16 SCOTIA - BUILDING INSPECTION k7luddinj
ofI]uiWing ReguLuions and Standards Cl IN OF
"ilssaehusctls State Building Code, 7SO CNIR SALEM
McII,e,l l6rr JeBuilding Permit Applicutinn TO Construct, Repair. Renovate Or Dcnulish a
Ore,-ur rlru-,`l U:rrllin,hThis Section Fur O icial Use Oni
Permit Number. ate,lpplied:
011icial(Print N:unc) Signature BDate /
SECTION I:SITE INFORh1ATIO
I.I Property Address: 1.2 Assessurs,flap di Parcel Numbers
/p 5Go9i A,
I.la Is this an acce tad street? a no 11ap Norther Parcel Numlmr
1.3 Zoning Information: 1.4 Property Dimensions:
Caning District 1'nrposeJ lJsc Lal Arco(sy III Fmntaga(Ill
1.5 Building Setbacks(R)
Front Yard Side Yurds Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:IM.G.1.c,40.§sa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System-
Ihtblic O Privuta O Zone: _ Outside Flood"Luna?
Chock if es0 Municipal O On site disposal s)stem O
SECTION2: PROPERTY OWNERSHIP'
2.1 Owners of Record, q�n
Matta(11nnt) Csq,Slull ZIP
No.and Sl relephona F.mail Address
SECTION!: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Constructio Existing Building❑ Osvner•Occupied O Repairs(s) ❑ Alleration(s) ❑ Addition O
Demolition t] Accill Bldg, l3 Nnnber of Units_ Other Q Specily:
Brief Description of Proposed \York':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
hem Estimaled Costs:
ILabor and.\laterials) 0MC141 Use Only
I. Building i I. Building permit Fee: f indicate how tee is determined:
`. I'lecirical S O Standard CityrTown Application Fee
O Total Project Coslr I Item 6)x multiplier
S
1. I'lumhing 1 ..— —
_. Usher Fees: S-
J. \le.h.mie,tl ill\ \('1 S List:
Su,vesviunl S rotai \11 Fees: s
I. fatal Project Cost: i P/d) am ('hal. Vu. _. __('beck Annnun: . _ _..l'.ieh \w,nmC
❑P.tid m Full 0 Outstanding 11.11.l Due:
ll)NS: ('0NSFRU("riONNER%'I('FS
S.1 C'unstrurtioil Supervisor License(C'SL1
--- I \"ration Date
�1:IS 1t .✓� k tea I icensc Ntmthar I
N,une ul'CS I. I InlJer Intl 51. 1)pe lsec heluw
I'ypr Descriplion
-No. and Slrcct — I I I1nreslrided Illui Win 6s lu 10 14,II00 al. IL1
P�0-aJ rJ �,q , 6Z L4 7 2 R I(r.tricwd I&I I.unil D"01111
_
Pity i I',m n.Suue,L I I'
RC k,tllhlt l'oserin
H'S Window.md Sidin
ii,, �{ SF Sulid Furl lluming,\pplimlas
1P17-9�� ,243 A2h,s./ ANW/AJeyAt ') ) Insulation
Talc hunt
Email—ad dre+s D Danoliliun
S.2 Registered Ilume Improvement Cunantctor(HiC)
IIIC' I(egist—Number livpiruliun Dalr
IIIC't'ompuny Ndlllr ur I IIC'i(cgistrunt Nanw
limail aJJnlsa
Nu. wIJ SWet
Ci /town,State ZIP file hung
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I32. 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.......... O No t]
SECTION 7a:OWNER AUTHORIZATION TO BE C0111PLETED 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 matte"relative to work authorized by this building permit application.
Data
Print o\voer's Nwne(Electronic Sianutum)
SECTION 7b:OWNER t 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.
Dula
Print D\s ncr'i ur\udnlrireJ.lgcnt's Nnma I lilcarunie Signawrr)
VOTES:
1. .\n Owner who obtains a building permit to do his.her own work,or an owner who hires an nvrgistcrcd contractor
I nut registered in the Hume Inlpruvtunent Contmctur I HICI Program),will io have access to the arbitration
Program or guaranty I"und under\I.G.L.c. l4'_.�. Other important information on the HIC Program can be found at
w,\,\ n .t.. " •v I Information on the Construction Supervisor License can be found at
a \\'hen substantial twrk is planned,provide the innuIlion inclludilbdg garage finished basenlcntanics,decks or rurdiI
Total flour area(sy. 11.) . --- ll;lbitable roum count _..
Grosilivingarealsy. 11.l ._ -
-- \anther ul hcJnun»s
\anther of lirerlaces __ --- Number of hall hotlls
Number"I hathnwuls - . - . . \unlhcr of dccki. porchcs
l\pr of hr.16014 it stcln 1,
ly pr��l'a`uhng iy srcnl
I!nclus.J 1 I en
i .•Total Project Square Pool•lya" may I`c ruba1tt1tcd Ii,r"Total Project C'o\I'.
5J 15-03/ 5-
CITY OF SALEM
ROUTING SLIP
New Construction
Certificate of Occupancy/ l -
LOCATION 1� SCUT/G� ��/' DATE
ASSESSOR— D DATE
93 Washingon St
CITY CLERK DATE '7 75 /l
93 Washington
rp PUBLIC SERVICES DATE
120 Washington St.
WATER DATE
120 Washington St.
CROSS CONNECTION DATE
5 Jefferson Ave
PLANNING DATE
120 Washington St.
CONSERVATION DATE
r 120 Washington St.
` .ELECTRICAL DATE
I 48 Lafayette St. pp,�
FIRE PREVENTION DATE 7 y
29 Fort Avenue
(� HEALTH DATE
120 Washington
-3 BUILDING INSPECTOR ATE
120 Washington St.