13-15 SAVOY RD - BUILDING INSPECTION ---
( I'he C'ununontvealth ol'Massachusclts
V ) Board of Building Regulations and Standards CI'I'1'UP
O + SALEM
htassarinuctts State Building Code, 79U C'f\IR
�>v,�,., H.rietd 1 Lu•all/
Building Permit Application To Construct, Repair. Renovate Or Demolish a
Une-or rnv-kano/.v Drrellin,\r
This Section For Olrcial Use Oni
Building Permit Number: lied: _
J - p
1" 1 (ding Oltieial(FrioI Mine) Sigtrol re Dale
SECTION I:SITE INFOR6LITION
1.1 Property Address: 1.2 Assessors Slap di Parcel Numbers
1.la Is this an acce ted streeti es no 1 ,%fap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area Isq It) Frontage(II)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.t.c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewmg*Disposal System:
Public❑ Private❑ Zane: _ Outside Flood Zone? Municipal ❑ On site disposal s)ilem ❑
Check it'ycs❑
SECTION2. PROPERTY OWNERSHIP'
2.1 Ownerr of Record:
1me(Prit) DEVTT �IE/h / /)IA
Name(Frio!) City.State,Z.IP
I)& n v4 a(Y6
Nu.and Street rclephone -Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ I Alteration(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ tamer ❑ Speeity: SMlp�he( Q2Jt p
Brief Description of Proposed Work': SH2 n a r( Q2 PwF
SECTION 4: ESTIMATED CONSTRUCTION COSTS
I1e11t Estimated Costs: Official Use Only
ILabor and \Interialsl y
1. Building S 1. Building Permit Fee: f Indicate how Poldc,,!r Hccrical S ❑Standard CityrTown Application Fee
❑Total Project Costtl Item 6)x multiplier --i. Plumbing S ' Other Fees: SJ, .Mcch.ulical III\ \(') S List:_hanical i Firc S - ..-uionl Foal .\II Fees: Sheck No. ('heckAtiotuir ('ash \o TuWI Project Cost: S `1,efaO.OJ ❑ Paid in Full 17 Outstanding Ilal:mce Due
SE("PION .S: CONSTRUcriON SERVICTS
.9.1 ('onstructiun Supervisor License(C'Si.I 191 aaD io_am Y
I icenee Nwnhar Fvplralinu DOW
N;une ol'CSI. IIIJJer rr��
PC Descriplion
No. And Sucet
U t 4veslriaeJ I Ih1ilJin gs LJO ut lt,llllll eu. il.l
it Rntricted I&) F'11105 INCIfillit
Cil�i loan, 5wte,%II' ,\I Aloion
NC Roolin ('uccrin
µ'S µ'indov%dnJ Siding
SF Solid Fact Burning Appliances
fi I S4'rrJ-1 t_ _ I huululion
'I victillone Finail aldrrss 1) 1 Demolition
5.2 Registered Home Improvement Contractor(HIC) j �) t 7-) g —5_�gr,
1�11j AA. R&UAAA A lc�e g12o t.J� — IIIC'RegtstrationNllMNr licpirniunUule
I IIC'l'ompany Numc or i IIC Itcgistra t Naing
�� 1/ntnnr SF —
No. and Strucl [-.'mail address
L,PA w ,nA r�tGcw 7El 3 salt
Ci /Town.Slate,ZIP Tale hone
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 Issuancpof the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION 7s: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.
Print ONocr s None(Elcorunic Signature) Date
SECTION 7b:OWNER' OR AUTHORIZED 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.
tl I(2nita r (n 7—aOLI
Print liancr i nr:\uthorireJ Agenl'i Noma Il.leclrunlc Signauuel Date
NOTES:
I. ,\n Owner whu obtains a building permit to do his.her own work,or an owner who hires an unregistered contractur
(nut registered in the Hume Improvement Cuntractur(HIC) Program),will n r have access to the arbitration
%
program or guaranty fund under M.G.L.c. 112A. Other important information on the HIC Program can be lhund at
n .n. p1+ 01 1 Information on the Construction Supervisor License can be found at tt)t,t may, Iry -III,
2. en substantial trk is planned
\Th w , provide the information below.
folul flour area (including garage, linished basement.attics. docks or porch I
Gross living Area t iy. Il.l __-..- habitable rouni count
i \umber of fireplaces .... Number of bedrooms .. .. . .
