43 VALLEY ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, T" memo
edition Budding Dept
OBuilding Permit Application To Construct, Repair, Renovate Or Demolish a
Otte- or Two-Fmni.1 Du riling
This Section For Official Use Only
Building Permit umber: Date Applied: / (J
\ Jl Signature:
8 ildingCommi5sionee,16spector of Buildings Date
SECTION 1:SITE INFORMATION
I.1• P,rope3rty A,7
, Le �7 S 70- 1.2 Assessors Map 6 Parcel Numbers
1.1 a 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(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal Cl On site disposal system ❑
Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 caner of R rd:
n / 4o r y 3
G - ��A
Name(Print) Address for Service:
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other O Specify:
Brief Description of Proposed Works: ('ryrt ST w
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: IOfficial Use Only
Labor and Materials
I. Building S 2S-V, 0, 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project C str(Item 61 x multiplier x
1 Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
s Mechanical (Fire S
Su ression Total All Fees: S
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S 3 2 Ste, 0 Paid in Full 0 Outstanding Balance Due:
r !
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) f0
/' 2 2 3 u Cl — ZJ51— 0 11
� y� o✓
�P� �., eZ Lurnae Number Expiration Dale
N;px of CSL- Helder Lut CSL Type lace bcluwl CJ
t G C C
AJ ress i Description
U I Unrestricted luo to 35,000 Cu. FL)
R Restricted 1&2 Family Dwellin
azure c1 M Mason Only
')I , /,�' l RC Rcvdcnnal Roofing Covering
Telephone WS Resdeni Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2/�Registered H to/e Improvem nt Contractor(HIC) //&0 3 z
( /�Pr - r Y NOJ 7, S 7- Ln <
HIC Company Name or HIC Rrgistrant N e Registration Number
Address
G���_�/S'- yr�9'j Expiration Date
Si azure Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.1 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.......... 0 No........... O
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.
Signature of Owner Date
/1 SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
� (.9 I I/rti.a f ,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.
6`0 r t >vO
Print Name
7 —/ L1—� i
Sin re of Owner uthorized Agent Date
ned under a ins and penalties 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(HIC)Program),will W 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 I IO.R6 and 1 IO.RS, respectively.
Lliving
substantial work is planned,provide the information below:
rs area(Sq. Ft.) (including garage, finished basement/attics, decks or porch)
g area(Sq. Ft.) Habitable room count
fireplaces Number of bedrooms
bathrooms Number of halfbaths
ating system Number of decks/ porches
oling system Enclosed Open
1. "Total Project Square Footage" may he substituted for Total Project Cost'
Y CITY OF S.0 EN1s ANSSACHUSETTS
BCaDLNG DEPARTMENT
120 WAS14INGTON STREET, 3'a FLOOR
TEX_ (978) 745-959S
FAX(978) 7400846
KI,I$FRi EY DRISCOLL
MAYOR THoms ST.PT m
DIRECTOR OF PL BLIC PROPERTY/St:MDLNG CO\L%1lSSl0%ER
Workers' Compensation Insurance Allidavit: Builders/Contractors/Electricisns/Plumbers
lnolicant Information Please Print LesiblY
Naine (Bush or ct/taraizsriomindtvtduaq: (97e q2 (9 lVn n S ` fJa
Address: 7 ll %G� ct-I Ir Il.J
City/Statc/Zip: 5fq l e/h (f904- 0/4'n_o Phone p:
Are you an employer'Cheek the appropriate boa: Type of project(required):
1.❑ I am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-tirrte).o have hired the subcontractors
2.❑ 1 atn a sole proprietor or partner- listed on the attached sheet. : �• ❑ Remodeling
,hip and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp. insurance 5. §9-We are a corporation and its
required.] otflcera have exercised their 10.0 Electrical repairs or additions
3.0 I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 152,$1(4),and we have no 12.0 Roof repairs
insurance required.[t employees. [No workers' 13.❑Other,
insurancerequircd.J
-Any applicant that citec-M btta II mual also fill uta the seclim below showing than worker campantution put"infurmarloe,
'I I,nnettwtaaa who subout this affidavit indicting they are doing all wort area then hire outside eaturaetare mail suhmif a now alndavit indicating seek
:r.mlraefon thee chock this beer mum anachod an sWiliud shear showing the rumer der sub-com ecs a and their workers•comp,policy infomuuoa.
I am an employer that b provid/n,8 workers'compensation Inlwranee for my emp/ay'eex Below/s the poll y andM YIV
informallan.
In,urance Company Name:
Policy N or Self-ins. Lie.M: Expiration Date:
Job Site Address: City/State/Zip:
Attack a copy of the workers'compensation policy declaration page(showing tiro 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■
fine up to S 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 S250.00 a day against the violator. Ile advised that s copy of this statement maybe forwarded to the Office of
Invcangmions ol'Ihc DIA for insurance coverage verification
/do hereby certify tdar the pa' and pena/des of perJuy that the in/armarloe provided above is true and correct
Win•r I u ' /� p �7 S� Date. — / y• D h
PhoneL9 l d — 21 ' %,/ d n ^/
iOfcial we oa/y. Do nor wrile in this area, to be s urnpleted by tity er yawn oJJlriaL
City or ruwn: __ _ Permit/License M_
hsuing.%whorily (circle one):
I. Board of Ilaalth 1. Ruilding Department 3. Ciiylrown Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
C.mtael Person: _ -_. _.. Phone g•
1
CITY OF SALEM
r � PUBLIC PROPRERTY
i"
' --� DEP.�IZ'I'�IENT
1N
Construction Debris Disposal .-affidavit
(rci.luiied lbr all demolition and rcnuvalion \vurk)
In accordance 1\tth (lie sixth edition of the State Building Code, 780 CAIR section I 1 1 5
Debris, and the prowisiuns ul'MGL c 40, S 54;
Building Permil 0 is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal lacility as detined by MGL c
I 11. S 150A.
The debris will be transported by:
e/vri. OJ
(IIanIC Of haler)
I he debris will be disposed ot'in
iVpr-AfId4 Car rl .�
(name ul Iicihty)
1•iJJrc;. ur lacilitvl
. �natw pi nnrt .y+plicanl
diw