19 TURNER ST - BUILDING INSPECTION 'a
The Commonwealth of Massachusetts
i r Bl/ard of I31I1h1111g Re&ulations and Standards I'OR
MUNICIPA1.II Y I
! ' ? Massachusetts State Building Code, 7311 C NIR. 7°i edition I1Sl:
yT as
. � Building Permit Application To Construct, Repair. Reno >*Ora0enutlisl) a RrrisrJ.hnuau v
One- or- Tov-Fantiht,Dn elling
This Section For Official Use Only wr_+
Building Permit Numb .+. ..� '`L Date Applied: —
Signature: iit
3 /
Building('�111fQ VAX n; or of Buildings Date
CTION 1: SITE INFORMATION _
A Property Addr 1.2 Assessors Map & Parcel Numbers 1.to Is thisan accepted street?yes_ no Map Number Parcel JVW
1.3 Zoning Information: 1.4 Property Dimensions: f9,
Zoning District Proposed Use Lot Area(sy 11) Frontage�lt)�, —
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
! Required Provided ReyuireJ Provided ReyuireJ 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? Municipal site disposal stem ❑
Public 01 Private❑ Check if yes❑ p n Pt s y�
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner[of Rec rd:
����Ul ea �+, rE�KI✓r >9 77iKnrE'�e
N�m• mD Address for Service:
� /-778"� 7 7/-Y37- -
tgnature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:--
Brief Description of Proposed Work': ,AWE_ DOEG /ST 06117—,, ;Citz_&-E�lv g'q"-,PW
�>;°LtdiY/ vYla95�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ Zfj exrn 1. Building Permit Fee: $ APL_ Indicate how fee is determined:
❑Standard City/Town Application Fee
3. Electrical $ i�� ❑Total Project Cost'(Item 6) x multiplier x
I
3. Plumbing 3 y,Jbv 2. Other Fees: b
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount Cash :\mourn:__ �
O. Total Project Cost: ZY,C52M ❑ Paid in Full ❑ Outstanding Balance Due:---
do ,�11
l`IL
SECTION 5a CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
/1 C5 8/867
/A �
Gf/'ie/(� /u. (�UN,�14 License Number li. pua sun Uate
Name ul CS - Hu er
1/9 '0" List CS Type 1( c bclw.l.
Type = Description
L Unreslri +d t 3i.(N)0('u. Ft.i
-- R Restricted Ivy[_ mnily Dsseihng
S gnat M Masonry Only
978"1(;1/Z9/D RC Residential RootingC'osenng
Telephone N%S Residential \b'mdow:md Siding
0 SF Residential Solid Fuel I3unmle A(>>h:mee InSlalllttngl
i D Re,idential Demolition
5. „ s /.tlf�l ��L6/
ry o ( mm
nt Contractor(HIC)
HIC Cop y Napte or HIC Registrant Name Registration Number
m
p r
Addr .3 09.E
97d�fy�870 . Fxpiratiun q
nawr Telephone J
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 .......... No ........._ ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, ✓F96VIC } M fE6KWJ as Owner of the subject property hereby
authorize Ia 14A0d R CaAl 14 4 to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1, D tf 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-
be • If.
Amato
Prin m
Sign r Authorize Agent Date
(Sig ed under the pains an ties of er'u )
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) 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 Lind
Construction Supervisor Licensing (CSL)can be found in 780 CMR Regulations 1 10.R6 and 110.115. 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 ISq. 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 [Inclosed Open _ ---_
3. '-Total Project Square Footage' may be substituted for"Total Project Cost'
CITY OF SALEM
PUBLIC PROPRERTY
DEPART
rn..esttarttsaoat.t. " �,-°�'
MAUS t30 ReamwtowStneas••Satate.�Inataaaarrts01970
TM WW45jM a IIII W We6*%
Worir W Compeasadoa Iatw"Mm Alfadav* HaittLrolCoa
VVIREAWS
Names
Addteas
City/ Ph=o Al 97J--7C/t/z07i(
Am you an am~Cleat the appropekle bees
1.p 1 am a employer with 4. []1 am a Souwd contractor end i Ty"stpry.a
(lhll miler paefrdme}• bow 6iwd the 6' p New
�
2 am a sole proprietor or poem.. hated m tM attached shalt t 7.
ii
Ship and hen no employees Then sub commetam hews R ❑Demolitiaa
working I*me in any capacity. waskew camp inananaw. y, ❑got�tng addbies
(No wakens'comp marrame J. p We area cwp m"m and is
Acquired) oMOM ban cowdsed their 10•0 Mmuied repdre or additions
3.[31 so a homeowner doing all work right of asemption per MOL 1 l.p pinmbiep mpdre or addidow"
mysebt(No weekmp'comp, e. 15%f1(4).end we hew no lip aa�rep�ns
b uea>tet )f anW�et Pro warkans' 13.p Other
camp.ionnow requ4d]
��.ppttmaetret.ddtn.rtmass..es.arse.at.ers - -b$6lr.arsa'ea.*.rrteeveurte�arta.
Ham.w.wanhesutmwttda.ladakbdudeoetawduko eadt.d4.tdweorldra.n.waamoae.w..sw.lgOwatri.tyssaL
tC.aa.mw.ar dater.tsr®e..read..deitl.al shawtkwtaa Mn�.atre+oe.mttti...�ott.a�..'.a.r.v,r�r t.tta.r:
I am an ewpbyw
�l watt toprrvldGt workers'eo—wp'.nr/edsw burw.wceJitr url e+sPbyaeR Below b rAe poBey earf/oI ads
insurance Company Name ��,g� Q-
Polley N or Selitbu.Lic.N, ke DO 2 SO 933 9 Eupieati�Datk_ 8�0%9
)ob Sites Addrew /9 — Z-�
Attscb a copy K tM worker'compeasadon ponry doeb ndem pap(sbawbg tbs poiley asmber sad eapkadoa dub).
Fai ure to secure oovansp ore required under Section 23A of MOL t 152 can lead to the imposition of ain"penalties of e
fine up to S „500.00 aad/ar one-year imprisonment,as wen as civil Penalties in the form of a STOP WORK ORDER sad a Rae
of up to 3250.00 a dty sgoiat the violator. as advised that a copy of this mtement may be forwarded to the 08kw of
Investigations of the D verifieaooaL
!Je lure8pr ardor rlv fo4juy rb.r wr&*ON afowPtoN/Nabore b wwoat eorrreut
PhoneM: �12P7yyt8�/C�
Of chill ate axtA D@ toe write In wb aree`to be compkied by rl&or low of eld
City or Towne Permltttkeast tt
Issuing Authority(circle one):
i. Board of Heaitk X Building Department 3.Chyfrows Clerk 4. Ehxtrieai Inspector S.Plumbing Inspector
6. Other
Contact Person: Phase w
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
�l.ncnc 120WMI1ING ONS-IAEET • SALE\4, MAss , ILSLClS0,97C
Tn.:978-745-9595 *FA-K:978-74QeA,R46
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CI41R section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# __ pr
.____ is issued with the condition that the debris resulting from
this work shall be disposed of in a operly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler—)
The debris will be disposed of in
��� . Vic,
(name of fa, ay)
taddres, ol-facility)
S .,'atura o pe ppiiunt -
/O /J
„ace