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7 TURNER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR,7'"edition OF SALEM Revised January Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling This Section For Official Use Only Building Permit N er: Date Applied: Signature: y� \ Building Commissionff/cf6spe&tor of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers Lla Is this an accepted street?yes A no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: i ,ez z3� ri o 0 39�5;, Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 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: Publiciiii- Private❑ Zone: _ Outside Flood Zone?Check if yesE3 Municipal 8 On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: '7 72� -3 Nmme yet)G+ /f560C. Address for Service: Signature Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply) New Construction❑ Existing Building® Owner-Occupied ❑ Repairs(s) 6 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other .0 Spec fy: eE io Brief Description of Proposed Workz: -t,sa c$c SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs' Official Use Only and Materials 1.Building $ 8ao_ Qo 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (IfVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ K� -o® 0 paid in Full ❑Outstanding BalanceDue: I \ SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) L ?Y a'Z p �-Za- eaZ /J7/C��4EG 9• AA-t G--S' License Number Expiration Date Name of CSL-Holder List CSL Type(see below) !.f l/ L'ZAYT0'-1' S l Address T Description O�Dy U Unrestricted to 35,000 Cu.Ft. � R Restricted 1&2 Family Dwelling Signature M Masonry only t,/?- 2<7- /414/3 RC Residential Rooting Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Registered Rome Improvement Contractor(HIC) HIC Company Name or HIC Registrant Name Registration Number Address Expiration Date Signature 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..........0 No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, I,CLW 4&'r A'ey , 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. Signature of owner Date SECTION 7b/:OWNER'OR AUTHORIZED AGENT DECLARATION I, /yJfCslA6G ,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. �-W C-4119eL Print Name Signatire of OWner or AV11horized Agent Date (Signed under the pains and penalties of 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(I Q Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basemenVattics,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" The Commonwealth of Massachusetts Department of IndustrialAccidents Office of Investigations 600 Washington Street Boston,MA 02111 UIF www.massgov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information / Please Print Leeibly Name (Business/Organization/Individual):IoWle,f� 6_6 Ayi Ooeeis Address: // Yr lo..,/ S T.eEEI City/State/Zip: Gyve A 0140 y phone #: G/7- Z s7- 17/ 3 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2JRf I am a sole proprietor or partner- listed on the attached sheet. 7. ®'Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' 9. ❑Building addition [No workers' comp.insurance comp-insurance.; required.] 5. ❑ We are a corporation and its ME]Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 11.❑Plumbing repairs or additions myself. [No workers' comp. right of exemption per MGL 12.❑ Roof repairs insurance required.]t c. 152, §1(4),and we have no .2EPutG� employees. [No workers' 13.© Other S�oi uCj Comp.insurance required.] *My applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information. t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such. :Contractors that check this box most attached an additional sheet showing the name of the subcontractors and state whether or not those entities have employees. If the sub-contractors have employees,they must provide their workers'wrap.policy number. lam an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to$1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby certify under the pains d pe of perjury that the information provided above is true and correct 0 Si afore: Date: — CV Phone#• Official use only. Do not write in this area,to be completed by city or town ojfwial City or Town: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person: Phone#: