15 SCOTIA - BUILDING INSPECTION 1
_ --- I'lie C'onunon weal lh of biassachuxns
1 I / 1: hoard of Building Regulations nnJ Slandards CI'I'1'OF
11L 1. Massachusetts State Building Code.'780(WR SALIM
Building Permit Application 'fo Construct, Repair. Renovate m
Or Demolish u Heri.roJ
(Ina-or Two-Funlilr L)mellimp
This Section For 011' ' I Use Old
Building Permit Number: D e Applied;
Iluildiny OI)iciul(Print N:une) Signature yDale
_
SECTION 1: SITE INFOR31ATION
I.I Pro erty A�Idress: 1.2 Assessurs slap di Parcel Numbers
!S� SCv-/iA
I.Its Is this an acce ted street? •a no Klan Numhcr Purcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Coning District I'r,poscd tlse Las Area Isy III Frontage I II)
1.5 Building Setbacks((I)
Front Yard Side Yards Ruar Yana
Reydred Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1.c. JU,§SJ) 1.7 Flocs one Informations 1.8 Sewage Disposal System:
Ihabllc❑ Privum❑ Zane: _ Outside Flood Zone?
Check it es❑ Mwieipal❑ On sits disposal s)stem ❑
SECTION2: PROPERTYOWNERSHIPI
2.1 Owners of Record:
'�Q1Qa1 ���sJtjr�
Naune(Pnnl) City.Slate,ZIP
Nu.and Suvel rdephuna Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Constructict E.risting Building O Owner•Occupied ❑ Repafrs(s) ❑ Alteratton(sl ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ .Specify:
Brief Descriptionofproposed Work':
SECTION J: ESTIMATED CONSTRUCTION COSTS
)tens Estimated Costs:
(I abur:md.Malerials) Official Use Only
I. Building S 1. Building Permit Fee: f Indicate how lee is determined:
2. 11wrical S ❑Standard City!Tuen Application Fee
❑Total Project C'ust'(11em 6)x multiplier r
1. I hushing S s
_. Other Fees: S
J. \Ivolal ral ill\ \('a S List:
\tKh.anli•d iFee '- -- ------•— -- --- . . .
`u,uesiuni S road \II Fees: S — —
n I'mil Project Crest: S /410 02M ( h"k No. _._-_( heck
C3 Paid in Full Outsrmding If,al,ulve Due:
7 der 4,54. w
4 15
t
SI:('I'ION 3: CONS'I'MICTION SYR%"('FS
4.1 Construction Supervisor License(C S4-) p y ys3 y !U 3
/ — — - I\oralioo Dote
y41 �,�,/ I iccnx Nunther I
Jai 1 �-. .- ..
oneo•l'CnSI. 11nlder J ) I »I('St. 1')puiscchclu,.l.__._—._ _-- _
��I G�' IJJIye - I)pc I)eicripliun
--J ---- - - . ..—_-
No. .lndStreet __— _--. I1 11nrestricicd IUuddhiis Ii to li,lllln al. It
L 1p, � .pz�f'7 Z ___—_ . . R Rc.trided IR? 142"' IA,allin
W �I �huun
l'igi I'oan,Skit¢.LII'
RC Roidin l'u,aria
µ'S µ'indttw and Sidin
SF SaliJ Fuel Mnin org AFpliances
179� 1263 �A7�IS-AJAK� E/-/a fwi , li»ulutiun
b Email addns D Drnullition
1'ck hone
1,2 Registered Ilume Improvement Cuntntctar(NIC)
II,C Itc Itruljun Ntlllt,.r ligiirotwn wig
I IIC lbmpalq Nante or I Ill'Iteyistrultt Na1119
limail addross
No. wid Street
Ci (town,State ZIP
fdc hone
SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.1.e. I52.1 2SC(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 .......... 0 No i7
SECTION 7a: E11
.11 AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, 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.
Data
14int owner's Noll IElwwnic Sianulum)
SECTION 71s:OWNERI OR AUTFIORIZED AGENT DECLARATION
By entering lay 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.
1160 1 hi nci i or.\othon/vu,\vnt'.i N;uac 1 I!Icctnmic Siyn;dun)
Dow
VOTES:
I. .fin owner who obtains a building permit to do hither own work,or an owner vvho hires an unregistered contractor
Inut registered in the Hwne Intproventent Contractor IHICI Program),will nu have access to the arbitration
program or guaranty fund under\1G.L.C. la'_A.other intponant information on the HIC Program can be round at
n,t.. I Information on the Construction Supervisor License can be found at,1 ...•1" S:" '111,
2. µ hen substantial work is planned, provide the information below:
total Moor area t sy. It.l . ____.._I including garnge, linishcd basement attics.decks or porchl
Habitable roost count _.. .
Groin living area l sy. tl.l . Number of bedrooms
\umherol Iirvpiacci .. -- Number ofh;dl'hath'i
\umber olbathrooms
\untherol'Jaks• pardtci
I\lie of he.tlntg iy Stem ..
I\Ile,dcoallW. :,,item
I'ndo,ed Ilpen
I
t ..1*, tal l'r„jed Isquare fool-We' 111;1\ be :uh�tituliJ tin"total I'mj¢il Co,I"
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy
LOCATION /5SLU DATE--��� ��
ASSESSORS DATE "7 o 1Z
v 93 Washington St.
