24 SURREY RD - BUILDING INSPECTION (2) 0, 'dd �f
I'Ile Conunolmealds of Mass;lchuscus
s Iln,IrJ of Iuilding Regulations and Standards CI 1,1, OF
a•J t�L , Massachusetts Slate Building Cude,'M CNIR SALli\l
Building Permit vocatiun 'ro Construct, Repair, Renovate Or Demolish a
Onv-or rtl-'). AN/1' Du ,It,,,.p
This Section For Olrcial Use Oni
Building Permit Number. Date Applied:
I wldinS 0111cia1(Print Nmnc)
final ! - Dale
SECTION I: SITE 6NFORN ATION
1h. Propere AJJrna: "
_`D.P� ev✓7er gal
_/ 1.2 Assessor N aree Numbers
I.la Is this an acre ted sheet? •es no �Iap Nunlhur I'urcal Numlkr
I.J Zoning Information: 1.4 Property Dimensional
Lnniny District Proposed(/.w Is
4 11)
1.3 BuIlJing Setbacks(R) Lul Ana Frontage I Ill
F'runl Yard Situ Yunla
RequiredProvidedroviJed Required Side
Required
Ncar Yard Provided
1.6 Water supply,IM.G.1.V. 40,§54) 1.7 Flood Zone Informations 1.3 Sewage Disposal System:
Ihiblle❑ Privule❑ Zone: _ 0ulside Flood Zone,
Check if cs❑ Municipal❑ On site disposal s).vlcm ❑
SECTION2: PROPERTYOWNERSlIIPt
2.1 Ow t
Mane(Print) C•ily,Stale,ZIP
Nu.and Strcel relrphana
Email AJdrcss
SECTION J: DESCRIPTION OF PROPOSED 1VORKa(check all that apply)
New Construction ❑ Existing Building❑ OWner•Occupied O Repairs(s) ❑ Alterationls) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other O 9pccily;
Brief Description of Proposed \Yorks: C/
SECTION 4: ESTIJI.ATED CONSTRUCTION COSTS
Ilunl Estimated Costa:
I(.abur and.\ illerials) Official Use Only
I. Building S CLX) ec,;, 1. Building Permit Fee: S Indicate how Pre is determined:
2. Illecirical S ❑Standard Oty+Tusvn Application Fee
s I'lunih;nq S ❑Tulal Project Cost'(llem 6)x multiplier
I J. \Iech.tnic.:l ill\ \('1 i List:
tns5i0n: S rotal \tl Fees: S
Tutul I'rnjcct CnvC i (hecA Vu, —( hccA .\niounr. . _. .._. C.ish \mounl:
Q Riid m Full Cl Oulsemdinq 11a1.mce Due:
SEC I ION 4: (-ON.SI'Rtic'rIONSFKN'I( F-5
Su -r%isior I-il-clist S I.) s-2
q 'oil D-fle
Number
N.tw x(SI Holder
Desi;ription
�Joo al. 11.1
,Lua-
l: ......suw KC K,,,l... Cot,erin
ttk-illdoo .uid Sidii
Sulij I:ugi Ilurning
SIF Appliances
X 7 I InsululitIn
-------
1'ele baud
I Injiladdruxi
111.2 Registered Ilunif Improvement Cuntruclor(111C) I�1111rllllllo Will
IIIC;tv&j,u;IIiun Number
SS ea/wj
IlIC N1111 I Nam" I 11C It"Aill'al"
Nano
litnail
uddre's
No. Id , wt Pro
_ _ (7) _aL�z
Ci rrown.state ZIP r9I9h92L_
SECTION 6t WORKERS,COMPENSATION INSURANCE AFFIDAVIT(M.G.L C. IS1 I 25C(Q)
Wort rs Compensation Insurance affidavit must be completed and s ubmitted with this application. Failure to provide
this atlldavil will result in the denial of the Issuance of the building Permit-
Signed Affidavit Attached? Yes .......... C3 No...........
...... .............
IpLETED WHEN
...... LETED
SECTION 7a:OWNER AUTHORIZATION TO BE CDliIFLETED
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Owner of the subject property,hereby authorize
1, as IN building permit aPPlic"O"'
lo act on my behalf,in all on ers relative to work audiciiiiedilail y 3 u
1 0 Date eW
prilit Uongir's Nw to Me to"c S' nature)
SFCTi N 7b:OWNEWOR AUTFIORIZED AGENT DECLARATION
By entering my noire below, I hereby attest under the pains and penalties of perjury that all of the inrarmation
Contained in this application
is true and accurate to the best or my knowledge and understanding.
