3 THOMAS CIR - BUILDING INSPECTION ��� d�/' �0'1 a•J�� I
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7ih edition OF SALEM
Revised Jurlau!v
' N Building Permit Application To Construct, Repair, Renovate Or Demolish a /. 00M
I One- Two-Family Dwelling
thii Section For Official Vie Only
Building Permit Nu r: I Date plied: ,l
Signature: / A
Building Commissioner/thnspeclor% 'Idi Date
SE 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
i rt�Y
I.1 a Is this an accepted street?yesyf no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.3 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?
Public❑ Private O Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2 1 Owner'qq4�Record: ,$wf -,
�26HOWl1� IYJ 7hOvnlaS C rcle wry+ 019-)0
ame(Print) Address for Service:
9X - /06 - 156V
Signature Telephone I
Ii
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Pro sed Work': I NS�t11 5 e iwitwl
3 Tr)a Sh r n
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllclal Use Only
Labor and Materials
I. Building S 8�•°0 1. Building Permit Fee:S Indicate how fee is determined:
1. Electrical $ O Standard City/Town 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
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S ySa�'`'� ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7 7/ q-7 /5/ z a
„-_;tJ SCf��/�� License Number! hspimtiun Date
Name of CSL- I[older� I.ist C'SL'fype(see below)SAID P10 g7a
_f Description
`dress U Unrestricted(up to 33,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
.'igna i M Maw Only
97Y- P� S a�l� RC Residential Routing Covering
Telephone WS Residemial Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 registered Home Improvement Contractor(HIC) 159 �'
N 6 �n I Sd�U����''�_^ Registration Number
flit Cf11C mu C&Name ur HIC Reglstra�lA,�'1 1 YrIB OIq-7U gJt' Z 7 2,01
� sPc�n.c 79, J l / z
Addp:ss g7 5-0 0 Expiration Date
Signat re Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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...........Cl
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
M1
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I) eyl J. aJ I A-rl-6 as Owner of the subject property hereby
authorize H 6w e C A to —.xD I uf�'0'Y) S to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION"r7b: OWNER'OR AUTHORIZED AGENT DECLARATION
M � n A4W SOILd f UY)S ,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.
1 r�n,el c»-� �l�-
Print Name
/o /ZS/lo
Signatu of w r r Authorized Agent Date
Si ed er ains and penalties of i u
NOTES:
I. 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 ContractorIHIC)Program),will pol 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 110.116 and I IO.RS,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 S.U.&A UkSSACHUSETTS
ftaM6VG DETART ENT
120 WASHI NGTON STRPRTa )ne FLOOR
TzL (978) NS-9S99
FAx(M) NO.915"
KI.I.IHEA"y DRISCOLL TkOloW ST-ilom A
VtAY01 DlREcW R OP PL SLIC PROPERTY/BV MDLV G CO%00SSIO\ER
Wurke►s' Compeasatioa Insurance AMdavit: guilders/Contractors/ElectriclanslPlumbers
>nellcant Informatlow Please Pr(nt Legibly
ValfleltluannrOrymrarietilnJrrtduall�//�
Address:
City/Statdzip: -�Cli hen ?Yli D// /�Plbl»N' 9 77
F
amplays'Check ohs sppnprlate bear Type of project(regralecO
umploytrwith 4. ❑ 1 am a general caatrector ad 1 O Now conaauctioayees(fWl and(or pan-unr).• have hired tlr wrh.atmracaors
role proprietor tx parinan listed dm Remalaling
al have no cmployces Then sub-costrsemrs have L Q Demolition
for me in as ca woAters'comp.instnasaa� y paciry. 9. �guiWing addtdonrkers'comp insurance S. O We am a cerpersten ad id
required.l
officers beer exeselead thou 10.❑Electrical repairs or addition
).❑ I am a homeowner doing all work riww of d:aer"Prioll per 111OL 1 I.Q PlumbhsS repairs or addition
myself.(No workers'comp. c. 1 32,#1(4),ad owes haw no I2.0 Roof repairs
insurance requirad.l► crrspleyewa LNe wedsee 12.13 Other
comp insurance rnquird j
'Any aprad tM saaY also II wdrr AM n0 err IM mti arlae rwiss tadr wwaw'owe frwsi,ra palky isAcerrlae.
't Lvrrrddwaw who sub"data of ldavis inehadq soy as dap all wart aid
Om Now wUii saw wows roar awlrale a now,aOldev i indkadidy attat►
<'.+ar Camp Policy ia6 mdm
/ua ew raPeye/rAr b/nr!/fwR rwrlt/s'eea/edamdrds/wasreases je.a9'taap/spera Sellsrr d rAe pwI4T rw/ja1 aGr
mjonwwlrra
Insurance Company Name:
Pnliey a ur Self-ins. Lis.Ak Expiration Dale:
Job Sire Address: City/StatdZip:
Airseh a copy of the workers'campsustlss pWey declarstlea pap(shewing the pNkty number and espl►aMaa dstds).
Failure to secure coveralls as required under Satios 25A of NGL a 132 can lead to the impositiee of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonmorK as well as civil penalties in On form of a STOP WORK ORDER and a line
Of up to S230.00 a day agalntt she violator. Ile advimd that a cupy of this statement maybe rurwarded to the OfAce of
I necstt galiunw.dt'dsw 1`71A forinsurance coverage v.•ritScatiaa
he rrrrljyr un4 rA WON'ws an penalties ajOn/u7 rAer As,injMwelfew Onrllydf uAws r is it"end a'w/reL
;"IIA ore: � p �22�_ - - - - oath[ !/�
OJf/rir/star mdp. Oe.dav wri/I:a this vrrry n M.uwy/ird by city or ushers n/jdridrl
Ciry or rusvn: eermiVIAcense/__.
— - --
lawng.\whunly Icircta unt►:
I. Iluard of IlraUb 1. Rudlding Department 1. C'irylfowa Clerk 4. Electrical Nipector S. Plumbing Inspector
6. other
i L.nlract Person: _ _ _ _. Phone a:
CITY OF SALEM, UxSSACHUSETTS
• BUILDING DEPARTMENT
130 WASHINGTON STREET, 3' FT.00R
s� TEL. (978) 745-9595
FAx(978) 740-9846
Kl\tBERLEY DRISCOLL
THO
i1r�AYOR .'�tAs ST.PtERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%L%QSSIONER
Construction Debris Disposal 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 transportc�d, by:
f f/r: e /I V E
(name of h uler)
The debris will be disposed of in
-0
(name of facility)
5vlyt.(ir:,
(address of facility)
signs ermit applicant
date
dnbristlT.J.k