15 RAYMOND RD - BUILDING INSPECTION ( � a The Commonwealth of Massachusetts
'un/ �►, Board of Building Regulations and Standards CITY
1 Massachusetts State Building Code, 780 CMR, 7'"edition OF SALEM
y evixerl Janaury
Building Permit Application To Construct,Repair, Renovate Or Demolish aIR
1, 2008
One-or Two-Family Dwelling
This SectiA For Official Vse Only
Building Permit Numbe I I R#c Ap ied: ` /
Signature: `�d'>✓✓ Lley/ 7
Building Commissioner/Inspector of Buildi4el v 1 Date -
SECTION IT INFORMATION
1.1Pr petty Address: ` 1.2 Assessors Map& Parcel Numbers
L—�f o r J
1.1 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 It) Frontage(11)
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 DiissPosal System:
Public 17 Private❑ Zone: _ Outside Flood Zone? Municipal 130n Site disposal system ❑
Check if yesO�
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owyer'o Record: /
Name(Print) Address for Service.
86( Pin(
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Uni s_ I Other ❑ Specify:
Brief Des
cription)o7f Proposed Work':
l a�c._c lnti � nrcx
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard Citylrown Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $ 11
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
WO 6.Total Project Cost: S Check No._Check Amount: Cash Amount:_
❑Paid in Full ❑Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) Q2g(J Cl Z
License Number Ex imtion D. e
Name ot'CSL-I]older 1 II List CSL"I'ype(see below)
f, Description
e
:1Jdre Unrestricted u tom 35,000 Cu.Ft.)
Restricted I&2 Fall Dwelling
�' atur _ / 7 M Mason Only
�/ / RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2r R-egis�tered-u7ome Imgrgv£men ontractor(HI ) tv�k-
UL
/�7( ! 1J lD-U�� � t�2 5 Registration Number
HIC Company Name or t IC Re strant Name
AJ (7 9 rK -Y11 FApiration Date
i a ore Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR=ONTRACTORLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
au orize 5 to act on my behalf,in all matters
relative to work authorized by this building permit application.
� 4 Date
Signature of Owner
SECTION 7b:OWNER)t OR AUTHORIZED AGENT DECLARATION
1 G�7JC�l /i as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Na
ature o wrier or Auth zed Agent Date
(Siv.ncd under the pains and penalties ofperjury)
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&of have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including 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 halt/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'
,S CITY OF SALEM
All PUBLIC PROPRERTY
DEPARTMENT
,n11; 81r\ nw 'g1
\I'.I1-N I'0\Y'.\;I IL\o:,INSCKUT •S.\I r
fFl:478.74 9i95 f.\`(:97S-740-9446
Construction Debris Disposal Affidavit
(required I'ur all demolition attd renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR scetion 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit p , _ 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:
Z-
�� ��i G
(name of hauler)
file debris will be disposed of in
6111
I cc
(n:uneulTa
laddrc+s ul laclhlyl
signaturo4t per ' applicant
IC
Icln Hall Sw I
CITY OF SM-EM9 A -hiss kaiusEm
BLMDLNG DEP.%M.(ENT
120 WASHLNGTON STUET, )so FLOOR
TEL (978) 745-9599
F.%x(978) 744984
KINIB EY DRiSCOLL 711oMUST.PMR11111
HAYOII
D1t1ECT'at oP PL gttC PROPEaTY/gL 12.DLNG co.',c%nssto.N EK
Workers' Compensation Insurance Affidavit: guilders/ConiractorWElectriclanslPlumbers
A a (leant Information lease
Vatne 1aee1rreu0rgrn1rsrior%InLhv,dralh: 5
Address. CI Lolt.�t �I
City/Statdzip: l��J , �/�/�/✓TPhonaM:(/ ,1A4) J.;r_�/9/
Ara yo employer'Check eke appropriate boa: Type of project(rtqulrei*
1. 1 am a anployer with�_ 4. Q 1 sm a prneral contractor and 1 b. Q New construction
cmployece(full andfoc par-time).• have hired the sub-con. tm
2.Q I are a solo proprietor or partner- listed an the adschad sheep i I I 7. Q Remodeling
,hip and hove no cmployea These surd-coat - - have L Q Domolition
working for me is any capacity. workers'comp.inauraocs. 9. Q Building addition
iNo workers'comp insurance 3. Q We am a corporation and is I0.❑Electrical repairs or addiroos
ruquired.l officers have exercised their
1.Q 1 am a homeowner doing all work right of eaeeeption par MOL I I.Q Plumbing repairs or additions
myself.[Na workers'camp. C. 152,'1(4),and wn haw no 12.Q Raof repairs
insurance required.)t %unployeas.LNG workers' I1.❑
comp insurance required.j
Other-
.Any opposer err disabled;at mew alto Ile uia the ratio brow Airwiag raeir worlae-c I polies irdrrrnaloe.
't hwnwatwas who tabour alb o fldevis Wkedas shay an doing dl work ere/thin hie aarir cone"wow ,hail a nor ilOdwTt Wei wag tak
<',wrravn tow cheek thie ter.urea anarW ere adiiiatl ahutl showing tti tsar of ore aA�aartaeraa W thek worhra'Camps pdicy ieaera "
/awe aw rtwp/ayar rher b pnrldhrR rvarhtes'rowpttoadsn lrrprotaaje►aq ta►pluyees Srhrw d nFe paffeP ew//t1 sins
injormarkia
Insurance Company Name:
Policy M or Self-ins.Lie.Or Expiration Date:
hub Sim Address: ! lZU gdA/1 y t City/StatwZip: �i
%track a copy of the worbon'comp uation policy dtelerallea pop(showing the policy number and expiration dslb)L
Failure to secure coverage as required under Section 25A of MOL a 152 can lad to The imposition of criminal penalties ofe
Pne up'la S 1,500.00 and/or anti-year imprisorimaro a2 wall IN civil penalties is tin farm of a STOP WORK ORDER and a floe
of up to S210.00 a day against the violator. I14 advi.tod that a copy of this oatcaume may he furwarded to the Office of
Itivc,ii gatiuno of ilie MA for insurance coverage verification.
/Ja htrrby rrrrl diet ins un lies o/per/ury that the injarnredoa provided above is tart end warred
_Ai �
P"!,,orc A•
OJJlcia/uet anJy, Da net write in this array ra ht.utnp/ird et'rift'or rotvw„//liia! i
I C'iryorfuwn: __ Yermir/LlernseM__, �
Tssuing Amhenly(circle one):
I. ❑uard of Ilralth 1. Ruilding Department 1.C'itytrown Clerk !. Eteciriul Inspector S. Plumbing Inspector
6.t)Iher
l .ntacT Perron: _ . _ _.. Phant t•