12 SCOTIA ST - BUILDING INSPECTION 30
11�\ The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
W� Massachusetts State Building Code, 780 CMR SALEM
Revised Nfar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A pjied:
Building O tTicial(Print Name) 1-- ' nature
SECTION 1:SITE INFORMATION
1.1 P o erty Address: 1.2 Assessors Nlap&Parcel Numbers
l� C, ,,q I* Nz;
I.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
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 yes❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
�me(Print) City,State,ZIP
Z T 4-rrt C.17 ,��. 7 S7o19
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 2( Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': p fN
S Q. F--T
w
SECTION 4: ESTIiNIATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ — I. Building Permit Fee:$ Indicate how fee is determined:
v. Electrical $ ❑Standard City/TownApplicationFee
--
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ O —' o. Other Fees: $
4. Mechanical (FIVAC) $ List:
5. itlechnnical (Fire $Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:_
6. Total Project Cost: $3 t ❑Paid in Full ❑Outstanding Balance Due:
e
MAt Lk=eQ 70 i AC Prr�1��� (2 I�
rt
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) cyn-7 Z /v
I IZp�i( (� License Number E.epirution Date
Name of CSLCSL Flo ^ l./
�� List CSL Type(see below)
Nu.and Street Type Description
['rl/o` &I /97O U Unrestricted 2 Family
D el ing cu. R.
d l-cJLL ( `_�9 R Restricted 1&2 Famil Dwelling
Citylfown,State,ZIP M Masomy
RC Rooting Covering
WS Window and Siding
/� ��✓� SF Solid Fuel Burning Appliances
✓ [ Insulation
Telephone Email address D Demolition /
5.2 Registered Hpoomee Improvement Contractor(HIC)
/ ' D U(go HIC Registration Number Expiration Date
HIC Canp:m Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.r. 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 .......... UZ 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 A,1,941,e� 726 j�6 5,
t9 act on my behalf, in all matters relative to work authorized by this building permit application.
' Print Owner's Name(Electronic Signature)U IDate
SECTION 7b:OWNEW ORAUTHORIZED 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 or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. 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 can be found at
www.mass..gov:'oca Information on the Construction Supervisor License can be found at www.mass.eovAlps
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) 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 SiuLEm, ,NL LASSACHliSEM
BUILDING DEPARTN NT
120 WASHINGTON STREET,3"'FLOOR
TEL (978) 7.45-9595
RLY(978) 740-9844S
KlNi-BERI.EY DRISCOIL
1'L1YOR TrlontAS StPtxRRs
DIRECTOR Of PULIC PROPERTY/13CII3JLNG COn6\IISSIONER
Workers' Compensatlon Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
APulicant Information J / Please Print Le ib_y,
Name(BusiTxs>OrganirationAndividuat):
Address: /+ /-"/
City/Statc/Zip: Phoney: 2 033
Are you as employer?Check the appropriate box: 'type of project(required):
I.❑ I am a employer with O 4. ❑ 1 am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time).* have hired the sub-eantractorx
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working.fur me in any capacity. workers'comp,insurance. 9• I]Building addition
[No workers'comp.insurance 5.0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption par MGL 11.❑Plumbing repairs be additions
myself.[No workers'comp. C. 152,§1(4),and we have no 12•E] Wrepairy
insurance required.)t employees.(No workers' 13. Other_(ZC I-fies
comp:insurance required.).
•Any applicants that chicks box kl must ciao fill out The soctiao below showing their woskms'oompousubm policy inlem atlon.
s I htmeuwm n who submit this affidavit indieaing They an doing all work and then hint outside cantmcton must submit a new alIIJavit indicting such.
:Commvton that chcsk this box must attached an additional ahset showing The names of the subeontrsenors and Thahr workers'comp.policy into motion.
I um an employer that is provlding workers'compeoratlon hrsurancejor my employee% Below/s the policy and Job site
iujorura0on.
Insurance Cantpany Name: Q a
Policy 4 or Self--ins.Lic.tl: �7t" J ow ""f'F Z•7�/ 'C/ — Z fj pimtion Date:_Zez
/ —
Job Site Address: [ L� )^GO r/I¢- S(_ City/Stale/Zip:-
Anach a copy of the workers'compensation policy 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
tine up to S1,500.00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a One
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be rorwarded to the Office of
Investigations of die DIA for insurance coverage veritieatiun.
/du/rerrby cenljy corder s pu mr pe !Ikea u er injurnrudat providrJ ubav is I us and correct.
i
Date;
r t ,/ O
OJJlekol use u,nly, na nor write in this area,to be completed by city or town offtcloL
Ci nrTown• I
ty ___ Permitli.lcemall _ __
ksuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/fown Clerk a.Electrical inspector 5. Plumbing Inspector
6.Other
Contact Person: Phoned:
)
CITY OF SALEM, INLxS&kCHUSETTS
' BuLMLNG DBPARTMEINT
N 130 WASHINGTON STREET, 3" FLOOR
T EL (978) 745-9595
FAx(978) 740-9846
{q.Ni3FRi FY DRISCOLL
;�4YOR THO:NtAs ST.PIERRE
DIRECTOR OF Pul3LIC PROPERTY/BI. LDNG CONNIS5IONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
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 be disposed of in a properly licensed waste disposal 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 :
ktbw� sVe� ---
(name of facility)
(address of facility) `
i
gnature of permit applicant
lZT
ate