14 SAUNDERS ST - BUILDING INSPECTION }
C_K, 25 Z
a
The Commonwealth of Massachusetts CITY OF
1 Board of Building Regulations and Standards SALEM
q / Massachusetts State Building Code, 780 CMR ReviseJdlur 2011
"�— Building Permit Application To Construct, Repair, Renovate Or Demolish a
I One-or Tivo-Fmnily Dwinellg
This Section For Official Use Only
Building Permit Number: Date Applied! 1uniber
Building Olticiul(Print Ni ne). SignaturemSECTION 1:SITE INFORMATIONrn
n1.1 Property AdJ ess: 1.2 Assessors Map&Parcel NumbrnASclun .2CS 59 GI.la Is this an accepted street?yes no Map Number Parcel 1.3 Zoning Information: I.d Property Dimensions:Loning District Proposed Use Lot Area(sq 11) Frontage(
1.5 Building Setbacks(R)
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 Zane: _ Outside Flood Zane? Municipal 3�On site disposal system ❑
Private❑ Check tf esl P P y
SECTION2: PROPERTY OWNERSHIP,:
2.1 Owner!of Record: �2M M 4
thine(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildingt Owner-Occupied La( Repairs(s) Alteration(s) ❑. I Addition ❑
Demolition YJ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work-:
OV4. 'ee- G !- 2
t re^ 0 15'1' n sc �
SECTION a: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs: Official Use Only
Labor and Materials
I. Building $ $ d v O I. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ O p ❑Standard City/Tgwn Application Fee
❑Total Project Costa(item 6)x multiplier x
3. Plumbing S oC 0 -2%9therFees: S
t. Mcchanicai (FIVAC) $ List:
5. Mechanical (Fire $ 'fatal All Fees;S
Su ression)
Check Na._Check Amount: Cash Amount:_
6. 'rotal Project Cost; .S � S0 0 ❑paid in Full ❑Outstanding Balance Due:
C_X\(✓1_ y �.� .
SECTION 5: CONSTRUCTION SERVICES I
5.1 CunstructionSupervisorLiecnse(CSL) —
�� License Number Expiration Dale
Nanifie urCSSL-[folder tr List CSL Type(see below)
S ii� ���l f(\� Type - Description
No.mid Strect
U Unrestricted(Buildings up to 35,000 cu. If.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
' SF Solid Fuel flaming Appliances
Insulation
ar w'isle bona Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ` 3 , I(Ltct -(�2f7L /
C(as te7 K are HIC Registration Number Expiration Date
HIC Cump:my Name or[IIC me
No. n�(Street� Email address S78 s5�j
City/Town, State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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 AUTHORIZATION.TO BE COMPLETED WHEN,
OWNER'S AGENT OR CONTRACTOR A PPLIES FOR BUILDING PERMIT'
[,as Owner of the subject property,hereby authorize C Aee KAo21 VCcl—
t9 act on my behalf,in all me tte3s relative to work authorized by this building permit application.
cr (hctnnon dry c� McX+irvn � h //5l/�
Print Owner's Natne(Electronic Signature) Dale
SECTION 7b:OWNER[ORAUTI[ORIZED 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.
Print Owner's orAuthtfrized Agent's Name(Electron c Signature) Date
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 nor 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.mass. a!i_OC71 Information on the Construction Supervisor License can be found at www.mass.gov/dvs
2. When substantial work is planned,provide the information below:
'rotal tloor area(sq. R.) ,(including garage,finished basement/attics,decks or porch)
Gross living area(sq. If.) 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 ofcoolingsystem Enclosed Open_
i. "Total Project Square Footage"may be substituted fur"Toed Project Crust"
OTY OF SALEM) MASSACHUSE M
BUILDiNGDEPARTMENT
'120WASIRN6TONSUEET,3'DFLooR
nL.(978)745-9595
KIMBERLEYDRISOOLL FAX(978)740.9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBUCPROPERTY/BUILDING COWflSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixti'edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, 5 54; Building Permit#f is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
e
(name of facility)
SI1 em
(address of facility)
Signature of applicant
Date
Q-1-Y OF SALEM, NWSACHUSETTS
BL'ILDI,\,G DEPARTLE.\T
3 ) t r l 120 WASHIINGTON STREET, 3w FLOOR
° TEL (978) 745-9595
F.--X(978) 740-984d
K!\tBERLEY DRISCOLL THOA(AS ST.PIERRH
`�,1L�Yoa
DIRECTOR OF PUBLIC PROPERTY/OCQ.DIVG CO\LUISSIO:iER
Workers' Cornpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Informalinn ^ Please Print LePibly
Name(nusinessOrgmiaarinrvindividual): �kA 1f—IrrI e—s Kti� Vl�
Address: S ��- C� � (IL-S s-T-
City/State/Zip: leC,-\ QP 7oPhone#: 'f7f 5 5S:S3
Are you an employer'.'Check the appropriate box: Type of project(required):
I.❑ 1 am a employer with 4• ❑ I am a general contractor and I
6. ❑New construction
yMfployms(full and/or part-time).* have hired the sub-contractors /
. ®
2.Q lama sole proprietor or partner• listed on the attached vhcet.) 7Remodeling
ship and have no employees These sub-contractors have S. Zemolition
working for me in any capacity* workers'comp.insurance. 9. ElBuilding addition
INo workcri comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their IO. crricaI rcpnirs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 t. Plumbing repairs or additions
myself.[No workers'Gump. c. 152, §](4),and we have no 12.0 Roof repairs
insurance required.) t employees. [No workers'
sump.insurance required.) I1.❑Other
.Any upplic:un our ehvcks bus 91 must also roll uul the section below showing their worker'compensation policy intmnatlon.
'I Inmeuwm"who,uhmit this s0fidbwir indicating nhey are doing all work and then hire oulsidacanimctax must suhmit a rmv.tfrtdavil indicating such.
:C.unmcwn that chsek Ibis bus most attached an addiaurul shay shuwing tlw narne ofthe sub4ronlnelun and their waken'comp.policy informatian.
I um can employer that is providing workers'compensation insurmrce for my employees. lfeluw is Ihr policy and Jub site
iuforinalian.
Insurance Company
Policy iJ car Self-its. Lie.N: 1 d R6 7A9(yJ /v,tTL 7 .�1�-�! /2 Expiration Date:
Job Site Address: /"I ,S'4V�e C-S S / City/State/Zip: SQ Net', c'M76
,%itach a copy of the aroriders'compensation policy declaration page(showing the policy number and explratton date).
Failure to secure coverage as required under Section 2JA of S1GL c. 152 can lead to the imposition of criminal penalties of a
line up to S1,500.00 and/or mu-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. 13e advised that a copy of[his statement may ln: forwarded to the Office of
Invrvligalions al'the MA for insurance coverage verification.
/du hereby certify jurdrr the puma cord peaaldrs u/perjury that the infunnutlon provided above is true and correct
Sion unre' / A. Date:
S7? SS
OJ/iciuf use only. Do nut lvrire in this area,to be cuurplered by city car rodeo n/JJeiu1
I
City nr'1'uwa: --- _— PermlUlAcemeN__.____. ..._—_-. . ..--
Issuing Authority(circle one):
I. hoard of lleahh 2. Iluilding Repot tulmtt 3.Cilylrnwu Clerk J. Electrical (uspcclor 5. Plnmbiog luspecrnr
6. Other
('"'diet Person: Phone Y: