2 1-2 ROPES ST - BUILDING INSPECTION The Commonwealth of Massachusells Town of
Board of Building Regulations rnd Standards
.Massachusetts State Building Code. 780 CPvIR. 7'a edition Budding Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a tlbvm�
One- or Tnu-Fumrh Duelling
a S tins For OfficiallJse Onl
Building Perms umber: Date lied: —/ a
Signarure:
Building Comm, sioner,In tar if in Data
SE ION 1:SITE INFORMATION
1.1 Prope O ddress: 7 r 1.2 Assessors Map A Panel Numbers
— I —
1.1 a Is this an tic ted street:'yea no Map Number Parcel Number
I.J Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq n) Frontage IR)
1.3 Building Setbacks(rt)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
ro
Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Public 0 Private O Check if W50
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of ord:
Name 1 Pam) Address for Service:
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building I Iwner-Occupied efl Ripairsi Altmtiort(a) Addition 0
Demolition Accessory Bldg.O Number of Units Other O Speciry:
Brief Description of Proposed Work": k
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OOlclal Use Oely
Item Labor and Materials
I. Building f ,3.50�. 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S .�D' 0 Total Project Cost"(Item 6)x multiplier x
J Plumbing S LOO 2. Other Fen: f � /ham
a. Mechanical INVACI f List: ,r /
i Nechamcit (Fire $ Total All Fees: f
Su re"'tars
Check No. _Check Amount: Cash Amount:
A Told Project Cost S lij J U, O° ❑ Paid m Full 0 Outstanding Balance Due-
T� d,\) 0wl
SECTION !: CONSTRUCTION SERVICES
5.1 Licensed Construction Super%isor(CSL) b Z23 'I
�0'IF e 61./ s•IIRJ S Li.cnse NumDcr Evpnauon Oale
N,yae ut('SL Hplder •l List CSL type I+or bauwl
t C� �- tat S.9/
AJikes rww I Description
I CU9Unrestricted u to 17.000 Cu. Ft.
R I Restricted 1R2 Family Daelhn
itlutur .M I Masonty Only
g 7 q- _ RC Residential Roofin Coverm
Telephone w'S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) /6 03 2.
HIC Company ants me or HI Registrant Na Registration Number
Address :ice CZ 5- //-/0
71 Expiration Date
Sigtunue Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL f 2SC(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 AffidavitAttachedT yes. ... a No...........0
SECTION 7a:OWNER AUTHORIZATION TO 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.
Si anus of Owner Date
/�� GI S^ECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
t, CAE 0 r . Cs �%a-,4 S , 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. C9//��
PW 4�e �s (,V z 0S
Print Nam
Si of or Authorized Agent Date
istried un the pains and penalties of
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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 I0.R6 and I I0.R3, respectively.
2. When substantial work is planned, provide the information below
Total floors area(Sq. Ft.) (including garage, finished basementtattics,decks or porch)
Gross living area(Sq. Ff.) Habitable room count
.Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type ofheating system Number of decks/porches
Ts pe of cooling system Enclosed Open
l "Total Pro)tci S4uare Footage" may he substituted for"Total Prolcct Cost"
CITY OF S.U.E.`[q A-kSSACHUSETTS
BVILDLNG DEPAIMIENT
120
W.uHmit;;TON STREET. len FLOOR
TEL (971) 745.9S95
FAx(978) 746-9846
KIMBEILLZY t)RJSCOLL
VU►YOIi TliohtAs ST.PIERItS
DIRECTO t OF Pt:DLIC PR0PEIITY/9t:D.DI.VG COSMISSICIN ER
Workers' Compensation Insurance AIIldavit: guilders/Contractors/ElectriclanslPlumbers
>nnllcant Information Please Print Leeibltr
Vatnt (tlwitw+rOryttuuiotr tndavtdtSatl:CTPnr'�'!_ �/y Nf/f C O/I f��c..T.o.� y!l L
Address:
City/State/zip:
Are you an employer?Check the appropriate box: Type of project(required):
I.0 I am a employer with 4. 0 1 am a tencrsl contractor and I & 0 Now construction
employees(full and/or part-time).• have hired the subcontractors
2.0 1 am a sole proprietor ar partner- listed on the anaehad sheet t y L�93
Remadelin�
.hip and have no employee These subcontnsetors have 8. 0 Mmolition
workingfor me in an capacity. workers'comp.inauance
y Pr ry• S. t(J/ We an a corporation and it. 9' ❑Building addition
INo workers'comp insurance We
have oration a their 10.0 Elecrrical repairs or additions
mquired.l
5.0 I am a homeowner doing all wort right of exemption per MGL I LC3 Plumbing repairs or additions
myself.[No workers'comp. c. 132.41(4).and we have no 12.0 Roof repairs
insurance required.] ► amployce.(No workers' 13.0 Other
comp insurance mquired.j
.Any appataa Ohr dOaeaw ben rl MUM AM fill aht 11111110116111111 tslow aDooiq tltdr waAorr'canpattatkr policy indhrnatlsa
't I.wrnuwnae who sound this aflldevil indicating they am Joiner all work ad then him oanids coaraclors OOaOr SuMnk a new arllbvil indicating Shte<
:r.mOranon OM ch.ek Ohio lint tour amaMd wa aJditio al dter Showing the Orr of then whk.csanich"will their who ,ra tnp,policy inamissime.
/a n an amp/ayrr that bororidfnT workers'cosrpaaraden/naanewnfor wy rwp/ayrn er/ow b rhr pr//ey swd/aI s/M
inform"I"
In.urrnce Company Name:
Policy N or Self-ins. Lie.Ah Expiration Data-
job Site Addross: City/State/zip:
.mach a copy of the workers'compensation policy doelaratlon pap(showing the policy number and expiration dalo)6
Failure to secure coverage as required under Section 23A of MGL c- 152 can lad to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment.as well u civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 u day against the violator. Ile adviwxl that a copy of this statement maybe forwarded to the 017Ica of
Inv %itgatiuns oi'tlie DIA For insurance coveralls veritieatioe.
/Jo hereby,a enify r older then iwa and pena/Nex of perfury that thr information provided above is true and.:ureter
O/J/cio/use mS/r Do nor write in Ibis orrq to be carnp/Nad by city or town t.///a•iint
I
City or ru%vn: _ PermivUeensel__,
Issuing.\ulhurily (circle une): I
L Iluard of Ilvulth 2. Rwlting Department J. City/rawn Clerk J. Electrical Intprclor 5. Plumbing Impactor
6. Other
L-mlact Person: _ ._ _.. Phone s:
_s.
CITY OF SALEM
PUB
LIC PROPRERTY
...�
DEPARTMENT
.4T�?iI
.I'.IIY. PI Y.1 !•Nlv 'I I
110 91'.\il II\G:(?V SrN EI'T 0 )•\I r\1, M.1ii.H
'I'FI:978.74 9i99 t°%x:978.740.9846
Construction Debris Disposal Affidavit
(required I'or all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR scetion It 1.5
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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will
be/transportcd by:
C�P9 �C� C9 1 y 2C7f
1 name ut haultr) -
The debris will be disposed of in
(name ut a�lty)
(address of f aci lily)
lature of permit applicant
date