17 SKERRY ST - BUILDING INSPECTION The Commonwealth of Massachusetts
i Board of Building Regulations and Standards CITY
�•!y j Massachusetts State Building Code, 780 CMR, Vh edition OF SALEM
t Revised Jurnevt•
(� Building Permit Application To Construct, Repair, Renovate Or Demolish a l• =//!hY
Jw One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Numb Date Applied: 1
(� Signature: U GLYy"' -LP.+,..,. //
Building Commissioner/In ectorof Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors rytsp& Parcel Numbers
I I 551<e r'r4 5T-re,Cr 36- 01L13- o
I.la Is this an accepted street?yes V no Map Number Parcel Number
1.3 Zoning laf6irmatIon: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(R)
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 Isposal System:
/ Zone: _ Outside Flood Zo e7
Public'❑ Private❑ Check if es� Municipal On site disposal system ❑
- SECTION 2: PROPERTY OWNERSHIP'
2.IJVi�t G>' r�C) ("^7
N• (Print) Address for Service: �3
r7�Q �
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': 'Cr •`T IVJ •r
d"A IsTIA7a1_ �Qt+rlclClY 0l6j
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 0171cial Use Only
Labor and Materials
I. Building S 00 I. Building Permit Fee:S Indicate how fee is determined: '..
2. Electrical S ❑Standard Cityrrown Application Fee
❑Total Project Cost (Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees: S
,i Check No. Check Amount: Cash Amount:
6. Total Project Cost: S In *� 101'aidin Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) C S q 7 1 3 t3 -1Q-ZO)O
L'lS '` ,�d License Number Expiration Date
Name of CSL-I folder List CSL Type(see below) U
r �Jerl f- Description
:\dd _ U llnrcstricted u to 35,000 Cu.Ft.
R Restricted l&2 FamilyDwelling
Signa urc _ M Maso Onl
�] c101-7 f SL RC Residential Roolin Coverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home lm@Rrovemeot Contractor(HIC) ) 5 b
rhtW AS ll 0�°r 1� Registration Number
111C Company lalame or IIIC Registrant Name
71 C,H O-r ve-I- _ l - I9'-200
A q-;p8' ga-) �),'� Expiration Date
Signuture '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 ..........V No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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.
Si tore o Owner Dare
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
py— as Owner or Authorized Agent hereby declare
that the statements and information on fht eoe rr going application are true and accurate,to the best of my knowledge and
beha .
Prinl,Nhme
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.115,respectively.
2 When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (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"
CITY
OF SU.EMq NLkSSACHUSEM
BLUMMG DEPART%=iT
120 W.Aal1LVGTON STRM. r FtOOR
TEL (978) 14S9599
FAx(9711) 740-9846
KI.*,®EItLEY DRISCOL L rM0sW ST.PMUx
MAYOR DIRECTOR Of PLOLIC PROPERTY/RLRDDIG COSMOSSIMER
Workers' Compensation Insurance AlRdavit: builders/Contractors/Electr(cians/Plumbers
>nnlleant Informatloes `\ 1 Please Print Letib
y� ht
Nahni Itlu-or.naOrgan,ranon l,wbr,duap: I ►1 q cq S. YO VJ
Address, ^7 1 h 0', ��ST
City/State/Zip l5: e�! Y�14 Phone M: q 7 a g I Z
Are you as employes'Check the appropriate boa: Type of project(requlrea
1.0 1 am a crreploye with 4. 0 1 am a general consistent and 1 6 New cansRtrctiae
employe"(roll and/or pan-time)•• have hind the sob s amraers to
2..U1 am a sole proprietor our pafftnar- lisled on the anached-heel. : y ❑Remodeling
:hip and have no employee Them sutseontramors have 1. 0 Demolition
working res nit in any capacity. workers'corer"insumacs 9. 0 Building addition
I No workers'comp insurance S. 0 We are a corporation and its
requireaLl
ookers haw exeeelsed their 10.0 Electrical repairs or additiorat
5.Cl 1 am a homeowner doing ail work risk of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No waken'comp. c. 152.f 1(4).and we have no 12.0 Roof repairs l
insurance required] t comF i'�INo workers. 13.(a0dav RCCtM S`TrJ01-
comp insurance required.)
