16 TURNER ST - BUILDING INSPECTION The Commonwealth of Massachusetts7edil
Town of
Board of Building Regulations and Standard
Vlassachusctts Stan Budding Code. 780 Ch1R. T" Building Dept
Building Permit p ion To Construct. Repair. Renovat �
On • or Two-funtrfs`Direffrng
is Section For Official Use Only
Building Permit Number Date lied:
Signature:
Building mmissioner o%( r t Dam
SE I 'SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
l I
],Isis[ is an acc led street?yes no
M Number Parcel Number
1.3 Zoning Information: 1.4 Property Dlmessloas:
Zoning District Proposed Use La Area Isq I Frontage IR)
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.e0,154) 1.7 Flood toes IiIIII: tloe: 1.2 Sewage Disposal System:
Zorar _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check ilive,0
SECTION 2: PROPERTY OWNERSHIPt
2.1 Owner iofRecord: •p
r VAIM M(21211?4—
Name(Print) Address for Service:
,?g&- 9K'3g7)01�
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek ad that apply)
New cons lion O Existing Building 0 Owner-Occupied O 1 Repain(s) Alterations) O Addition O
Demolition O Accessory Bldg.O Number of Units_ Other 1] Specify:
Brief Description of Proposed Work': tO �tC(S?IA)le .E.Pf O P
�g r Q/�Q Ir is-0 r^i,Atif 1291 AND t11I�/-FYtlI '"tJ� 9V66FA
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: 011lclal Use Only
Item Labor and Materials
1. Building f y � 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Elecmcal f O Total Project Cost'(Item 6)x multiplier x
) Plumbing f 2. Other Fees: f
a. Mechanical IHVAC) f Lisl:
S NechamCal (Fire S Total All Fees: f
Su ression
Check No. _Checl Amount: Cash Amount:
6 Total Project Cost f ybU, r/U ❑ Paid m Full O Outsundmg Balance Due'
$fN1p pd7mc�
i
SECTION S: CONSTRUCTION SERVICES
S.I �Li)censed Con�sir��uctlon Supervisor, (CSL)
r,! l� mRVr �il� Lrcen.e. umber Es ratio D to
N,Ppe ul C IIpIJer Nb /ktnn List C'SL Type(xv Wow)
G
AJrkr s / T Description
U f Unrestricted(up to 1s,000 Cu. Fl.
R I Restricted 1&2 Family Orellm
sisno f
/, M Masonry Only
C Residential Roofin Covering
Telephone 'S i Residemtal Window and Siding
Residential Solid Fuel Burning Apolearnicir Installation
Residential Demolition
5.2btered Home Improvemeat Contractor(HIC) �6(o92`�
Registration/Number
Hit.C y Name or IC esp tfant Name
Address ddGG ,-12 `6
apirsti n Dale
194'ron, Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.1.e. ISL J 21C(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..........cy, No........... 0
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.
Signatum of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, N&1 , 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 il'1d2�
Print Nuns
Signature of Owner or Au1hqzcjd1kAseru Date
lSigned under the ains and albas ofperjury)
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 Sg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110,R6 and 110 R3, respectively.
2. When substantial work is planned,provide the information below:
Total Goon area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ff.) Habitable room count
Number of fireplaces Vumber of bedrooms
Number of bathrooms Vumber of halfsaths
Type ofheating system Number o(decksf porches
i pe of cooling system Enclosed Open
1 "Total Project Square Fomage"may he,uh,muted for 'Total Project Cost"
J
� CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I`.1��It I'Q��.\iI II]G:i1N 5rN GL'T •5.\I I'\I,
-1'EI: '178.74?-1i'15 • 1'.\Y:978-1449846
Construction Debris Disposal At'tidavit
(required fur all demolition wid renovation work)
A
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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The debris will be transported by:
' (name of haultr)
The debris will be disposed of in
C
(name or facility)
A/1vA
c1dress or raclllty)
I f
+i jnal r of Ix i tpplicant
—� (late
Icln i.,i1 dim
CITY OF Sm.E.`[, IL-SS.kCHL•SETTS
BL DLVG DEP.\RTIENT
120 W.+smiNGTON STREET, )ace FtooR
7 7� 9 TEL 9 5-95 S
FAx(M) 7O-99"
IQ\fBEA"Y DRISCOLL THOMyST.PIERIts
MAYOR
DIRECTOR OF Pl.BLIC PROPERTY/{t'¢DNG CON01ISSIObi F1
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electricions/Plumben
Anolicant Information rr / Please Print Legibly
Valtye 10uairteuOrganttatiothlttdavuhul): �l�N�C� G�M._�
Address: �� /� CtJl92.JVC1f ST
City/Stateizip: ildTjQ4A4 a&!/ Peon ir:9ZB- S3/%69,9
Are y a as emplayv!Cheep the appropriate boa: Type of project(requlrce•
1. 1 am a cmployv with _ 4. Q 1 am a gencnl contractor and 1
anployees(full and/or pan-time).• have ots hired the su¢racb 6. Cl New construction
2.Q 1 am a sole proprietor air partner- listed on the attached sheet S 11 7. Q Remodeling
+hip and have no employees These sub-eontrochm have a. Q Demolition
working for me in any capacity. workera'comp,iewraarx 9. Q Building addition
(No workers'comp insurance S. Q We are a corporation and is
required.l of7kels have exercised their 10.0 Electrical repairs or additions
J.Q 1 am a homeowner doing all wont right of exemption per MOIL I L Q PI bing regain c r additions
myself.(No workers'comp. c. 132.f 1(4).and we have no 121 Ronf repairs
insurance required.l t employeoa.LNo workers' 1).❑Other-
Any comp insurance require&)
appacae tti aeachs ban et mare ale tit ota Ire arenas brlow Showing their werlita'eartpwaataas palay infinn"ade6
't vnewwna who cubsue Ohio afllMis indlad"they ae doing all work ate rhos hits otdrid♦aosreeertr swat atMrtb•now allltkrO indicting srk
:C..mmun the cheek thin bat mud asaslyd as addtiatl rhea Jmwine the nett of eta et►eoauseaars mW their wothno'cantp.pdicy inai n sda►
J am ex emplayer that b providing we4ers'tong aamaleta Jnsaneaeejer my exWeryers. Below is tLte peJJgr ewd joa site
iacjormarlaa II
Insurance Company Name: b6e_ z!1 7J//�L /WT
Policy M or Self-ins. Lie. p n3a l�9 to l Expiration Dns: N /O
Job Site Adalress: City/State/Zip:
.mach a copy of the workers'compeasanoa Volley dec tba Pap(showing
the Volley Dasher and expintlw date}
Failure to secure coverage as required under Section 25A of MGL a 152 can lead to the imposition of criminal penalties ors
fine up to S 1.500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a Brae
.rf up to S230.00,a day against the violator. IIe advi..%W that a copy of this statement may be forwarded to the Office of
Invcbugatium afthe DIA for insurance coverage verification.
J de hereby Oyer/ ma/i®r tt/h�/o pains nd penolues djper/rary that the Jnjormaifow provid�sd�above is true and:meet,
,Z1,17AII re,
P. one a• 92e,--nI' �T
O/JJrieJ use d.dn Dd racer write in this area6 to be.atwp/i/d by tits Or town ri//Java[
City or ruwn: Pcrmit/Llccna M
i
hsuing.%uthurily (circle une):
I. Ituard of llrallb 2. Ruilding Department J. City/town Clerk J. Electrical Intpccear S. Plumbing Impactor
6. Other
lunlaclPerson: _ ._ __ Phones: