56 VALLEY ST - BUILDING INSPECTION (2) The Commonwealth of Massachuscus Town of
Board of Building Regulations and Standard;edilion
t� Massachusetts State Building Code, 780 CMR, T" Budding Dept
Bwlding Permit Application To Construct. Repair, Renovatolish aOne- or tiro-Fum s•Duellingis Sec ion For Official Use OnlBwlding Permit Number ate Applied: .
Signature:
Building Commit toner/ nspector of attgaings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map k Pareel Number
S'
1.1 a Is this an accepted street!yes no Map Number Parcel Number
1. Zoning Information: 1.4 Property Dimensions:
cS�Wti'
Zoning Disinct Proposed Use Lot Area(sq It) Frontage(R)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water upply:(M.G.l.c.40,S54) I Flood Zone Information: 1.8 Sewage g9disp"os"alsystem
Zone: _ Outside Flood Zone? Municipal�Public Private❑ Cheekif es❑ P
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: 5A C
a C /
Name(printl Address for Service:
Signature - Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek 11 that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) Alteration(s) O Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Descripti n of roposed Work': E
N� r_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
lie rn Labor and Materials
I. Building f I 0�1 Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical S ❑Total Project Costs(Item 6)x multiplier x
7. Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List: c. f ��
s Mechanical (Fire S Total All Fees: f
Su ression
Check No. Check Amount: Cash Amount: '
6 Total Project Cost: S `7 �.1� 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL) 2,2.'2/6 7 �- �6
'' rC2 �TRC (� La .e cn Number E rtmi n Dam
Name of CSL Hylder a List CSL Type Lce tkluw) 00
z/lam )2-✓ L 52
Address T Description
U Unrestricted(up to 35,000 Cu Ft.
R Restricted 1&1 Family Dwellm
Signature V M Masonry Only
y78"20 RC Residential Rocifinti Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 9�]�btered Home Impnro/v^em�e�J Contractor(HIC) � 2>
/ �TtC f? S7-I�l./U
HIC Company Name or HIC Registrant Name Registration Number
a- LE• 2A t (S
Address
Expiginon Date
Signs rc Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.# 2SC(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 Issuan of the building permit.
Signed Affidavit Attached? Yes.......... No........... O
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.
Signature of Owner Date
ESECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
thestatements
F a ��a0I� ' ,as Owner or Authorized Agent hereby declare
ts and information on the foregoing application are we and accurate, to the best of my knowledge and
w th rued A t Dataim and nalties of ru
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. 102A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110,1 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(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaths
Type of healing system Number of decks porches
Typeofcoolmgsysrem Enclosed Open
1. "Total Protect Square Footage" may be .uh,istuicd for"Total Project Cost'
• � CITY OF SALEM
j• "i PUBLIC PROPRERTY
4
�. DEPART
MENT
\I'vlrq< 120 ''Ailll\GIONSrl(Eff • SAI1'\t, MAiiAt'.IIIitI'iiJI`l
Tn:978-Ni 9395 • PAX:978.74G-98a6
Construction Debris Disposal Affidavit
(retauired for all demolition and renovation work)
in accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit H is issued with the condition that the debris resulting from
this vivrk shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The Iebris will be transported by:
Il/crUJ2�"ikSfY�E �trfZl"1)U �
(name yt hauler)
The&bris will be disposed of in
(name of facility)
Gb
(a dress of facility) - --
signam permit applicant
(late
dc6rrun' :rrc
CITY OF S.U.EM, , LkSSAC1iUSETTS
BUILDING DEPARTMENT
120 W.ASHINGTON STREET,Jim BOOR
TEL (978) 745-9595
FAX(978) 740-9&M
KIJBERLEYDRISCOLL THomksST.PIEm Wr
AAYOR
DIRECTOR OF PLSLIC PROPERTY/Bt:MDLVG CO%M(2SSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers
Antflicant Information p r Please Print Legibly
Nalne (dusineai Orgaoiratiorrindsvodual): iTE2 W v �U; , G N • C—AV T '
Address- 2/ (/4L.e,- a�S�! y p
City/Statc/Zip: sSA_ LC24 - M- 067 Phone #:
Are oat as employer?Cheek the appropriate box: Type of project(required):
I. I am a employer with ;?,� 4. ❑ I am a general contractor and 1 6. ❑ construction
employees(full and/or part-time).* have hired the subcontractors
2.❑ I am a sole proprietor ar partner- listed on the attached sheeL : 7. Remolding
.,hip and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. worker'comp.insurance. 9. ❑Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its j
odicers have exercised their 10.❑Electrical repairs or addition
regrdred.] I,
3.❑ I am a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or addition
myself.(Net workers'comp. a 152,§1(4),and we have no 12.❑Roof repairs
insurance requited.] t employees.two workin' I3.❑Other
comps insurance required.)
•Any applicant that drag"bass al must alai fill uw the sactian belw thawiaa their wsxkee'ctmPmudsa policy insis m adose.
'l lso owrwn who subaail this aflldsvk indicting they are doing all work and than him amide ,euracran must submit a now alltdavit indicting Lock.
lwnravn shot duels thin bass mutt attached an slitio d sheet-hawing she rmme of the N►COnlradpa and their wtrkare'comp,policy informouw.
I am an employer that h providing workers'cornpensadon insa►ance fo►my emphtyeas Below is the potley aed/ob site
information.Insurance Company Name: U _IV ko(J
Policy #or Self-in. Lic.. M: ' / W C �'c3 Y Expiration Data:
Job Sire Address: ST YWLGGr y 57� City/Slawizip:
,%ttacb a copy of the workers'compensation policy deckarstbn page(showing the policy number and ospirsdoa date).
Failure to secure coverage a required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
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$250.00 a day against the violator. IM advivil that a copy of this statement maybe forwarded to the Office of
Invcaugatinna al'dro DIA for it once cover verification.
i do hereby crrlify us r rho pai s rr jper/ury that the inforsoaion provided above is Irma and coned
,i,nm tire
Phonc A: % 7JQ OO ICI
iOfciai use aady. Do not write in rhis area,to be cumpleted by city or town a/Jicial
City or futon: evrmit/LicenseM__.
Nsuing.\uthurtly (circle unc)
I. Ruard of lleallh 2. Building Bepartmcnt J. Citytrown Clerk J. Electrical Inspector 5. Plumbing Inspector
6. 01 her
L„ntactPerson: _ _ __, Phone#•