12 PURITAN RD - BUILDING INSPECTION 5o 3 q2-
�f3-.1
rheCommonwealthofMassachusetts �T�� AIA gVdFES
f Board of Building Regulations and Standards SALEM
I Massachusetts State Building Code, 730 CMR 2114 SEP
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official U Only
Building Permit Number: Date Ap lied:
/9
Building Olticial(Print Name), Signature - Date
SECTION 1:SITE INFORMATION'
I.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers
vr — 2i /
I.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: LS Sewage Disposal System:
Zone: — Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ p p y
SECTION 2: PROPERTY OWNERSHIP)'
2.1 Owner'of Record:
Je,r _e+ I 'TPiz MA QN70
'roe(Print) City,State,ZIP puV
1 z P'�. }u� �R-A �77k -79't 53k8'
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(thee all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) If I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other ❑ Specify:
Brief Description of ProposedWork-: 44FVj( r eL_�rv<r Naf'A �L-OA-112A 0el!/1 �-
v
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building ( o+ mo 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Cityfrown Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S Other Fees: S
t. blech;utird (HVAC) S List:
5,Mechanical (Fire i Total All Fees:S
Su ression)
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S Li ✓1 a., n ❑Paid in Full ❑Outstanding Balance Due:
zT Mo N o ta-r)-f L ( Zy
�►D Tb � L?'N�
1 .11 = t"` SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) S_ ( g
tI7/
License Number E.e imtiu
Nantc of CSL Holder (�7 List CSL'rype(see below) )
6 -FA +ft.-MGUN i Ila Type Description
No.:ad Street
U Unrestricted(Buildings up to 35,000 cu. 11.)
B R Restricted I&2 Fzunily Dwelling
City fawn,State,'ZIP M Masonry
RC Rooting Covering
WS Window and Siding
SF 1 Selid Fuel Burning Appliances
�i'IS"'7 ' -1�c1 C' N2tSAQt,.,4lC€� PA•LKJW'T I as
ld
"fete hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) I w) ( Aga I e
CN eurrce t5tt /�•-��1(g HIC Registration Number G ptr ton dote
HJC Cunt n'y Name o Ur Re hstmnt Name
(' 1=PA >< M.oNTHIC
ULL and Street Em'ui�l admit ress
ss n a
Cit ITo+vn,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L,c. 151.$ 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 Is?iu he of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION,TO BE COMPLETED.WHEN.
OWNER'S AGENT OR CONTRA CTORAPPLIES FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby authorize C�✓i + R l k ILc
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:OWNEW 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 this application is true and accurate to the best of my knowledge and understanding.
CH&i's Toe Uzi A C6L.A)cg
Print Owner's or Authorized Agent's Name(Electronic Signature) 1pate
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 nut have access to the arbitration
program or guaranty fund under NLG.L.c. 142A.Other important information on the HIC Program can be found at
www masSAcov'oca Information on the Construction Supervisor License can be found at w+v�'dus _
2. When substantial work is planned,provide the information below:
Total floor area(sq. tt-) 4 ,(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
Type of heating system Number of decks/porches
'I'ypeorcoolingsystem Enclosed Open
3. "l'otal Project Square Footage"may be substituted f'or-rotai Project co$"
Q-1,Y OF S \I.EM, NL1SSACHLSETtS
Bt.1LDNG DEPARTNIE.NT
120 WASHLNGTON STREET, 3"°FLOOR
T EL (978) 745-9595
F vx(9 7 8) 740-9846
KI%IBERLF-Y DRISCOL-L
T14 msST.P11i
tiL1YOR
DIRECTOR OF PUBLIC PROPERTY/BUILDING CMCOISSIONER
1Vor]cers' Compensation Insurance Affidavit: Uuildcrs/Contractorv/Electrlcians/Plumhers
Applicant Information �J It cave Print ii.eiiibl,
Naine (pusiines.Organiratiom'Individual J: GtJL15' r� Ly61[,Yy J�/5'fv�,,,(�f Ttar�/
Address: ro�r�
City/State/Ztp:7rr.Af?G � . La Phone lit: `� '� '�--972
Are you in employer?Check the appropriate box: 'Type of project(required):
1.0 1 am a employer with 4. 0 I am a general contractor and 1 6. 0 New construction
_ _/11ployees(full and/or part-time).• have hired the subcontractors
2 1 ana a sole proprietor or partner- listed on the attached sheet. f 7. ❑ Remodeling
f ,hip and have no employees - These sub-contractors have R. 0 Demolition
working for me in any capacity. workers'comp, insurance. 9, 0 building addition
[No workers'comp. insumnce 5. 0 We are a corporation cold its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.0 I ant a homeowner doing all work right of exemption per MGL 1 l.❑ Plumbing repairs or additions
myself. (No workers'sump. c.-152, §1(4),and we have no 12.0 Roof repairs 6G_a4t vc,e L n%A-V.4 �
insurance required.) t employees. (No workers' 13.ff Other NEvJ fros fl rvef
cump.insurance required.)
Any ar,13kase dui checks but 21 must aLu fill caul IN section blow,howmi;their workers'compensmiun pulicy iutlsrmatiun.
'I L+meuwm"wha whmit this atrldavit indicating they am doing all work and then hire outside contractors mtat suhmit a new 31M,,it indicahing such.
:('moneton that chw<k this bux mint attached an addidunal,hut showing the mune of the subaanineton and their workers'cump.policy information.
/cans an employer that!s providing Ivorkers'compensnton insurance for my employees. Rdhuv is the pulicy and Jub site
infornsation.
I isurance Company Name:
Policy 4 or Self-ins. Lio. 0: Expiration Date:
lob Site Address: City/State/Zip:
Aeach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
h'ailure to secure coverage as required under Section 25A of bIGL c. 152 can lead to the imposition of criminal penalties of a
line up to S 1,500.00 und/or one-year imprisonment,as wall as civil penalties in(he form of a STOP WORK ORDER and aline
of up to 5250.00 a day against the violator. Ile advised that a copy of this.statement may Ix: funvardud to ilia Office of
Invesligationc ofilte DIA for insurance coverage veriticatiun. -
=1wre , der the pains mtd pen allies of perjury that the iufunnutun provide)abcovle,is true and correct
(� (� Q�q p oar g I a r
Phone d: —1-2 r -! 7 T — JO 1
Official use only. Oo out wfife in this area, tube cumpleted by rify ur town gJiciaL
Cirynr'I'uwvn:
tssuiag Aii1hurity (circle one):
1. Ituard ul'llealth 2. Iluildinq I)epa,tutent .l.Citymmn Clerk t. F;Icc tricsl t�t}preror 5. I'linuhing Inspector
6. Other
Cu nhaU Phonc :f:
— _
aCITY OF SALEM, MASSAMUSEM
BUILDING DEPARTMENT120WASHINGTONSTREET,3RDFLOOR
TFL. (978) 745-9595
F
KIMBERLEY DRISOOLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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:
l'N .cIT '1�L-Alc�
(name of hauler)
The debris will be disposed of in:
(name of facility)
C-?,o , '?S mx 3 CO-
�t�o�c,cuToWr�( � MR c�1B33
(address of facility)
Signature of applicant
. 91 ill IQ-
Date
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
41
construction Superrisor
License: 6S-102110 '
CHRISTOPHER A-�B
6 FAIRMOUNT 130
PEABODY MA 060
ne" Expiration
05/25/2016
commissioner
e.