1 SETTLERS WAY - BUILDING INSPECTION s� The Commonwealth of Massachusetts CITY OF
r« Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Oilq £p "r `
Building Permit Number , x to Apphed• zW
�9]
BuildmgOfticial.(l'untName),, t' a , signafn Dat
SECTION.1>. SITE'INFORMATION :;
1.1 Prop ert Address: 1.2 Assessors Map&Parcel Numbers
/,� r s W
1,! is rhis an accepted street?yesno Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use or Area(sq ft) Frontage(ft)
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system
❑
Public❑ Private ❑ Check if yes[] p p y
" S1 CTION 2:'r,PROPERTY OWNERSHIP'; `
2.1 Owner'ofRecord:
X (,/c/,S ;r Sh LJTE
ame(Print) City,State,ZIP
No. and Street Telephone Email Address
SECTION 3. DE, CRIPTLON OF PROPOSED WORK"(check all that,apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Df*nptio9 of Proposed W k`:
/3CCa75 �/ C�ltialou� Cti/ lil S
SECTION 4: ESTIMATED.CONSTRIJCTION COSTS
[tem' Estimated Costs ? .
Offietal Use Only
Labor and Materials
I
1.Building Building Permit Fae $ "'Indicate how fee is determined
$ 017. C >4
❑Standar City(Tov n Application Fez r '
2. Electrical $ ❑Total P>olect Cost _(Item 6) emultiplier x
3. Plumbing $ 2.'.Other. ees $
4. Mechanical (HVAC) $
-List '
5. Mechanical (Fire $ Total'All Fees $
Su ression)
Check No. Check Amount: Cash Amount
6. Total Project Cost: $ .2 (/00. OP O P.atd in.Full ❑ Outstanding Balance Due:,
I•
=Supervisor
ECTION 5i CONSTRUCTION SERVICES
ervisor Licen a(CSL) 2 rWDemolition Sr��A LicenseExp ratio t DateList CSe below)_��No. and Street v Type - Description
` Ustricted Buildin s u to 3d,000 cu. R.
Rricted 1&2 Famil D-
-ii-City/Town,State,ZIP Mon
RCfin Coverin
WSdow andSidin
SF Fuel Burning Appliances
Ilation
Tele hone Email address Dolition
��R..egis,tte�red �Jome Improvement Contractor(HIC)
PY°r R1�la,,l c/ Sn,�t (I�a�s c l �D 3 O&S� 7 /�
HIC Registration Number xpiration Date
HIC Con,Aany Name or HIC istrant Name
�� r�Y1�A -P f
No.and Street
�5d /�e %4 , � e2/oT�a, Email address
Ci /Town,State,Z''IP""11 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 7ai OWNER AUTHORIZATION TO BE COMPLETED WHEN '
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property, hereby authorize (f 2r g/�A�
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWINEW 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 application is true and accurate to tb.e best of my''- owledge and understanding.
Pe./,°r XIi
Printer or Authonzed Agent's Name(Electronic Signature) ate
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. I42A. Other important information on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass �ov�dos
2. When or
work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable roorn 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�
a
CITY OF SALEM, r'as&kCHUSETTS
BULIDING DEPIRTNIE—NT
120 WASHLYGTON STREET, 3aD FLOOR
TEL (978) 745-9595
FAA(978) 740-9846
�.NBOLL
MAYORTHObtAS ST.PIERRB
DIRECTOROFPUBLIC PROPERTY/BU DLNGCMMIMIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Q Please Print Le ibl
Name(Busiix'ss,OrganiratioNlndividual): Pr J- S91
Address: j ;:2 a Y I C/
City/State/Zip: S� 2220 Phonek: GI7.F�= 7f/y'o23�a
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. C]Now construction
employees(fill and/or part-time).* have hind the suiv contractors
2.�I am a sole proprietor or partner- listed on the attached sheet: 7• ❑Remodeling
ship and have no employeea These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. [] Building addition
(No workers'comp.insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.C1 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof rupoirs
insurance required.)t employees.LNro workers'
comp,insurance required.1 13.C]Other
;Any applicam that ch�tiks box at must also fill out the sectiw blow showing their workers'compenaa°n policy infurmadon.
t I hwnvorrtes who submit this anidwit indicating they aro doing all work and than him outside contractom must submit a new amdavit indicating such.
