21 TURNER ST - BUILDING INSPECTION (3) / The Commonwcallh of Massachusetts Town of
t Board of Building Regulations and Standards
Massachusetts Stale Building Code, 780 CMR. 7" edition Building Dept
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One. or Too-Fmruls Dwelling
Section For Official Use Only
Building Permit Number Ogre Ap
Signature: nNumbers
Building tssw a Inspect o ngs Date
1 1:SITE INFORMATION
1.1 Property Addres : 1.2 Assesson Map& ParcelU21 j��I.Ia is this an accepted street''yea no Map Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq R) Frontage III)
1.5 Building Setbacks(ft)
Front Yud Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Information, 1.8 Sewage Disposal System:
Public O Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if s❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wner'ofRecord:
712� �i .lfYt3 r —
atne(Print) Addrcsa fa Service:
Si 'tare Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building® Owner-Occupied 9 1 Repairs(s) O 1 Alteralion(s) ❑ Addition ❑
Demolition wl Accessory Bldg. O Number of Unita_ Other ❑ Specify:
B 'ef Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building f 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical f O Total Project Cost(Item 6)x multiplier a
Plumbing f 2. Other Fees: f
4. Mechanical (HVAC) S List:
5 Mechanical (Fire f Total All Fees:S
suppression)
Check No. _Check Amount: Cash Amount:
6 Total Project Cost: f 3( ❑ Paid in Full ❑Outstanding Balance Due:
0"s- bl2- �)V- 63 () 9
SECTIONS: CONSTRUCTION SERVICES r
S.I Licensed Construction Supervisor(CSL) CS'NGD S [O (Z n
r.
• L.ccnx Number Expiration Date
N,4 ql"CSL=.lyldern ,� l List CSL Type(,cc A.luw) ' y
k' vJt Description
Address
U Unrestrmud u to "S Cu. Ft.
R Restricted I 2 Famrl DwelLn
S nat� b statutory Only
RC RQSIdenUal Rmfin Co
vering
Telephone _ wS Resdential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Re redH me prove entConlractor(HIC) 149�3�
H IC�omp uorHISR 7 � r� Registration Number
s Dr� nd .O
Address
Eapir Lion Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. IS2./ 25C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
III this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes..........it No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize �282tO SAMPAX to act on my behalf,in all matters
relative to work authorized by this building permit application.
IdClf2
Signature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, L ,-Owner or Authorized Agent hereby declare
that the statements an rformation on the foregoing application are true and accurate, to the best of my knowledge and
behalf,
Print Name
Signature of Owner or u gent Date
(Signed under the pains and penalties or perjury)
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 Contractor(HIC)Program),will 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 R6 and 110 R5, 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. Ft.) i Habitable room count 10
Number of fireplaces Number of bedrooms ?1
Number of bathrooms Number of halfibaths 1
Type of heating system a-et' Number of decks/ porches
Ty pe of cooling system Enclosed Open I
3 ' Total Pro)ecl Square Footage"may he substituted for"Total Project Cosy'
' G
The Commonwealth of.4fassachusetts
Department of Industrial Accidents
kv
Office of Investigations
j
600 Washington Street
Boston, MA 02111
www.ntnss.gov/din
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information `n Please Print Le 01y
Name (Business:Organization.'Individual): 1 t�t't LlL o
Address: ID CIWA+ 4L
�J
City/State/Zip: `= tin 1 A OU�hone#: �Q Cf
1 "O
Are ye6an employer?Check the appropriate box: Type of project(required):
Ej7 4. ❑ 1 am a general contractor and I
1. 1 am a employer with 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ [am a sole proprietor or partner-
listed on the attached sheet.= 7• ® Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers' comp. insurance. 9. Building addition
[No workers'comp_insurance 5. ❑ We are a corporation and its Io.❑Electrical repairs or additions
required.] officers have exercised their
right of exemption r MGL I l.❑Plumbing repairs or additions
3.❑ 1 am a homeowner doing all workP per
myself.[No workers' comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees. [No workers' 13.(- Other
comp. insurance required.]
*Any apply that checks box#,must also fill out the section below showing their wodcers'compcosatim policy information.
t Homeowners who submit this affidavit indicating they ere doing all work and then hire outside contractors must submit a new affidavit indicating such.
;Conaachas that chedc this box must attached an additional sheet showing the name of the sub-contractors and theitworkem'wmp.policy information.
I am an employer that Is providing workers'compensation insurancejor my employees. Below is the policy and/ob site
information. y
Insurance Company Name: (�I LZLL -te �2 .J—Ltrn' "Kt�
Policy#or,Self-ins./ I
Liicc.#:'fit e3w 1� Expiration Date; 19 'I— ,jig
Job Site Address: `L - Crb b? j � �� City/State/Zip: ciri,�Q
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 certifi,under the pains and penalties ofperlun•that the lrtformation provided abov rs true and correct.
Signature: Date:
Phone#:
Owicia!use only. Do not write in this area,to be completed 6r city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
t. Board of Health 2. Building Department 3. City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
y
CITY OF SALEM
3i PUBLIC PROPRERTY
a; ,r=�
.. / DEPARTMENT
\I11q( 120 WAiIIIN(i IONS TNLET • SAIr\t, NiAsiA(.IIIII I'is II)
'fEI:1)78-74 9595 • 1:.%X:978J40-9846
Construction Debris Disposal Affidavit
(required fur 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 tf _ 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 hauler)'
The debris will be nndisposed of in
(name of facility)
(address of facility) _
signature of Ixnnrt applicant
lc�t IF�q�
da
dc6u all'd,k -
Srr�c;i.� :��� 2- s-r��r � •
Rs
`l"��l.E. SS02.'S(1� '2t TURhi�
_fin,
*4
o
ap IL �11 W¢�Etl 11
5.
ti I a 7x �
i
{�2x 'IIIttC� bPEIJ�NI� .