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69 SCHOOL ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR,716 edition OF SALEM Revised January Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling 1l\ This Section For Official Use Only ry�.l Building Permit Num er: Date Applied: Signature: Building mmissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 1.,}Prope�'�'Address: 1.2 Assessors Map&Parcel Numbers f � SChmfJ� 5f l.la Is this an accepted street?yes no Map Number Parcel Number 13 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 Rent 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 ifyes❑ SECTION 2: PROPERTY OWNERSHIP' s 2.1 O e� Recor :AI l9 �� 66/1(, keG7 A l� Name(Punt) Address for Service: Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction - Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Specify: Brief Description of Proposed W ork2: e CC Cl U SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ (30 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:$ 6.Total Project Cost: $ 12 Check No. Check Amount: Cash Amount J 90O 0 Paid in Full 11 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) (r� 1 0 00-- 26_a©tr/ Rtfz�1T P bO �\C/tT" License Number Expiation Date Name of CSL-Holder List CSL Type(see below) 7� �S(S lnnun �O NO �/L�e� Wo4li, T e Description Ad 'hE f /r— r /� 3 t U Unrestricted(up to 35,000 Cu.Ft. R Restricted 1&2 Family Dwelling i store M Masonry Only &2-1=7G.�— 3�S t RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2�fJtt�epistered Home Rp em�ep Contractor(HIC) ac Ir ('Jl�l`��-T�1 HIC y Name ��Registrant amine `Reegistration Number Ad AN -- I( �3_���3�-r Expiration Date tare 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 AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I , as Owner of the subject property hereby authorize 'o h o �''f t/ to act on my behalf,in all matters relative to work authorized by this building permit appli n. 9r 6Z b I I Si of0 er Date SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION I 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. Print Name Signature of Owner or Aathorized Agent Date Si ed under the and nalties 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 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 I I0.R6 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( 9Ft.S . 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" i CITY OF SM-F-11, NANSSACHUSETTS BUILDING DEPAMOUNT 120 WASHINGTON STREET,3t0 FLOOR TEI- (978)745-9595 FAX(978)740.9946 KINIBERLEY DRISCOLL MAYOR THObfAS ST.PlERRfi DIRECTOR OF PUBLIC PROPERTY/Buml)LNG COMMSSIONES ♦Yorkers' Compensation Insurance Aftldavit: Dtulders6ContractersfEteericiansfPlainbm Applicant Information / I'llean Print Legibly Name(Business organizatiaN4ndivedval): nnti l'trQ.iC�� Address: ��b lAn34 Vot�'to 0s2a--14 W.9t-( n City/State/zip-, , 1YK 0 3/0 9 Phone#: (�03- /FS`3-0-5- Are you an.employer?Cheek the appropriate box:- Type of project(required} 4. ❑ 1 am a contractor and.L ❑New construction 1-❑ I:amacmployerwit$ � general g layees(W and/or part-time),* have hired the subcontractors 2 I am a sole proprietor or partner- listed on the attached sheet.➢ 7. ❑Remodeling ship and have no employees These subcontractars have 11. ❑Demolition working for me in any rapacity. workers`comp.insurance. 9. ❑Building addition [No workers comp.insurance S. ❑ We are a corporation and fa. I0.0 Electrical repairs or additions required.] ot'frcets have exercised their 3_❑ 1 am a homeowner doing all work right of exemption per MGL L➢.❑Plumbing repairs or addaioas myself[No workers' comp. c- 152,$1(4),and we have no 12,.❑.Roof repairs insurance required.]t employees.(No workers' 13.❑Other comp.insurance required.) 'Any applitma that dleCks boa 91 must ahw fwa ma the+secrion bdow showing their wwktaa`wmpenaatiwt policy information.. r I hmumasen wha submit this affidavit indicating they arcdoing all work and the hire masidremaractms must submit a emv awdavit indicating weh, =C,nA— nt that cheek this bwt must atraW,,sddiritmal,lion showing the ewtm of the sub.euntrae4xa and:their mwkwa'as lnp,.policy inrem ado$, arrt ort rmployrr that&presorting workers'ramprnsatiort irtratrancejar my empioyeex Below is the pollay rtndfob st)e injorarmioaa insurance Company Naintr Policy 4 or Self--ins.Lie.#: Expiration Date: Job Site Address: CitylStawizip: attack a espy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Scclion 25A ofMGL c. 152 can lead to the imposition of criminal penalties;ofa fine up to SI,560.00 and/or one-year imprisonmcnt,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to S250.00 a day against the violator, Be advised that a copy of this statement may be forwarded to the Office of Investigations,al'the DNA forinsurance coverage verification. l do hereby rrrt r der the pal art xa flu of perjury that the ferjarowroort provided above it!rare and corrrK m.r t t}ate: O O pffrial use only. Do not write in this area,to he completed by city at rower official , City orTownr _ PermiULlcense# ___ ___ lsauing Authority(circle one): 1. Board of flealoh 2.Building,Department 3..Cilyffown Clerk 4:.Electrical Inspector S. Plumbing inspector 6.Other . ---- Contact Person: _ _ Phone#: ] ROBERT P DOHERTY '" 250. LONG POND'BROOK WAYS a a MANCHESTER, NH Mio9 , c�- iy - ..•. 'Xpvatxon: 8128Mi1 t'onuni.<pmrr TM: 2497 f� i tlrvrdul use only Licgnse or reArstrstion vsLB ib.Yitd found retgrjo;. ibef4!'f.F°C d��5310YddA `r, CONTR �� d Stau3ei'd5' A!GTVR� 3. B,oaYd f$,+,u1d1n tnce f3o� d e)2 b 28'1798 Io�On,�V1u 03108 r _ Ono• P DWERTY ; pOFfERTY = Nabd wRhoak Pst4re nr" 2 LONGPE)N045� SAKIPAY ESiEF `!NkF0310�3'°• C to )+ .;pdssroisustor i Lifetimle Energy Me the homeowner(s) of the premises mentioned, hereby contract with and authorize you as contractor to furnish all material, labor, and workmanship necessary to install and place the improvements according to the specifications, terms and conditions, mentioned below,described with reference to which we warrant are the record holders of title. street City: Salem State: MA imal � I I holm i I I °�sasi:=� IiTiS'vieit'aiies ; j I �i.� iirn8 j f I Loior i MIDNIGHT ECLIPSI i/VREA Gi-__.1. Ca no -- I — finllS � � IT CS I �Y.�n11C�it1]f rTrL �Color JGrids I SUP. i I I Screens Rdaze!rent i _ YES Color OH Drip Ede YES Fascia _ 2 L Slider Color 3 L Slider ChimneysYES Li htIS it Casement Skylights YES Color 2 L Case Vent Pipes YES -channel Color Iq Lite Bat, Low Slope to be. WIDNIGHT kILIP511 UCase3ndsfinsulated ulatedSe� Color MIDNIGHT CLIPS Main Hous /N YES ditions /N YES Gars e /N na Seat Porches /N es Buildouts /N es Hardware Color Panel Vent Left/Ri ht Out to In Additional Details a new bird houses to be installed per customer request -•_ ...- ... ing collar new velux sxyu[e wnn flash remove 1 satellite ant and disposal !rs se -1— ntanunnYJ nos _ rl/stnm_er Inra}inn _a11 ma}nri21 and rubbish and yard to be rloa nerl screens provided by customer for us to secure in guttar 1 rharlr mimhor 1777 117 riannei}nairi inriiilinn i ft , rw TOT9 nn Vnil An— tn pay Cash aCCnrr}inr� M the }arms lic}arf ahrrnro nr if n�fr rrnlfi}ig arnrnmyar} vnv+agree to make ayailahla Il7e funds aS a Hach r}onnei}nnn}rari sio page in worK a.ae to ine'Dreceding, wiii delay Cortipielion of the job. `rs}from }ha r}ata navmpnt i-c rfl Ip At}ha annnat ra}p of inal uoouiGJJ ua uuv.rul ar"`i u++ ui Y c ay i++ iwin..+n, u u ` ...0 aid v+iii adii iJ "'o u5 iiii-iiii UUSiS ii ii:U:icU a5W rii6+ aJ l y y Yv yi�:c i++.•i yUu yv }+ y rlafo ni'nanna0afinn fnr{hp materiaa/c anrf/phnr n/nc ^.FC/ nf{hn nrirp nn fhic rvr ''''' ..- p Ynpn cps I' r=.•.K7lnn r pMrO.art '.nrn ! -c roq.0 fn ,T !Penn , !?nnprcronn.nor nv toe enr! !t 1.-ei �!:!P e.. ••fE!erase .r.:.•Vu 4 ..rvn f ❑n.- hn.n ,•fn,m ran- T -::r e3::,n n-:,.-.�-lnnnn_ ,e_u},y fh_n 1 n_n hl_n I 1 -�qn Vn n fhnf, :I01 n n.f.ininnf6 nfn nln rain of fhn nlJnnhln ..+ ninnfnmr•n, nfv Thin n of u,. .a.... ..i::...a driz3 :;3 LIMVVI You /"iiv r:i nurf1 this auror-Foeln it it ohs- (1Ye11 Sionrin fiv par1Y therrtn at a Warp nthpr than an ar}rrrpns nt The rr-Her_ __ __ ___ - . r.Yax_ Y.i_ia .Sf:._.__ __ ...:_ ....v .... r.�i a . . . . . • .... _-,.u__` _ '. ::_..t_:J _4.,:a:!_rs�:+ -s ..S, :!sl:.,.+. ::• �-a__.y_> >_ -44F:.! h..ni.enee ,inv fnllnurinn�6p ""•,••-'••_:-: :. tarn«e+n .Sd_r-..a raw aYe ...._.._____ .-._.. _.._-_.___ a.o-rr+e. .lull .uss.r a..u.. r-:-u:8"" . ... auux Y•aYwue.ai ww w..v.erYYy snr ._ c=_;�_• - s yr vy i , . e,.a yr ., p 0914 I{lilji Vi U005 391 CCi11ClIL. 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