76 SCHOOL ST - BUILDING INSPECTION r
�)O The Commonwealth of Massachusetts
FIBuilding
wnof
Board of Building Regulations and StandardsToMassachusetts State Building Code, 780 CMR, 7'"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish arorFtry 1s,Duelling
is Sectio or O icial UeOnly
Permit Numbe ale Applied: zre:
Buildm Comm sinner/ s or of Buildings Date
SECTION I: SITE INFORMATION
I.I Property A��ess:e „ 1.2 Assessors Map At Parcel Numbers
I.la Is this an accepted street,'?ye�'s_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq fl) Frontage(fl)
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 es❑
1etp SECTION 2: PROPERTY OWNERSHIP'
2.1 w er'd—J�vrh V(]AP LbW 7 � SL ffoo/— 9
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check oil that apply)
New Construction❑ Existing Building❑ I Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition 13 1 Accessory Bldg. ❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
--510M FV'n0..=
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllelal Use Only
Labor and Materials
1. Building S I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S 2Do .00 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. .Mechanical (HVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: S D00,o0
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S 0 Paid in Full ❑Outstanding alance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) G 20 e GS 2 /ai 0 Cl
License Number Expiration Date
N;)me ow` iplder Lit CSL Type(see below)
a � Qr-v-U T, Description
Address g � T ^
/< - �� U Unrestricted u to 35.000 Cu. Ft.)
�/R R Restricted I&2 Family Dwelling
Signature M Masonry Only
Cf A- -7Y J—5ZI—J"-2 RC Residential Rooting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) /00 16 7
HIC Company ame or HIC Registr}�t Name Registration Number
Addrc� n _ L_• 61101/6
)6 Q/o, � �C 97�-7sS�Ss�2 Expiration Date
Signature Telephone
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... O 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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 _ e G,e A,& M , as Owner or Authorized Agent hereby declare
that the statements and info ation on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Y Mvlb D IFE/f�PRC
Print Name
Signature of Owner or Authorized Agent Date
(Stared under the pains and penalties of perjury)
NOTES:
rlAn 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�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 IO.R6 and I IO.RS, respectively.
When substantial work is planned, provide the information below:
l floors area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
s living area(Sq. Ft.) Habitable room count
Number of fireplaces .Number of bedrooms
Number of bathrooms Number of hal0baths
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-
f CITY OF S.II.E.Ni, NiskSSACHUSETTS
Bt:BDING DEPAxT.%m 1T
120 WASHINGTON STREET, Vat FLOOR
"IL (978) 745-9595
FAX(978) 740-9846
KI%IBFJtI.EY DRISCOI L
MAYOR THohtAs ST.Pm m
DIRECTOR OF PLSLIC PROPERTY/suaDLNG CO\L%assto.%,ER
Workers' Compensation Insurance Aif)davit: Builders/Contractors/Electricians/Ptumbers
Annlicant Information Please Print Legibly
Nalnt: (RusimvOrganization,lndsvrdual): ka, a.:.. �-�o
Address: T�
City/State/Zip: Phone q: 9 Z.f — 7 V-5 — Ss 2—
Are you an employer'Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time).• have hired the subcontractors 6. El New construction
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9• ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' I;.❑Other
comp. insurancerequired.]
-Any applicaal that Altslu boa 01 MUM also fill Wall Ihs sectim bclws ahawiat their vrorltIo'comprnsatiun policy infurmsdor,
'I Lvrsewnm who submit this aflldsvit indicating they an doing all work and then him outside co urselon must submit a new anidavit indicating soils
{,,mm:ton shot check this bass mud anached an sWitiwnl shies showing the none of tits subaVnnfdon and shalt wvrkem'comp.policy informality.
l am an employer that 2r pravid/ntj workers'compensadon lnsaranee for my employees. Below Is the poncy and job site
information. Q -
Insurance Company Name: A
Policy M or Self-ins. Lie.N: L/, /
C Ce C/s 3-r-2 - 5 Expiration Date: /r2dt'l( i
�
Job Site Address: 7� � l City/State/Zip: 0/.97d-
Attacb a copy of the workers'compensation polity declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Ile advised that a copy of this Matemcnl maybe forwarded to the Office of
Invc>tigatioas of the DIA for insurance coverage verification.
/do hereby certify under the pains and penalthr,of perjury that the information provided above is true and correct
)arc: `F.1 yl c1
Phone 4: k — 7YS �SeP2
iOfcial use only. Do not write in this area, to he,toripleted by city or town offlciaf
City or ruwn:
Issuing Aulhority (circle one): - _ -
1. Illoard of lleallh 2. Building Department 3. City/rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Cuolact Person: _ ___ ___ Phone#:
CITY OF SALEM
PUBLIC PROPRERTY
DEPAR'I'NIENT
III V'9.'41.);"; ♦ I %X 'i'A V_ '!i L,
Construction Debris Disposal .affidavit
(re\luired litr all demolition and renovation work)
In accordance \\itIt the sixth edition of the State Building Code, 780 CNIR scction 111.5
Debris, and the provisions of:tiIGL c 40, S 54;
Building Permit K is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
�ramc tit'WOW)
The debris will be �disposed off in
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'1vilatulcotloluut applicant
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