39 TURNER ST - BUILDING INSPECTION ,47 I-_7 1 .
1 The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR RevisedSALEM
Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Fmnily Dwelling
This Section For Official Use Only
Building Permit Number. DateApplied:
Building Official(Print Name) Sigoa D
SECTION 1:SITE INMAMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
3yTVXIV /z5r
l.la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions,
Zoning District Proposed Use Lot Area(sq it) 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:
Public❑ Private❑ - Zone: _ Outside Flood Zonc? Municipal❑ On site disposal system O
Check if ycs[3
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
pwl �. LA-wie�tiCE S�Lr,�1 � �' � 1�( 7D
(Print) City,State,ZIP
3 ° 77,/e/E, rz S1` 9787V,/-7/o-7 �jvanz�CDQol, cawl
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED ORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg.O Number of Units_ Other ❑
ZI i m-rr
r I Scp ecify:
Brie°fDptioofaWork2:— q w
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ 101 $0V .0 0 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
OJ• ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 3 P 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su cession Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ DrO� ❑Paid in Full ❑Outstanding Balance Due:
�p
vW,vL1r,-7 7L�> M r f
c
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
_ q t5 34 ' 0I�
�•a Gr.—�i w�t�4lL License Number Exp on
Name of CSL Holder
X r1 List CSL Type(see below)_
No.and Street Type Description
unrestricted(Buildings up to 35,000 cu.ft.
``r \ R Restricted l&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Renting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 14 7 (ei(P 211
ZDI
r, �?.r-v�c�,t2.h,S HIC Registration Number Expiralion Date
HIC Company Name or HIC Registrant NameA t
S"1 �,, 'JA Call ctl F! �+�`q QRS L'�DMC4S , Mo' -
No.and Street
Email address
State,,ZIPM TelephoneCi /To 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..........15' No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this applic ' is true and accurate to the best of my knowledge and understanding.
/�2 >/
nt w�trer's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.massgov/dos
2. When substantial work is planned,provide the information below:
Total floor 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"maybe substituted for"Total Project Cost"
CITY OF SMEN4 N-W&NCHUSEM
BUILDING DEp.jLmm T
' 130 W.JLSHudGTON STREET,Sea FLOOR
TEL (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
NMAYOR THOMAS ST.PB RRB
DIREcr0R OF PUBLIC PROPERTY/BUILDLNG CO%AMIONER
Workers'Compensation Insurance Affidavit:Builde%WContractors/Electricians/Plumbm
Applicant Information Please Print I eaibly
Vame(BusinessrOrgarriratiomindividuap:tea- �y Q �c•� �.J�.1c�efL � a e CQ l�.Me.(�
Address: S., 9 .x 4 e-c j% tw Qc�
City/Statc/Zip: mac. .,x cL S Mr, 0623 phone aY: Ci AS 59 t) Lto 1`A
Are you an employer?Check the appropriate boa: Type of project(required).
I.[] 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
/tmployees(full and/or part-tine).• have hired the st&camacmrs
2.0 1 am a sole proprietor or pmtner. listed on the attached sheet 1 7. ❑Remodeling
ship and have to employees Them sub-contractors have S. ❑Demolition
working for me in any capacity. workers'cow•insurance. 9. ❑Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its
mquired,] officers have exercised the 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.(No workers'comp. c. 152,$1(4).and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers' 13.❑Othar
comp.insurance required.]
•Any applicant that chrdn bar el mwt also fill cut the section below ahowina their workere'companmioo policy information.
'Ittateawras who submit this aftidwit intimating they an,doing all wort and thin hoe matidc commCtem tram eablMir a Mew affidavit Wielding and.
:Commeton not cheek this hat muss anoehed an a hstianl Rine showing the name of nor wbdmtnct rs and their wadm a'comp,policy ins Oft.
I one an employer that hr pravidhng workers'eompensadon hnsarance for my employees. Below Is tho polley andJob site
infwmaiioa. `
Insurance Company Name: 1 A. ott�.rt
Policy Nor Self-ins...Lic.N: — -i MO (. D 10 Expiration Date: 13 uoo ae f 2
Job Site Addregs: -O W C Xe,„n h'lu.. City/State/Zip: S"".,•. VV\e,OlQld
Attach a copy of the workers'compensation policy declaration page(showing the policy number and aspiration 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 S1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a flue
of up to S250.00 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 thepolas and penalth r of pnJary that the informadon provided above/s true and correct
r— Date: �CG �-o
PhoneN: �rl� fib tk0��
OJflcial use only. Do not write Is.this area to be completed by city or town offchd
City or Town: PerankILIcanse N
Issuing Authority(circle one):
1.Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone N:
CITY OF SALE�i, N'LkSSACHUSETTS
BUILDING DEP.itmIENT
' 130 W A.SHINGTON STREET,3i0 FLoOR
T EL (978)745-9595
FAX(978) 740-9846
KIMBERL£Y DRISCOLL
MAYOR T HOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COWN(ISSIO,iER
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 transported by:
name of hauler)
The debris will be disposed of in :
(name of facility) y�
(address of facility)
signature of permit applicant
date
dcbris f.dm