15 1-2 RIVER ST - BUILDING INSPECTION (2) t
y� 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
nk �This'Section For:Official
Building Permit:Number > Date pplie 'i'>
Building Official-(Pont Name) 4" Signature k Date;
1 SECTION]: SITE'l NFOR TION M
1.1 Property ddress: S 1.2 Assesso s Map & ar umbers
vim✓
1.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property D' nsions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes[]
' SECTION 2i PROPERTY OWNERSHIP[` t
2 OwnertofRecord:
J�
Name(Print) City,State,
No. and Street Telephone Email Address
SECTION 3`s DESCRIP.TION OF,PROPOSED WORK' (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition El
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION COSTS: ':
Estimated Costs: Official Use.Only
Item Labor and Materials
I. Building $ �%p U l' 1 Building PermitTe-e $ Ihdicatahow fee is determined.
❑ Standard CitylTown AF lication Fee..
2. Electrical $ % a• — pTotal Project Cost (Item6)xmulnplier x
3. Plumbing $/ S
4. Mechanical (HVAC)
5. Mechanical (Fire $ Total All Fees.$
Suppression)
Check.No� _ Check Amount Cash Amount
6. Total Project Cost: $ f J D e'7a,
I ❑ Paid in Fu1L ❑ Outstanding Balance Due
r �
SECTION 5: CONSTRUCTION SERVICES
rofCSL
upervisor License(CSL)
G �a y� .pr- L'cens Nu er Expir ton D ei
List CSL Type(see below)
No. and Str et Type ;, o .`� DescriptionU Unrestricted Buildin s u to 35,
/FYI ✓PrS —��_ R Restricted 1&2 Famtl Dwellm
City/Town, State,ZIP M Nlasonr
RC Roofin Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2/Registered Home Improvement Contractor(HIC) /S9 -/1�4 �J �
HIC Registration Number , pir ion Date
zIC Compai N, or IC 7 v gistra 7
O J a r e { (� y yn Q 1 G !rl
No and Street
-/ � 8 9 9 eJ 9 Email ad rest
Aity/ATown State, , ZIP Telephone
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... ❑ No ...........
SECTION 7a: OWNER AUTHORIZATIONTO BE'COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR"APPLIES FOR'BUiLDING PERMIT
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 1b: OWNERt:OR AUTHORIZED AGENT DECLARATION-
LBytering my name below, I hereby attest under the pains and penalties of perjury that all of the information
ned in this licatio ' true and accurate to the best of my knowledge and understanding.
wner's or Au[honzed Agent's Na ectronic Signature) Date
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 Horne Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
www.tnass.sov:/oca Information on the Construction Supervisor License can be found at ww•w.mass.gov dos
2. When substantial work is planned, provide the information below:
Total floor 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 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"
CITY OF S�u.Etii, UNSSACHLSETTS
3U1MNG DEPARTM&NT
j° 130 WASHLNGTON STREET, 3" FLOOR
" t TEL. (978) 745-9595
FAX(978) 740-9846
Kl-,IBER FY DRISCOLL
ANYOR THOJIAS ST.PIERRS.
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG 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 I 1 L5
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 defined by MGL c
111, S 150A.
The debris will be transported by:
S; 40 S2 /✓r c of
(name of I er)
The debris will be disposed of in :
A 0 < <
(name of facility)
A--(addr(ss of facility)
signature of permit appli
iv Zz
Li
debrisatf dux
CITY OF S U ENI, AXSSACHUSETTS
BUILDING DEPART. tW_NT
`•�r O 120 WASHNGTON STREET, 3'a FLOOR
a TEL. (978) 745-9595
FAx(978) 740-9846
KI\(BERLEY DRISCOL L
MAYOR. T�30MAs ST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CONNISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Lepibly
Name(13usiiws.vOrganisatiamindividual):7�/i— Pvt i C' �i r,r• ( iy✓,r�Q- 1 �t,,.t d �t __ _
Address: lOJ fa i-AC/—s T F C� �F✓r' ✓�J
City/State/Zip:1�k2 a—�rs Phone M: g'. elfQ/ — 8 s 9�_5
Are you an employer?Check the appropriate box: F9. 03
project(required):
L❑ I am a employer with 4. ❑ 1 am a general contractor and 1w construction
�, '"pioyees(full and/or part-time).• have hired the sub-contractors
2.L'i 1 am a sole proprietor or partner- listed on the attached sheet.1 modeling
ship and have no employees These sub-contractors have K. molition
working fur me in any capacity. workers'comp. insurance. ilding addition(No workers'comp. insurance 5. ❑ We are a corporation and itarequired.) officers have exercised their ctrical repairs or additions
3.❑ 1 ran a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp. C. 152, 41(4),and we have no 12.❑ Roof repairs
insurance required.)t employees.[No workers' IJ.❑ Other
comp, insurance required.)
'Any applicum oat clucks box AI must alw rill out the section below showing their workers'compensation puliry intbrmatlon.
'I hvneowncm who submit this anldavit indicating they am doing all work and then him outride coni0ctor5 moil mhmh a rrcw amdavit indialing such,
:(:onuactors that check this box must attached an additional wheel showing the name of the subs ntnctmv and their workers'comp.policy infumotiom.
l um an employer that/s providing workers't omttensal/on hrsurance for my employees Below Lr the policy and Job Nile
information.
Insurance Company Name:
Policy 4 or Self-its. 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 imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to S250.00 a day against the violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigations of dtC DIA for insurance coverage verification.
t rto hereby certify under the pains used penaltles"/'perjury that the hrfuraratlan provided above is true and •arrect.
r
Po ,�• / 7 �� / J
01)icial use only. Do nat write in dris urea,to be completed by city at town n�J/rluL
City or'1'uwn: PermitiLlcense#
�uthoril Lssuin
K� Y (circle one): — ------ ----._.._
1. Board of Ilealth 2.Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other _....
Contact Person: Phone#: