49 TURNER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
OIL[-(P ED 7,,oard of Building Regulations and Standards-/ CITY
Massachusetts State Building Code, 780 CMR, 70i FSALEM
4�cfLtiG2tF CK Revised January
Bu din Permit pplication To Construct,.Repair, Re a Or D o 'sh a 1, 2008
L One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: ' �y
Signature: -' Arl
0 �LBuildingCommissspectorofBuildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
Ll 9 Tv r n 9'(r- S+ —
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District . r Proposed Use Lot Area(sq'11) Frontage 01)
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 Zone? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownerr of Record:
Nam*Ure
Address for Service:
Sign Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply)
New Construction ❑ Existing Building❑ Owner Occupied ❑ Repairs{s) G19 Alterations) ❑ Addition
Demolition b Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed WorO: R ( h_�t_i_C�—C_�Lm.o.2.K f_O_m g_._TO_CJ l=I_i_i2e—vP
SECTION 4: ESTIMATED CONSTR13CTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
1.Building $ ti too, 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: $ A I d
4.Mechanical (IiVAC) $ List:_ U
5.Mechanical (Fire $
suppression Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S y g 0 U. 00 ❑ Paid in Full 0 Outstanding Balance Due:___
SECTION 5: CONSTRUCTION SERVICES
, .1 Licensed Construction Supervisor(CSL) 3 I L ' 3 I s
,di I
p V n WQ"� S License Number Expiration Date
Name of CSL-Holder List CSL Type(see below)
5�r c�G-Cd�fi I P.l->1 Address Type T.. e - Description
U Unrestricted(u to 35,000 Cu. Ft.)
S: nature
R Restricted 1&2 FamilyDwelling
1/-l ao r M Mason Only
RC Residential RoofingCovering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel BurningAppliance installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(H1C) LJ g L/ Z
F[1C Company N me or H C Re ant N c Registration Number
Address
q7 t'j t�i_1QQL Expiration Date
Signatu - 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 wilt 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
[. fGLGGL ity Dti. as Owner of the subject property hereby
authorize 1°{,r w0-A-51 to act on my behalf,in all matters
relative to work authorized by this building permit application.
2 -f4q
Si ' u of OWn'eT� Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
[_—J 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
behW..
---!1 dhr, UJw -ls
Print Name
2-
Signature of Owner or Authorized Agent - Date
..(Signed under the pninsjmd nalfies of 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(H[C)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 1*10:R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. FL) (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"may be substituted for"Total Project Cost"
CITY OF ScU-Eii, tiANSS1CHUSETTS
BUILDING DEPAR-INLE'4T
�Il � t
< 130 WASHLNGTO;V ST2EET, 3rO F'E.00R
c3� TEL (978) 745-9595
RkX(973) 7 0-98445
umBERLEY DRISCOLL
NfAYOR TttontAs ST.PmRAa
DmECToit Of PLBLIC PROPERTY/St:fMt:!'G COSLLMISSiONEM,
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibiy
Name(0usin¢syOrganization loJividuai): �A 0 -
Address: .5� 11J!'�
City/State/Zip: Phone✓#: 9 7 8 - 7 Y I/ - I UU/
Are you an employer?Check the appropriate box: F(O�Nc%w
t(required):
1. t am a employer with `� 4. 111 am a goncral contractor and 1nstruction
employees(full and/or part-time).' have hired the sub-Lentractars2.0 1 am a sole proprietor or partner- listed on the attached sheet.: lingship and have no employees These sub-contractors have ionworking for me in any capacity. workers'comp. insurance. addition
(No workcrs comp. insurance S. ❑ We are a corporation and iu
required.) officers have exercised their ME] Electrical repairs or additions
3.❑ 1 ant a homeowner doing all work right of exemption per MGL I I.C1 Plumbing repairs or additions
myself.(No workers'comp. C. 152, 41(4),and we have no 12.0 Roof repairs
insurance required.)t employees.L\'o workers'
comp.insurance required.] 13.C1 Other
Any appiicun dza tqua kt lwx st mot aho fill out the uviioo l clowshowing ihsv worken'com epcnsario»Policy sntonnation.
I T'weownets who suhntit this aHldnvit indicating they arc doing all work and then hire outside con m ms maul tuhmit a new atrdavit indicating$uch.
K:umrxron that check This Wx moot anach xJ an additiunal.hect showing the narr!c of the YUlatanttzaam and%belt-xorken'ramp.policy infotmntion.
!am on nnpluyer that is providln q avorkert'ramprasatlan insurwece jot my iuj employers B¢laav!s t/ta policy and job rdte
mmutiox
Insurance Company
Policy It or Self-ins. Lic, tl: t Q gm L ;-1 S 3 7 r�I O 30 l Z Expiration Date r�J 1
lob Site Address: 4 /iJ n in o n i� ^J i Y1 76� CitylStatei2ip: /� O/ Gi
Attacb a copy of the workers'compensation policy declaration page(showing the policy number and txptr2don dato),
failure to secure coverage as required under Section 23A of MGL e. 152 can lead to the imposition ofcriminal penalties of a
iincup to S I;500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up ro 5250.00 a day against the violator. 13e advised that a copy of this statement may be forwardud to the Office of
Investigations ol'the DIA for insurance coverage vcrilicatiun.
✓tie hereby c•errtfy i�-
certify
wider thhe pales uud petholdes of perjurythat the itrjurrrruduu provided ubuve is true and correct
St;LL l_.
4rc, [�
Phorgli � 7t�- 7tft/ �
01)iciul use uufy. Do nut Witt iu this urea,to 6e eun+pleted by city oe town n/jicyut i
t City or•rown:
Pcrmit/i.iccnse#
! Insuing Authority(circle one):
1. Board of 1lealth 2. Ilufhling 1)eparhnwu S.Citytrown Clerk 4. Electrical Inspector 5. Plumbing (tlspeetor
6.Other
fContact +-_�.....- .-., - Phone 4; _