29 SILVER ST - BUILDING INSPECTION V
The Cumnson%calth of Massachusctts Town of
Board of Building Regulations and Standards '1ommomw
Massachusetts State Building Code, 780 CNIR, Ts edition Building Dept
Building Permit Application To Construct, Repair. Renovate Or Demolish a *kmm IBR
One. or AtvFunuls•Dwelling
This Section For Official Use Only
Building Permit Nu m Date Applied:
Signature: , �^
Building Commissioner/Inspect«of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property A dress: 1.2 Assessors Map 6 Parcel Numbers
I.la Is this an acc led street:'yes no Map Number Parcel Numbs
I../ Zoning Information: 1.4 Property Dimensions:
Zom $Disinct Proposed Use Lot Area(sq B) Frontage I It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
I.f Water Supply:(M.G.L e.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zons: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if esO
SECTION 7: PROPERTY OWNERSHIP'
&COMMMhOn
' rd.
A✓ESMH'/ Address for Service:
Telephone
ECTION): DESCRIPTION OF PROPOSED WORK'(check a0 that apply)
O Existing Building O Owner-Occupied O Repain(s) Alteration(a) O Addition O
Accessory Old$.O Number of Units_ Other O Specify:
Brief Description of Proposed Work': ga&MATE
�v-
f/
SECTION k ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building f /Ot7 I. Building Permit Fee: f Indicate how fee is determined:
O Standard CiryiTown Application Fee
2 Electrical S O Total Project Cost'(Item 6)a multiplier x
Plumbing f 2. Other Fees: f
a. Mechanical (HVAC) f List:_
s Mechanical tFire f Total All Fees: f
Su remon
X Check Vo _Ch ck Amount Cash Amount:_
b Total Project Cost f �a O Paid m Full O Ouisundmg Balance Out
SECTION !: CONSTRUCTION SER VICES
9.1 Licensed Construction Supervisor(CSL)
iikv%6 " 1.Vv�lkh - Licen,e Vumbcr E� taut n Daft
Nyoe1o`f C 11 Led CSL Type Me tk-low)
b v- I✓IA
A s tRDRt1Cs1,'1d'cmisJ
Description
estricted u to 33.000 Cu. F1
�( Signat re tricted 1&2 FamilyDwcll
Onl
denturl Roofin Covering
Telephone Jenual Window and S�dm
ential Solid Fuel Burning A lance Installation
Demolition
3.2}hl0s ✓leroHho Its7 , M7meotContractor(HIC) J3��
HIC pomp faq or HIC R grsuarn� Registration/Number
[piraTan Date
Si Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL f 2SC(6►)
Worker Compensation Insurance afrdavil must be completed and submitted with ibis application. Failure to provide
this at davit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes.......... No...........C
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. L V I 5 as Owner of the subject property hereby
authorize L LA on: to act on my behalf,in all matters
relative W autho ed by this building permit application.
�/# /ID
Si Owner Date ,
SECTION
+ Rt7b:OWNE OR AUTHORIZED AGENT DECLARATION
1.
1, to f l V N 14*- ,as Owner or Authorized Agent hereby declare
Xthat the statements and information on the foregoing application are true and accurate,to the beat of my knowledge and
belies1.
v4
Print
3J��t0
Sign Ow Awhwized A Due
(Sistrinfundri,thepsins and penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to do hiAer awn work,or an owner who hires an unregistered contraclor
(not registered in the Home Improvement Contractor(HIC)Program),will do have access to the arbitration
program or guaranty fund under M.G.L c. 1 d2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110 R6 and 110.RS,respectively.
2. When substantial work is planned,provide the information below-
Total Goon area(Sq. Ft.) f including garage, finished basement/anics,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 holing system Number of decks/porches
T)ptof cooling symerrl Enclo,ed Open
1 "Total Project Square Footage"may he,uh,ntntect for 'Total Project Co,t"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
Ht., •�
\I'.t"n I!Q VP.wnr�c;oNSrnCET 0 5.ur\l, St.\+i.0 nt
I'rl:ws-14 9i95 1'.\!f:978.710-'1846
Construction Debris Disposal Affidavit
(required lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.3
Debris, and the provisions of MGL c 40, S 54;
Building Permit q _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
Ill. S 150A.