Ntimberot'bathrooms — -- \umberul'halfh;uhs
I)pc of heating . aem _ _ _ Number of dccki, pordles
I 11 pe nl et4thng i)item lanclo:cd ..(ll+en
1, "f olal Fr ie" Square Fotd,ige" Ills\ he uhintuicd fl r"lolal Project Cali' �
Cn*Y OF SALEM, \tWSACHUSETTS
t BUILDING DEP.%wrNLENT
[?O \Y/.%3NIINGTON STREET, 3oa FLOOR
TEL 978 735-9505
Rt-x(978) 140.9844
\1pER[YDRISCOLL THOt1ASST.P1FiA8
�L�YOZ
DIRECTOR Of PUBLIC PROPERTY/0l:RDtN(,CO\L\If55(OrEA
Workers' Compensation lasurance Al'adavit: [3uilder9/CuntructoNElectr[c[3ns/Plumbers
+,pplleant information Ptease Print Lea-[hly
Mimi: (A:! 1hA.M I—/QRNQA/T.V2 orbeU '1.1 )cTIM SAJC
Address: a/S VEkL-A)A Si
City/state/Zip: Nit) ,MA n /� 90Y !'hone N: 7P./ S9'9 /a2//
Are yt as employer?Check the appropriate box: 'Type of project(required):
I. I am a employer with._LL_ ;• Cl I am a general contractor and 1 6. ❑New construction
employees(NII and/or part-time).• have hired the sub-contractors
2.❑ lain a sole proprietor or partner. listed on the attached+hoer. : ?. ❑ Remodeling
.,hip and have no employees These subcontractors have 8. ❑ Demolition
Workingfist me in an capacity. workers'comp.insurance. 9
y ❑ 3uilJittg addition
(Nis workers'.comp. insurance S. ❑ We are a corporation and its
required.) o.Mears have exercised their 1U.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of examplion per MGL I I.❑ Plumbing repairs or additions
myself.[No workers'camp. c. 152, §1(4),and we have no 12. oof repairs
insurance required.)t employees.[No workers' I).C]Other
comp.insurance required.)
•.\ray appliumr raw ehwka box rl meal Aw,ml uul the w%lim below ahowine their workers'camp mu lug policy inlla.nanon.
'I1,",owmne who,uhniil this arldm it indicating ihcy an doing all work and than him oulside contractors mime mhmlr a new ailidavil fndi"ing,uch.
$Lmrxtun ttml,han:k this box most auachod an.uWtdun l.hst.huwine the name of the tua•eomractws and their woken'ramp.policy information.
fain an enepluyer that ii pruvidlnX Ivorkert'cumpertradun beturance for my employers, Below is the pollcy and Job site
infonnudnn.
In,umnce Company Name: AQ_*1�..... !
Policy 4 or Self-ins. Lie. it: S)-7 SOG 7 1q_ Expiration Date:
Jule Site Address: L2-/� (kl— Cityistate/2ip: SA)eoll,41A
Attach a Copy of the workers' compensation polity declaration page(showing the policy number and expiration date).
F.idurm to,ccuru coverage as required under Suction 23A of,%IGL e. 152 can lead to the imposition of criminal penalties of a
rirc on to SI,SUU.UO unJ/ur one-year imprisonment,as well is civil penalties in this form of is STOP WORK ORDER and d lino
of up ro S_'iQUO a Jay against die viulamr. Ile advised that i copy of this mAtetrmnt may bu eurwurdud to the 011icd of
lavc,tigatiuns�ti the fIIA fur insurance coverage verilicaliun.
/du I,rreby cerrify/tosd�er r th pu is andimliald el,ifprr%ury shut the infurnwNum provided above it irut,urd carrrcr.
i :rntt r hJ / ' r c%`4qLt/K�N� Data: `2'oto
zQil
!official rue.ndy. /7,r not write in th,:e area, to Se completed by city or tuwn n/Jit'iaL
City or 1'.nen:_ _. _ . _. I'crntitiLiceme i_._. .. .._ _...
1••uiii-Authorily (cireld nnc):
I. llo:rd of Ileallh !. Iluilding Dep.lrlineal .1, ( ityi roan Clerk I. haeetrlc.11 loyrc,tor i. phunbin4 Iutpeeror
G. Other
Lunl.l,l I'crum: t hone .h
CITY OF S.u.Eai, AUSACf- USETTS
ilt.tLncvc Dep.�rtntF.�r
I _0 '.IV.U,4CVOTON STAE.XT, jy FZOO,1
IUJ11ERLBY OUSCOLL Fkx(973) 740.9W
MAYOR i aumST.?MAAS
DIRscroaOitptBLICpROpjATY/at; .00YCC01c11ISdt0.%felt
Constructioa Debris Disposal Affidavit
(required for aU demolition and renovation work)
fn accordance with the sixth edition of the State Building Cade, 790 CUR section I I I.J
Debris, and the provisions of WX a 40, S 34;
Building permit At isissued with the condition that the debris resulting from
INS
S I JOA.work shall be disposed of in a property
1 I licensed waste dispose) facility as defined by rbICL c
The debris will be transported by: DLAIP 'r2j�1<-
I .JIIf AA,T r(a 1- 3fL-
(M+me ut'hoular)
The debris wi 11 be disposed of in :
fpMn,.e 2 cyn/AJ�Yli9-
ddreu orrJcil,iy)
�nJrure u(�ermit rpplic�nt
�Jili