CITY CLERK DATE
93 Washington St.
PUBLIC SERVICES DATE i
120 Washington St.
WATER DATE
120 Washington St.
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNING DATE
120 Washington St.
CONSERVATION DATE
120 Washington St.
ELECTRICAL DATE
48 Lafayette St. Q
FIRE PREVENTION DATE
29 Fort Avenue
HEALTH n DATE
120 Washington (y�
BUILDING INSPECTOR DATE v
120 Washington St.
k
CITY OE S,V-&Ni, AUSACHUSETTS
dLLLDLNG 0EP.1RT3tLNr
I 'u I,1 UMLNGTON STRpgT, }'O FZOOI<
rM t973) 745-9509
K1313F A F AY OAUXCL L P,Vt(973) 1 t49&W
N YoJt moxwST.Pm"
DlitacrCA OF PC BLIC PROPIATY/BC QDLVG Comms310N ex
Construction Debris DIV01131 At'ttdivit
(required for aU demolition and renovation work)
fn accordance with the sixth edition orthe State Building Cade. 190 QN R section 111.1
Debris, and the provisions of,MGL a 40, 3 54;
Building Permit a is issued with the condition that the debris resulting from
this work shall be disposed of in a praperly licensed waste disposal facility as defined by NIGL a
I 11. 3 150A.
The debris will be transported by:
Ck3el_R
(n,+ma of hauler)
rho debris will be disposed of in
(name o%(uil��y) ..
(rddras of frcil.,y1
c
❑fn�mreufpermitrpph� nf
,:pie
t� CCCY OF S.11l.LEm, A SSACHUSE-ITS
t 1J BUILDING DEP.IIUMENT
120 W.UHNGTON STREET Joa FLOOR
TM (978) 745-9595
F.kx(978) 7 498.16
.<I.\l[3E,U.EY DRlSCOLL
AY0A 'M USST.PIE_.U.1
DIRECTOR OF PUBLIC PROPERTY/13ULDING CONNISSIONEA
Workm' Compensation Insurance,%lVdavit: I)uilders/Contractors/Efectrlclans/Plumbers
linolleant Informatlnn Please Print Latriblr
Mu Tic llhuitac,�Ureamnlian lndividu.di: SA e KI_S
Address: z I
Citylsratc/zip: Wti6efo, 'i 1�°• n I?z PhunttN: (fl17 9 IS, -Iz6�
Are you an employer'!Check the appropriate boxt E
f project(required):
1.�] I am a employer with 4• ❑ 1 um a general contractor and IMatt,construction
ntpinyea(full and/or part-time).• have hired the subcantrsetars
im a sole proprietor or partner- listed on the attached.4hece. tRemodeling
t/ \hip and have no omployecs These sub-commotors have Demolition
working for me in any capacity. workers'camp.insurance. building addition
(No wurkcrs'.camp. insurance 5. 0 We are a corparstion and its
rcyuircd.l officers have exarcised their Electrical npsits or additions
J•❑ 13111 a homeowner doing all work right of exemption per MOL lumbing repute or additions
myself. (No workers'camp. C. 152,4101.and we have no oof mpoirx
insurunea«yuireJ.l r umpluyeee. [No workers, Other
comp insurance rryuireJ.j
•.vuy applk:ud dud divoks boa r I most lwa fill out the...:Iiva bafaw ahawial Chair rmksat'Campenudun utlo4
'I hMYuwAT Nha.ull-nil'his rmlblvil fndlralnx they are daina all twrk and then hit*"tilde rammrtons mast 1001111 new anrdavil indicainx.udL
t'•�mmawn that chock this box most aluchud an WdlnunW.hat,huwine 14 Awns of the mb.unlrsctor*and thatr workers'wmp,pulley infomudoe.
I inn un rnrpluyrr thur Pi pravhllnX workers'cumpauarlan Luurunaejear my elnp/uyerx Bdaw Is r/u policy and Jub site
inlarnrrtrinll.
In,urance Company Name:__
I'olicy J or Scif-ins. Lic. to: Expirution Date'
Jub Site.Wdruss: Cityisfute/zip:
.httacb •copy of the,vorkers' compansatlae policy declaration pigs(thawing the policy number and expiration data).
Ih'.liluru to sccuru coverage ay required undur.Seclion 21A ufblOL c. 112 can laid to the imposition oPcriminal penalties oPa
:i.:e up to 11,500•00 und/ur arse-year imprisonment. as%veil as civil12MIllos in the form ul'a STOP WORK URD n and a fine
❑(up fu$250.00 a Jay Igainst file violator. Ile advi.,ed that A copy nPthis,141emcni may b.a furwurdv to fire RDE of
I,n r,ligatiuns ui th r71A Gar inauran Ce covuage vcritiealiun.
/du lrnrby coot/y nJ,rr the pint m1J prnsldri i/perjury Jiur the i,r�ur•nr.nlmr provided uGuv.r iv True,11fJ a•onrrt
�19- F69 -1Z�
l7//iri�l u.e,nay. /7,r n„t w,it•in thin:one, lu Se runrplNttJ 5y cloy or to rvn�,jJ/ciuL
Gry of 1'ttwn: -_. i'cnmitr Llccme i
h,ui,ty.\ulhorily
I. L'uurd of Ilealth !. IluiLling I)rp.t rltnent i. ( ilyil'nun Clerk I, I.ire tric.tl In, uco
4. Uth.•r I tr i. It ll ,,fit In.pec t�lr
l�n�t Lril i'cr,ur.: