nC4 m/0 1'r u /< (name of hauler) The debris will be disposed of in: Nok-+- -SI'a (name of facility) Swzn pf'co CI � , (address of facility) Signature of applicant Va3 1 <<( Date '• 11 r •11 11 r -r r r. r r r rr- r - 1 :• 11 r• y w' � a YplMFa kt t'"QT 3riY1 � t �' r+ i B .jl a �` : � oN j A 1* 'f� 'x U;•.�ity !4� yy�, F .rF ' ! f+�l. ,`+ �M a 7S r ,a '� �t 4 • r �•`r a, J .tlrA>�t, r •1�' �'J F'T '�.�1� 1F� + le.i� .l I � �. i itt:t t � rC. K yJr sr r r 40 l 3 7 Jr+9tj!a a'13-1 tra1a I 3s Nj,F�}Fr