10 PURCHASE ST - BUILDING INSPECTION (4) 3-21
The Commonwealth of Massachusetts Town of
,1 Board of Building Regulations and Standards
�� Massachusetts State Building Code, 780 CM1IR, T"edition Building Dept
Building Permit Application To Construe a tr, Renovate Or De ish a
One-or rn u-Fur ls•Dis ling
This Secaon or ORcr Use Onl
Building Perini Number: Date 1' /n
Signature: Id-
Building
Commissioner/In tar of Buddmgs Dats
SECTION 1:SI FORMATION
1.1 Property An�drew: .2 Assessors Map 6 Parcel Numbers
/n f'v2�Yr�t S�
1.1 a Is this an accepted street''yes no Map Number Parcel Number
I Zoning Information: 1.4 Property Dimensions:
Zomng District Proposed Use La Am(sq R) Frontage IR)
13 Building Setbacks Iit)
Front Yard Side Yards Rear Yard
Required Provided Required Provukd Required Provided
1.6 Water Supply:(M.G.L c.40,134) 1.7 Flood Zone Information: 1.8 Sewage Disposal
System-Zone: _ Outside Flood Zone? Municipal Gam&site disposal system O
Public G Private O Check if sO
SECTION 2: PROPERTY OWNERSHIP'
2.1 r art of Record:l 3b Qyk d r, LG S�
8 l
Name f 0 Address for Service:
Si Telephone
SECTION 2: DESCRIPTION OF PROPOSED WORK'(Cheek All that apply)
New Construction O Existing Building O 1 Owner-Occupied O 1 Repairs(s) O 1 Alteration(s) O Addition O
Demolition O AccessoryBldg.O Number of Units_ Other O Specify:
BriefDexriptianofProposrdWork2. '-s�lr5Y79-LL A.T-rnr Gf9'TI'ff�� 1'
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building j ��L7� I. Budding Permit Fee: f Indicate how fee is determined:
O Standard CityrTown Application Fee
2 Electrical S Q T ' O Total Project Cost'(Item 6)x multiplier x
3 Plumbing f 6v17 2. Other Fea: j
a. Mechanical (HVAC) S List:
s Mechanical (Fire S Total All Fees. f
Su ression
Check No. _Check Amount: Cash Amount:_
is Total Project Cost S G FY7j 0 Pad in Full 4� 0 Outstanding Balance Due
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supenisor ICSI.►
� I.icanve Number Erpir.mon Date q
Nyac of CSL 1lylda Lw C'SL Type(xv he low) /
A,►kesa Tim I Description
U Unrestricted(up tols,00OCu. Ft
R Restricted 1ik2 Family Dwelling
Signature M Masonry Only
RC Residential Roofing Covering
Telephone w'S Residential Window and Siding
SF Residential Solid Fuel Burning Appliarag Installation
D Residential Demolition
1.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Nam Repstratim Number
Address
Expiration Date
sigtunue Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS2.f 2SC(6►)
Workers Compensation Insurance affidavit must completed and submined with this application. Failure to provide
aPP
this affidavit will result in the denial of the Issu ce of the building peril.
Signer)AlRdsvit Attached? Vex..........A No...........O
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.
SixiiiiofOwner Due
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
kell as Owner or Authorized Agent hereby declare
that the s to en u and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print
Sign solpt of tat oru Date
(Signedlundare 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 IM have access to the arbitration
program or guaranly fund under M.G.L. c. 1 o2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.RS,respectively.
2. When substantial work is planned,provide the information below;
Total Moon area(Sq. Ft.) (including garage, finished basement/anics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms V umber of half baihs
Type of holing system Number of Jeckst porches
T.peofcoolingsystem Enclo%ed Open
1 "Total Project$yuare Fooiage"may he.uhstiluled for 'Total Project Coa"
CITY OF S.1LE.N1, L-kSSACHCSETTS
BL•ILDLNG DEPARTMENT
120 W.ASHINGTON STREET, Yes FLOOR
TEL (978) 745-9595
FAX(978) 730-9111.16
KI.,fgERIEY DRISCO[l
MAYOR THohtws ST.P�ItRIa
DIRECTOR OF PLBLIC PROPERTY/11 [IOLNG CO%L\USSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electriclans/Plumbtn
Applicant Information Please Print e 1
Vaine (Bueimw Ortaniaaliomllfn,Lvldu l): G✓•p M
Address: 10 PyVo� YC- S+
City/State/Zip: S41- MA Phone a: 4 4M-7L`(z�l O
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with general contractor and 1 6. ❑New construction
employees(full and/or pan-time)." have hired the subcontractors
2.❑ I am a sole proprietor car parer- listed on the attached shcel : 7• ❑Remodeling
:hip and have no employees These subcontractors have 11. ❑ Mmolition
working for me in any capacity, workers'comp.insurance. 9, ❑ Building addition
INo workers'comp, insurance S. ❑ We are a corporation and its
;�,J officers;have exercised their 10.❑Electrical repairs or additions
1. lI am i homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,§IM,and we have no 12.❑ Roof repairs
insurance required.)t employees. (No workers' 15.0 Other.
comp. insurance required.)
•Any applicant than aitecka boa el mum also rill wt the saclim below showing their workee'compennaGm polity infumnWa
'I I.astanwsees who subsea this affidavit indicting they an doing all work and thcs him amide cannacson mum sohmh a now affidavit indicting mwL
:C,,n~9n IhN check this bat mum anshad an 3"tional AM showing dr tame of Ae nsh.ta tncmn and their wwbm,ry g.pat icy infamuion.
I um an employer that&previd/nir workers'compenradon Insurance for my employee& Below Is fhe pollry and/ob sip
iaaformatiom
Insurance Company Name:
Policy N or Self-ins. Lic. N: Expiration Date:
Job Site Address: City/State/Zip:
•%ttrcb a copy of the workers'compensation policy declaration page(showing the policy number and espiradom date).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of■
nine 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 fine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement maybe rurwarded to the Office of
I llcea11�a11Utlf Uf the DIA for Insurance coverage verilleattUn.
/do hereby c rI under Ilse pains un an117
, ujperfury that rkr information provided above is true and carrel
\ t �
iOffilciul use only. Do nor Ivrire in this urea,=10he'unlPletedbyL or town of lriaL
City orruwn: lcenseN__,Issuing.\uthurily (circle one): — - - jI. hoard of Ilealth 2. Building DepartmeJ. Electrical Inspector 5. Plumbing Inspector6. Other
Phene N•
r w
,S CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
?+ly w/
I'.11: NI t) I-K1-I'I1
\I`.1.9t 1_'Q Vi'.�II II\b:+IN 51'ala'T ).0 I M. St.\+i.\I -
TF 979-740-9446
Construction Debris Disposal Affidavit
(required I•or 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 N.. . _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The
debris will be transported by:
1 rIIC� VhL'�—
(name of Iwuled
The debris will be disposed of in
(oJdressul'1'uclluy) '
+igl •rmit up I -ant
31�v
. Joe
loln i.dl :.K