2 SOUTH ST - BUILDING INSPECTION • 't
a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR.,7"edition OF SALEM r Revised Junnon•
Building Permit Application To on truct. Repair, Re ovate Or Demolish a /. zotAY
One-or/Two-Pumily Dwelling
This Section For Official Ve Only
Building Permit um6err: D to lied: n
Signature: "�Yk'*'
Building Commisi d Inspector of Buildin Date
SECTWK I•SITE INFORMATION
1.1 Prope Adess: 1.2 Assessors Map& Parcel Numbers
lJdr
y
1.la Is this an accepted street?yes V-�-no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions-.
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if esO P� y
SECTION 2: PROPERTY OWNERSHIP'
2. wnert of RecAro y S T
Name(Print) Address for Service:
t
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied O Repairs(s) O Alteration(s) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other O Specify:
Brief Description of Proposed Work': (ten.n < T e7l-e-f / Z >- / 6 of ¢c ('
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OIIIcIal Use Only
Labor and Materials
I. Building ( 6 rand. at 1. Building Permit Fee:S Indicate how fee is determined:
Cl Standard City/Town Application Fee
2. Electrical S O Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IfVAC) S List:
5. Mechanical (Fire S
Su ression Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S 6 Rap 4 i tYJ O Paid in Full O Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisoor�(CSL)_ 6 2 Z 3 V P _ Z0 _
C9/) S / License Number L Expiration Date
N/a�me of C/SI�.- I lulder /� I.ist C'SL Type(see below)
5 4a" I C L f�,a¢-7� (5 c�
T De I Description
Addre U I Unrestricted(up to 35,000 Cu. Ft.)
R I Restricted 1:2 Family Dwelling
Signs M M Only
�— RC I Residential Rooting Covering
1'elepht WS I Residential Window and Siding
SF I Residential Solid Fuel gaming Appliance Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC) 1/ A O 3 Z
111C Company N e6r IC Registrant Name Registration Number
Address e,
S l a 1 /
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 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...........O
SECTION 7a:OWNER 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.
Siarraturc of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
(U—j ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Si Ow o uthorizcd Agent Date
under t ains 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 l0.R6 and 110.115, respectively.
'. 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/b21hs
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"
III
CITY OF S.�I.ENis lWSACHUSET M
XMDCIG DEPARTMOOT
120 W.\immTOn Mast 1"ROOK
Tti. (978) 14S.9595
F.�x(97ZA J�49baf
KJJ®CA"Y DRISCOLL THOJAU Sir.ftim"
MAYOR OIRWM R Of R eLIC PMOPEpiTY/st'RDNG COSORSSMN Ei
Wurkers' Cotepsnsstlon Insllrance A ffidsvit: guilders/Contraetora/Elttet/lclsnsiPlunlilers
r,Irnllcant Informal olk P11, iTrint Ledbhl
ValnelYwur+r�r{M�fanowlnJv�diW1:��L��i'Q o- ��n i.,i
Address: `l /sJ, T(-G, r rY34-r- ad
cily/stalazip: . {'nR l 4 �o i'11o11s w: Cl'2L Y2 '1 1
.vie yea as empbyw!Clients;the app boss Type or Project(rnVW►M%
I.❑ 1 am a.enplofer wile a. Q I>A a pellsd eoaarse6rr awl 6 ❑Now caaoucriw
etnpla"(�and/ae pare'dowhr have hirer the er►csttrecgsrs
1.Q I am a sob pepriats or pat oleo
IislMaa Ihesl aahisd rbtst= 7. Q Melno;Mlinr
.hip and titi no rmpbynt� These tu►eentrssabn have e Q Demolitlae
%varklrt{ far mr is my capacity. workan'romp.inetreeals. 9. Q guihlhy adddrios
f N��wee coop` in"81106a S. We we a contending alas is I0.❑Ebcaiwl repair,or additiotes
arVka have elberelad their
).0 1 am a hansowear Join/all work ^IiM MenfroPfoa per Mat. 1143 P wMft repairs ar addkbaa
myselL I've workers'comp. c. 13%#1(4),ad we have no 12.❑Roar mpeks
i narranoe nVuieedl t 4mpls2 - IN*wmmw 1 y.Q Otbr
comp,intros regsiler.l i i
'May aPraCMW 1kW eawaa ber rr nrra aY N Iry IW swoon lahw ' Iq tads two caAwwe+ropier intineh++
'I F donna ne oho rub"tab dltarNl tadhodq 16er s tat"JI wM Mil than NO alleirrateanare awa wt6tab a w aIffavif .e&
T.+rrwlww afte cbeeil lob 60 read awarb�M ad�nwd dhoti showing on ow"of ft nt►eeraaws w,ti6r W~not peb iaerawlhon,
/ear sw rw/tlryw rAartrRrar/IbR ItnlrRers'rrw/rnrtlre Gursateepr q raltpolgoes erArr 6/M/Nky aw/�hi elan
injwarrrlaa
In%urince Company Name:
Policy e or Self-ins. Lie.V. Expiration Data
/ob Sire Athlrcu Citydlais,V
.\trace a copy of 1eo worsen'compeasaWss polky deebralbs pap(eessrlq yes ps"esoew ear espbstlsa tlepJ6
Failure to aocum covemp as required under lntcliae 2SA of MGL a. 152 cant lentil to the impaeitien aferiminal penalties are
rpne up to S I.joo.00 and/or one-year impri:nnwnt,as wed as civil penalties is the farm of STOP WOMK ORDEK AM a floe
Of up to S23010 a Jay ayainsl the violator. Ib adviavl That s copy of this atatemem maybe forwarded to dw Olrles of
hn.au aariuta.J'the 171A for inauraneo coveralls v yilktlio a
/�/�hrrr6y rrrd n/N tAr M rw1 yrnrhHs rj/rr/ary rAw rAi in�arrr�dw�nrie6rd uMw is/rw rwI a wrreY
I — Z/ - /O
O/J/rir/rtrJnI/t Or4aMfivisthir der*to1ervempkfdAyairyar town n/�hiM4
City at ruwn: Yrrmif/l.kenrtl__
Itautnt.\uthonly(tirclo unr):
I ituurJ ut llratrh 1. Rveming mpartmvm ). citytrowo Cloth 6. fleciriea/ Impector S. Plumbing Inrprelor
6. Usher
e -
l•.-ttaet Perron; _ _ Phone l:
CITY OF SALEM
PUBLIC pROPRERTY
i " DEPARTMENT
SrwtrI s l\n+r. '11 .4
\I .�. w Irl:-7:M•'IS'!yN �F�<:/7/.:43"1046
Construction Debris Disposal A111davit
(rcyuired fur ull dcmuliliun jlxl renovation work)
In accunlarxc with the si-Xtlt edition of the State Building Code, 730 CMR seetiun 111.3
Debris. and the pro ul'MGL a xis sssued with the condition that the debris resulting ass
UuiWinl{ Permit N l licenx'd waste Jispoaal facility as daflned by
This work shall he disposed of in a properly
ill. S 150A.
The debris will be transported by:
�fj`(�t`►2 � c�8 �r T
flume ur houled
fire debris will be disposed of in
(name uul ace aty .
All,
t:�rlre> ul Cwthlyl
� � e,rrtwrmira(ryli�ant
�- .0
Jalw
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