7 PYBURN AVE - BUILDING INSPECTION ( o lJ� FT1
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One or Two Family Dwelling
\ This Section For Offrci s Only r '
Bulding Permit Number Dat" Apphedj-
eK
Building Official(Print Name) . �"` �„'"Signature,,', Da e,
SECTION 1: SITE INFORMATION
1.1 Pronerty Address: 1.2 Assessors Map& Parcel Numbers
I. a Is this a� l n accepted street? yes_ no Map Number Parcel
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards 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 Disposal System:
Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Public❑ Private ❑ Check if yes❑ _
SECTION`3c PROPERTY OWNERSHIP' `-
2 pwner'of R cord:
t17 �
Name(Print) City, State,ZIP
-� v 9 s- 9 5s+o
N .and tr t Telephone Email Address
SECTION 3: DESC`RIP.TION OF PROPOSED WOW (check all that_apply}
New Construction❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: <
Brief Description of Proposed Work : �.r
SECTION 4: ESTIMATED.CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only e
Labor and Materials
1. Building $ S Zr�_00 1`Building PermitFee $ 4 Indicate how fee'is determined:
❑,Standard City(Town Applicatron Fee
2. Electrical $ ❑'Total;Ptolect,Costs (Item 6)x multiplier - x
3. Plumbing $ 2. Oth6rFees--
$
4. Mechanical (HVAC) $ List
5. Mechanical (Fire $ Total All Fees: $"'
Suppression)
Check No Check Amount Cash Amount
6. Total Project Cost: � ❑Paid in,Full ❑.Outstanding Baiance;Dup
r�
r—
i
SECTION 5i CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No. and Street .,:TypeDescription
.r , ... . .
U MFamilDwellin
ted(Buildings u to 35,000 cu. ft.
R d 1&2 Famil DwellinCity/Town, State,ZIP M RC CoverinWS and SidinSF l Burning AppliancesI Tele hone Email address D on
5.2 Registered Home Improvvement Contractor( C) v (� _ J -7 y' �, ` }
��"' HIC Registration Number `D it ion Dale 1 `/.•
HI Co any Name or HIC Registp t Name
No. anStreel oLe).� �_g E it adressl-� ` 1
1
Ci /Town, State, ZIP Telephone
77
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G:L. c. 152 § 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 Issuancee the building permit.
Signed Affidavit Attached? Yes .......... No ........... Cl
SECTION.7a.OWNER AUTHORIZATIOIN T0'BE COMPLETED WHEN
OWNER'S AGENT'OR CONTRACTOR APPLIES FOR B BUILDING PERMIT` `
I, as Owner of the subject property, hereby authorize 6V h -root t 1r(,1y.,7G(t,(.(�j'00 . oAt4� /
to act on my behalf, in all matters relative to work authorized by this building/permit application
tl-Za GQlUroh ( f4VAA� l o /50 /!2
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 this application is true and accurate to the best of my knowledge and understanding.
IZrn CatIlGrh I/ Jtfi.
Print Owner's or Authorized Agent's Name(Electronic Signature) — C�Date
NOTES:
P2. When
Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
ram or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
.rnsss. ,,ovi"oca Information on the Construction Supervisor License can be found at www.mass.<gov.dps
substantial wor �s planne p uvide the it a, rmation below:
r area(sq. ft.) i o eluding garage, finished basement/attics, decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
i CITY OF S�U.ENi, N-L--1SSACHUSETTS
BUILDING DEPARTMENT
t 1'. 120 WASHIINGTON STREET, 310 FLOOR
T EL (978) 745-9595
F.kX(978) 740-9846
KON(BFRT FAY DRISCOLL
i�1AYOR: THObL►S ST.F1ERRli
DIRECTOR OF PUBLIC PROPERTY/BUII.DLNG COt12MISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print LLeeihly
Vame (l3usinaasOrganizatioMndividuai): "'�""^ I�M�T r`�a""r+ � � V'CJ l�C. r
Address:
(� O
City/State/Zip: ✓ � �� �`` Phone: Z,3(e — �O
Are you an employer?Check the appropriate b Type of project(required):
1.❑ I am a employer with 4. 01 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
workingfor me in an capacity. workers' comp. insurance.
Y9. ❑ Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself. [,so workers'comp. c. 152, 41(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.LNo workers' 13,0 Other
comp. insurance required.)
;Any applicant dot clucks box AI must also fill out the section Mowshowidg their workers'compensation policy inlurmation.
I kwncownen who suhmit this affidavit indicating They am doing all work and then hire oulsida contractors must submit anew aMdavit indicating such
Contractors thol chock This box must an m ao achod an additional sheet showing the nue of the tubnlraAon and their workem'ramp,policy infortnatioo.
l um an employer that is providing workers'compensation insurance for my employees Below is the policy and fob site
information. _
Insurance Company?lame: _
Policy 4 or Self-ins. Lic. 0: Expiration Date:
Job Site Address: City/State/Zip: -
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Of lice of
Investigations of the DIA for insurance coverage verification.
/de hereby certify under the u' ens/ties ofperfury that tire information provided above is true and correct
-Skmat Irc' Darn• Z- (`L
Official use only. Do not write in 11tis area,to be completed by city or town official
CityarTown: Permit/f.lcense#
Issuing Authority(circle one):
I. Board of licalth 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing inspector
6.Other ,---
Contact Person: .....--....____..___ Phone it:
CITY OF SAL.EM, TNL-kSSACHUSETTS
• BUILDNG DEPARTMENT
N 130 WASHINGTON STREET, 3m FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
1QNiBFRt F.Y DRISCOLL
MAYORTT-iOatAs ST.PIz=RRB
DIRECTOR OF PUBLIC PROPERTY/BUILONG COSL\IISSIONER
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 c 40, 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 disposal facility as',d"efin`cd by MGL c^
111, S 150A.
The debris will be transported by:
( .dam,
(name of hauler) I`
The debris will be disposed of in
(name of facility)
(address of facility)
nature of permit applicant
date
1
i -
�ri�arr<rnamue<rlfl o�C%�lraaar�uielG 1. >�
aa-1 Ogee of Consumer Affain&Business Regulation
ME IMPROVEMENT CONTRACTOR
egistration: �1Y22-13 ` Trym
,. t
apiration 6/1/2014- OBA.
KEVIN P.TOOMEY REMODEE DESIGN -
KEVIN TOOMEY " �_"s' � g,
74 LAWRENCE ST SU�TE'Y'>" -
SALEM,MA 01970. _`' Undersecretary