The debris will be transported by:
(name ut hauler)
'file debris will be disposed of in
/Vv'9,�
(name ut7acltty
(address of I'acduy)
• � lefll
date
CITY OF S.UX. N[, ,LXSSACHL;SETTS .
BUILDING DEPARTI[ENT
120 WASHINGTON STREET, 3aa FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KIJBFRt EY DIUSCOLI
MAYOR DR THOhtAS ST.PII m
DIRECTOR OF PLBLIC PROPERTY/11CI DING CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r llcant Information Please Print Letibi
Naine (9usirw�0rg4ntzanon lndsvtdaal)! ✓✓ 6 M J,kA-
Address: 10 �wO�w r-� `b� TVA- 610no
City/StatriZip: Phone*
Are yo employer?Cheek the appropriate Iron: Type of project(requlred):
I.3<arn a employer with�_ 4. ❑ 1 am a&moral contractor and 1 6. ❑New construction
employees(full and/or pan-time).• have hired the mtbconoactors
2.❑ I am a sole proprietor or partner- listed on the attached sheet : 7. ❑Remodeling
,hip and have no employees These sub-contractors have V. ❑ Demolition
working for me in any capacity. workers'comp.insursoca 9. ❑building addition
I No workers'comp. insurance S. ❑ We are a corporation and its
10.❑Electrical repairs or additions
required.l officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MOL 1 I.❑Plumbing repairs or additions
myself(No workers'comp. c. 152.41(4),and we have no 12.❑Roof repairs
insurance required.)t employers.(No workers' 13.0 Other
comp. insurance required.I
•Any applicam that ehwb Doer ate meal alw fin me the serum balm stowing their wakes,compensation policy Inwnwion.
'I1,mwme es who submit this affidavit indicting 1hcy are doing all wont and than him ouaside coat=ftee muu submit a new affidavit indicating eack
:r,1n1eo%3U a ghat chuck this ban must attached an addilkmel shot showing dw nmrte of that IutSmaaatas and thelr wwkan'romp.policy infmnation.
l am as employer that Is providing workers'compensation Insareaee jot my emplaym Below le the podry and Job slfe
/nfarmution.
Insurance Company Name: /�z:✓�ni�� �rr�?e t: ��/yX Gp
Policy N or Self-ins. Lic.p: WC &W;L—3f S7720 Expiration Date:: —9 /O ✓o
lob Site Address: n1.l Sl/vIry- City/State/Zip: 41'7v
,teach a copy of the workers'compensation policy declaration page(&bowing the policy number and expiration data)6
Failure to secure coverage as required under Section 25A of MGL c. 132 can lead to the imposition of criminal penalties of e
fine up to S 1,500.00 and/or one-year imprisonment,a well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be rurwarded to the Office of
Inveattgutiuns al'tl insurance covcrago vcriticalion.
I do hereby a rl y under the p i s used una/ is a tr a that the information provided above is true and carrecL
Win•r t it ' Dutc: 9 /O
,
Phone s:
iOffh-ial use aaly. Do twat write ire this area, to be rumpltted by city or town a/JfciaL
City or Tuwn: __ PcrmitR.ken:e M
Issuing Aulhurity (circle une): — —
I. Iluird of Ileallh 2. Building Department J.C'ilylrown Clerk J. Rledrical Inspector 5. Plumbing Inspector
6. usher
l.untact person: _ ._. _.. Phone g•
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y •1,1\.��II IIU.Ii111.11.11 .1. I II,I„l ........
(� Bo4wil of Buildin_ Re_ulatiuns and Standard,
Construction Supervisor Licensp
License: CS 81867
Restricted to: 00
HILARIO M CUNHA
S
10 PURCHASE ST
I
SALEM, MA 01970 7
Expiration: 5/28Y2010
( wmni,.iuner rt/� Epp Tr#: 228160
;�. . BOi♦�19m U�U�UO➢!eU tflU 8rU!
_ HOME IMPROVEMENT CONTRACTOR
Regft"0 in: 138261 f
EaPIMUon. It'
32011 Tr® 281903
HILARIO M.
HILARIO CUNHF�
10 PUCHASE ST
SALEM,MA 01-9 r%"� Administrator
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