:Cmtmcton that Owk This box must attached an addittutud ahrae showing the name of tho suS.aintndon and their wurken'camp,polity information.
I am an employer that laproviding workers'compensadon hisurance jar my employees Below Is rho polley and fob site
information.
Insurance Company Name:
Policy 4 or Self-ins.Lic.Il: Expiration Date:
Job Site Address: City/State/zip:
mtach a copy or the workers'compensation policy declaration page(showing the policy number and expiration state).
Failure to secure coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 S230.00 a duy against the violator. Ile advised that a copy of this statement may bs:forwarded to the Office of
Investigations ofthe DiA for insurance coverage verification.
1 do hereby ce y rat der that u1. and pm fifes of perjury that the firfurmuNon provided above is true and correct
Siemuurc: b� )ano'
Phone qY- ?VV-aQd��
Official use wdy. Do rat Ivrite in this area,robe completed by city or town afflclat
CitynrTuwn: __ PermitR.lcemeft
Issuing Aulhorily(circle one): ---`_-
1. Uourd of health 2. Building Department 3.Cityffown Clerk 4.Electrical inspector 5. Plumbing Inspector
6.Other __ ------
Gmlact person:
......... Phoneti:
CITY OF SM.EINI, NWSACHUSETTS
BUILDING DEPARTMENT
} ' a 120 WASHINGTON STREET,31D FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI.%BFR1 F.Y DRISCOLL
MAYOR Z�IoatAs ST.PIERRI3
DIRECTOR OF PUBLIC PROPERTY/BUIIDLNIG CON12MISSIONElt
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A a slicant information Please Print Lei 1
Valnc t0usin"ysgrganiration/individual): �� It� /G/
Address: Z2 &I L'o -sr
'57City/State/Zip: u/.��c7 0/'-"0 PboneM: 9?�=7y�/—O23d'a
. Are you as employer?Check the appropriate box: 'Type of project(required):
I.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.;Lain a sole proprietor or partner. listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in my capacity. workers'comp. insurance. 9, ❑Building addition
(No workers'comp.insurance S. ❑ We are a corporation and its
required,) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'camp. C. 152,$1(4),and we have no 12.E] Roof repairs
insurance required.)t employees.ENO workers'
camp.insurance rcquircd.) 13.0 Other
Any applicant that chooks box o I must also rill uut the section W.ow showing their wotkms'compenndo s policy infiemanon
!I t weuwm"who submit this affidavit indicating they am doing all work and than him outside contractors most zdmdt a new amdawil indicting such
:Cuntraotors that chmk this box must anachod on additional shoot showing oho none of the subcontruiom and thele workers'romp,polity infomutot.
I um an employer that Is provldhrg workers'compnssadon insurance for my employees. Below Is die pulley end Jab site
fnfonmaflon.
Insurance Company Name:
Policy 4 or Scif-ins,Lia H: Expiration Date:
Job Site Address: City/State/Zip:
Attach 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 ofMGL c. 152 can lead to the imposition of criminal penalties of a
line up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a fine
of up to$290.00 a day against the violator. Ile advised that a copy of this statement may but forwarded to the Office of
Investigations of the DIA fur insurance coverage verification.
I do hereby ser uder rhuRulns r/n ries ujprrJu that rive fnjunnudon provided above is true and correct.
Si�n�ttttr • [��lj/�.(//�/�ti
Data: /D,Iy/g�9lP—I/3
P n
OJjlcial use wdy. Do not write in thhr urea,to be completed by city ur tows oJJlclut
City or'ruwnt PermitMiceme N
Issuing Authurily(circle one): --'
1.Board of Health Z. Building Department 3.Cityrrown Clerk 4. Electrical inspector 5. Plumbing Inspector
6.Other _.
Contact Person: _ _- . ._---.._ Phone tt:
i
CITY VA JME.Nf. 1 LAsSACi3 SE— LS
BL'ILDLIG DEPARTMENT
' N 130 W.1,SHINGTON STREET, 30.0 FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KimBERL.EY DRISCOLL
AMRTHOMAS ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COS0IISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 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 NiGL c
1 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
sw sce s�
address of facility)
signature of permit applicant
i ate