UL_—ID-0 L
Mite
Print M1191' i lorit,ed 6vill 4;, TES:
1.atu�kor an owner who hires an unregisteredtwnir'Out
1.
An ,,icr %%h-jobtaitisabuldiniptrinitt000ntsiler,j%v LU) have access to the arbitration
Ilic ,Ipr�avvllleat Cunt rl%:tor I H IC) Program).
will
Inut registered in the Hume er illiportam inrormalion on the HIC progr.1lit%;.in be 11ound at
program or guaraill) fund der.M.G.L. C. 142.A. Oth se�nn be found at
Wt,% MI" ;0% .1% 1 111rort ion on the Construction Supervisor Lit;en
2 \l,lien substantial%vu(k is v.......... proiJe theIlloriliatiun below: finished basement.1tti%:1. leeks or porch)
I including garage.
rotas iloorarca(1+ 11 ) lkibil.tbld romp%;ok"It
1 LIrklij li%togarea I iq. It kifbedroomi
\mIl b%:r 0 f ha I I.hallli
N11111her of je,;ki porches
lle.1ting 'telli 1,110ed
let,%
j,e IIl,,IIIIjtk;,I Ill("mill IrtqI:;;t COA
A
CITY OF SIU.S. I, ANsSACHUSETTS
BmDmG DEPARTN NT
j° 130 WASHNGTON STREET, 3' FLOOR
TEE- (978) 745-9595
FA.r(978) 740-9846
KI:tIBERL.EY DRISCOLL
M,AYOIC THOsw ST.PIERRa
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COMMISSIONER
. r
.Construction Debris iDisposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 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 MGL c
111, S 150A.
The debris will be transported by: ,
(name of hadler)
�1
The debris will be disposed of in : ti
('-m AC
(name of facility)
I c
(address of facility) -
"J— 'X
' gnatura of permit applicant
- date
lcbrisalLJx
a °"r CITY OF SALEM, NLNSSACHLSETTS
BuimiNG DEPART\(ENT
120 WASHINGTON STREET, 3ae FLOOR
TEL. (978) 745-9595
FA.X(978) 740-9846
Kl\BERLEY DRlSCOLL
�Y.=1YOR THOM.LS ST.PIERRB
DIRECTOR Of PUBLIC PROPERTY/BUILDING CO\c\iiss[ONER
Workers' Compensation insurance Affidavit: Builders/Contractor.9/Electricians/Plumbers
Aprilicant Information y Please Print Legibly
Name
(13usincsi Organira_tiovfndi vidual):
AV4css:_,3 ]/91-S 11e
City/State%Zip: Metni o/ 1i%3/�9y -�//�e
a r —
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time),* have hired the sub-contractors 6' ^❑LNew construction
2.[Main a sole proprietor or partner- listed on the attached sheet t 7. [i emodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 0, ❑ Building addition
(No workers'comp. insurance 5. El We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself. (No workers'Gump. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employee_.(No workers' 13.0Other
camp. insurance required.)
Any uppliewt that chccka box el must also till out she motion below showing their workers'corapenaatiun potiry intimation.
I r,"euwner who suhmtt this affidavit indicating they are doing all work and then hire outside contractor most suhmit a new afildavit indicating such
-Contrueton that check this box must attached an additiuwl short showing the name of the sub.contmefor and Ihdr workers'wrap.policy infomution.
fain on emplayer that is providin workert'c'ompensadon insurance for my employeex Below is die poilcy and Job site
injorinution. n 1
Insurance Company
Policy 4 or Sclf--ins. Lic. it: Expiration
N��t Expiration Date' ,(�
Job Site Address: I7<..�City/State/Zip; JGav '�►7
t
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 23A of3dGL 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 line
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ufthC DIA for insurance coverage verification.
/do hdreby cerrijy under rlie putts and penoldes ujperjary that the i rotation provided abuve is
true and correct
c2dz Z
i
Phone�
O%%icial use only. Do not write in Ibis area,to be completed by city ur Iowa gj$ial
_ I City or'fuwn: _.__ ,_ PermitRJcense X
-i Issuing Aulliority(circle one): ----- __
V6.
'soard of Iicalth 2. Building Department .3.Citylrown Clerk 4. Electrical luspector 5. Plumbing lnspeetor
Other _ontact Person: Phone M:
1