•Any apparaw u,ir shwa boa el msw alwr f10 toe the eerie-e.lew ae.iq r6dr'watr..•oaapwg4m puiky in&wmadea
'I I.wwuom,.A who o alma dria aeldvit indicalsoe they most Joins ell work and the his awidr caeteartmn,eons.suhwb a nao atQJwis irdlnaine weft
'r,woru m ohms Avok JJ.6m~a"whod as aJditiwml rice.Aswity do n.tY of ft wdFsa minswe a W,h.ir wwrbrra'come,puti:y,iaa.wmdg►
w0000ll
/ore ae rtwVbyer rAer trPrurJ//n;iwrkers'ro wNwsaleo/warneerjer w2,nnployees Ocbw O tkO"elfin)ewI fat slat
injornrarJwa
In.urance Company Name:
Policy, 4 w Sclf•ins. Lie.At: Expiration Daft:
Jub Site Address: City/StaldZip:
,mach a copy of the workers'compensation Volley declarstlee page(showing the Polley number and eapiradloe daft),
Failure to secure coverage as required under Section 23A of MGL C 152 can lead to the imposition of criminal penalties of
fine up'to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the farm are STOP WORK ORDER and a fine
of up to S250.00 a day against the violates. IIe adviwd that a copy of this statcmcnl maybe rurwa rd d to the OMce of
I ncc,ii V ium ul'ilia n1A for insurance coveraip vuiticaiiom
/Ja hereby c erri y under rh ppdrins a yenwlrles 0/perjury that the inloornrerlow proeiJed ubew is true end cal-feet
4z"IMIUM Adm.
P'n ,i S/ qa- I sZ
O/JIc'ial use e..ly, era nW write in this area6 to be rwnsy/efeal by city or town.r/fktdA i
City at ru,vn: Pcrmit/Llccnrt M__, _
Issuing.\uahonty (circle one):
I. tluard u/Itealllt 2. Iluilding Departmcnd 1. Ciiy/town Clerk !. Electrical Inspector S. Plumbing Inspector
6. Other
L..ntacl Person: _ _ _ Phan,is:
l
,A CITY OF SALEM
PUBLIC PROPRERTY
�• DEPARTMENT
I��.\+111.\1.:�4v�1'M l:rr �)•\II\t.51.Ni.N III J 1.•.1't'.
TFI;4,ry•NS•livs �I'.\s:%TY•T13•'laih
Construction Debris Disposal Affidavit
(required t'ur all demolition and renovation work)
in accordance with the sindt edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit p 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
5 150A.
The debris will be transported by:
c S•
Q% ILJ V''19'r1
The debris will be disposed of in
(namtr ul ace rty
o I��c�' — fl6vg
,Ignature w pernut applicant
datr
GtM S �t��l CT\ 4 VlI
1 Massachusetts- Departrucnt of Public Safctc
Board of Building Regulations and Standards
�J Construction Supervisor License
License: CS 64793
Restricted to: 00 -
THOMAS R DOWDY
71 CABOT ST
BEVERLY, MA 01915
Expiration: 8110/2010
<'onnnis.ionrr Tr#: 1838
800rd of Build ng RgrRe lat n�✓llam¢ .
eguulations and Standards
HOME IMPROVEMENT
Re 1st a CONTRACTOR License or re 9 igtl°n 152663 before t gtsttion d valid for in Expiratlon he expiration date. If found
use only
9/18/2010 Board"Build" return
- q �;TYP,e: Individual Tr# 273255 One Ashb 19 Regulation,and to:
,; urton Rm 1301 Standard THOMASTHOMAS DOWp.r. Boston,Mo.02108
1CABO STRDOWEET,",
1 1 l
71CABOT STREET` `;, .,
BEVERI v r..