4 ROOSEVELT AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
OFSALEM
Massachusetts State Building Code, 780 CMR, 7" edition RevvisedJanuary
Building Permit Application To Construct, Repair, Re nov to Or Demolish a 1, 2008
One- or Two-Familv.Dwelling
This Sec ' n For qfficial Use Only
Building Permit Number: / to Applied:
Signature:
Bwlding Commissioner/Inspector Date
SE .SITE INFORMATION
1.1 Prope 1.2 Assessors Map& Parcel Numbers
L I 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 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
`3r n (�'I a .oc s 4e e l + Q.J P
Nam Print) Address for Service:
q-7ct'- -1yU- o64y
%gn urc Telephone
SECTIO DESCRIPTION OF PROPOSED WOW (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work2: — ( 1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only `
Labor and Materials
1.Building $ 4,So 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire SuppresSion) $ Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ Z y SO.— ❑Paid in Full ❑ Outstanding Balance Due:
I
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Is- 2 - 13 - ►4
Bohr+ Walsh License Number Expiration Date
Name of Cl Holder List CSL Type(see below) V
sz O,cl�a d St Sake,w, rnA
Address Type Description
U Unrestricted(up to 35,000 Co.Ft.)
R Restricted 1&2 Family Dwelling
ature
�- 74L/-1001 M Mason Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation.
D Residential Demolition
5.2 Registered Home[m rovement Contractor(HIC)
-�o h �S h I Y l' t-1 28
HIC Company Name r HIC Registrant Name Registration Number
S2 o c�iar Sr
Address Ci — 2 ( 3
5 7 4 7IN rap Expiration Date
Signature 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 pennit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, On LJ o 1G MCa Y1 as Owner of the subject property hereby
authorize e C k ,m n P vl Cm to act on my behalf,in all matters
relative to work authorized by th's building permit application.
Ai g n ture ofWQefDate
S CTION b: OWNEW OR AUTHORIZED AGENT DECLARATION
4 0 k owc Le n e -moo �t 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.
Chr lease ob-e
PrimaI- /� , p
l ' V\lut�+� --L44A _ 3 ( 3
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u )
NOTES:
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.R5,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 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"
C rrY OF &M-F a ;4L-�S,:kCH SETT's
4 120%V.k&Hr iGTON S-InMEL 3' FLOOR.
.. ? I�''z (hr9�79} gf i5.95965
ix
78)
'rt ltilERLEY DRISC(?I,1. �+�r3�L!,�
MAYOR(MAYORt lLSS$T.PtEitR$
Workers' Compensation Insurance Afl{duv)t- butte#erxlCorttractorsiElectrietaaatptumbers
A 1 tilcatst Infttrmatinn PtLas Prtn klogihl
City/stasefxip.,. 01119-70 -- Phone 1{;
AFT yov as tmotatyer'! "k the apprvtprlate bov � `i`yt�a of piroject{requiroi :: ..^•
1. f un a;mploy r will. t/�. 4. (_ [arm.a getusat anvtrracw and t 6. 0 New co+tstrtactic n
etstplayeaa(full aoGitrpaat-xitau?a have liken d1d sub-v:ontractom
Z. I'am a IOU promictor or pam-mr- listed oa:trt attsehod;sired.$ 7.
ship WW have no empleycna Thew sub-contrzoors have h. Vesnofitlors
WAXAfns for me is anycaatacity.. work"%,corn. invognm % 0 iduildirts additioca
('Fo wwkers'comp.imummt S. We art a CWrXXV4m atsd its d
9 r,gutted,) l O.�i Fltclsocal rapatr3 or aGdciiaas
o€Ctaexs have txcrtistd tkasr
3.0 i orrt a hoovo v om doing all work right ofexamptitm per h4ZZ I i.o Pia t burg rcTa srs ar rr xl' rms
nsyscte[;V'o Workers'"mv. G 15.4 41{4),and ux havc no 12.0 Roormpa rs
irsuranca requires£)t +gnr!oyo et.[NO worker'
_ ean;p.imuranat rev sairad j 73. Qtftrr _.-_ ...
•nRy tpptitwk elru d!ceka bast s t ewer atx.r t3dD aw sM wa:3iw hekas z}gaceul�a°adr�aYans'rs��SdN.y'rsr'uaxsrailra�
t ivn ,:aeon uF+x Whamie this etVd*vK:sMt rat wx!hsr$rs dnial a:i wvskaaA dar:tkixs"Wo mWoraan cram Av mk a ftV aCrdpoit irukco;f4 awly
'C:aer Iom xras:hmt 04#box omw a%3dW Am 3akl mAg 4mYA Jww*V to fr m of th9 A6-oCAtr"tm%aid 71.`4ir ekyrwft,omw paltry tVP". m--im
s
t err*Nee ent}+hryrr that tYpravFdlrtf trsrkrra•raxprarva7ou iraturuucsfa►hay emplayt+ra llrBasr is rhw,pa{try rrna?/eb s}tt
;ea�erssnradrrt.
los runt t.;ompiny
h.',.wy�ssrSel,"•gists Gla ?�: �k7
lob Sit�a�atckt u1 9!l..o c s e_V_P)-Y—1-4 vP c:i ytgt:ctrtzip-,.,SH C Eict /H i4
:Sttxcls a CQP7 at the wori trs'tcaptxsatkstt pouei daclartttota pa;;t(IM wista tha pAlcy amtabor xtt3 estgtraxi a date).
PAhAm to Wcum correrager as revpuired UWk-'r 1kCd4M 13A of:`Gf,e. 132 cart leas)talk*imprsxtipst of criutiaktl pel'A.16 s o ra
tt up to S 1 1400,00 arut<or age-year impt*.o4mcn4 as.volt as civil gcr.Agns iat il`.e Corte of' STOP WORK i ORDU aa;i a fuse
,sfu+to�''S0.^url;t nay t,�uxt r!^.t wroSatr�. )lac asfvix+s;t tita`.:t sxtpy vtf thii+aasccraat msy bet iw"+vazrl,:d ao ttsa t3tYi.x s�f
Ltwaxttyutl<ai},t€altr CIA fat fasa:raoee eovcragc vc,,Wwatiort.
1.10 hsrcbr certify ugrdor thrpaimy sswaditenol:f"of pwriary1.'catMr M(me eationpraw'ded a5uvx.:.t scare azrd 'etrrt�c
1316cial use entyt :)a nos#write ht this zwev.to be tvrmpxk"by city or to Ws t,Tz at
s 1
{.ity ar 2'uts;t2
I.,soog Authority Wroo unt)!
f, lJoard tat tttalt'a I,tBWiding uepartguat I C.ifya'fowc Clerk d. :ttctrfrx6 f+rspattitor 5; €*lumbin,„' pecrsr
6.04hcr
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OP ID:SS
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NON OWNED AUTOS E
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EXCESS UAS CLNMSMADE AGGREGATE E
DEDUCTIBLE E
RETENTION E S
WORKERSCOMPENSATION WC STATLL
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