19 WALTER ST - BUILDING INSPECTION r 'w
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Nassachusetts State Building Code, 780 CivIR Revised Nfar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family avelling
This Sectton:For Official Use only
Building Permit Number; Date plied';.
Z z
Building Official(Print Name) .Signature. 7 Date
SECTION 1: SITE INFO IATION =
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
i.1a Is this an accepted street?yes_ no Ntap Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) 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 Zone?
Municipal if yes❑ unicipal site disposal system El
SECTION 2 PROPERTY OWN ERSHIPI
2.1 Ownert of Record:
lok &F�Pav ski 5a�w Gt^t�
Name(Print) City,State,ZIP
l� L✓Ct.��'-cr b f- (a I� - cj(aU -"I 1l>
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check.all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ NumberofUnits_ Other ❑ Specify:
Brief Description of Proposed Work: 00 - w ,��G� &',�c L t q t�1 Go✓t h
SECTION 4: ESTINL4'TED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only.,
Labor and Materials
1. Building $ 3B � I Building Permit Fee $ Indicate how fee is determined:
❑ Standard.CityYCoryn Application Fee
2. Electrical $ d OfUc ((U ❑Total ProjectCost',(Itern6)xmultiplier x
3. Plumbing $ a orio cJ 2. Other Fees: $
4. Mechanical (Ilw Cq $ List:
5. Mechanical (Fire
5ii Cession) Total All Fees: .$
l _ Check No. Check Amount: Cash Amount:
(, 'fatal Project Cost: S C/ 0 Paid in Full ❑ Outstanding Balance Duo:_—_--
SECTION 5: CONSTRUCTION SERVICES —
5.1 Construction Supervisor License(CSL) D('yd/V
_`� r —
"L 6— —b —: ✓t Licens'z Number Expiration Date
Name of CSL [loldcr
I List CSL Type(see below)
1f} Type Description
No. and Street
/ U Unrestricted Buildings up to 35,000 cu. It.)
R Restricted 1°&.2 Fainil�y Dwelling
Cityrrocvn,State,ZIP M Nfasonr
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Horne Improvement Contractor(HIC) //?f7 �
s�G00— ) HIC Registration Number Expiration Date
HIC Company Name or II'C Registrant Name
'1 q�fz-(66s(, SDC-feS e 60, 1(L'! �
No.tajt�$ reGt� N 1.4 O '362S, �U.r--?C —(J�?6 Email address
Ci /To[[wnn, State, ZIP 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 will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... 9--' No ........... ❑
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 S Cov71 C0r 1
to act on my behalf, in all matters relative to work authorized by this building permit application./
Print Owner's Name(EI L[ronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, [ hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Antllerszed Agent's Name(Electronic Signature) ate
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 not have access to the arbitration
program or guaranty fund under NI.G.L. c. 112A. Other important information on the H[C Program can be found at
%ww.nctss.eovi'oca Information on the Construction Supervisor License can be found at www.ntass._o�iclL
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:u'ca (sq. ft.)_ _ Habitable room count
Number of flreplaccs_ Number of bedrooms _
Number of bathrooms _ _ Number orhalt/baths _
I'ype of heating systcut --__- __ Number of decks/ porches -
Ftilieofcoolingsystem__--- — — Enclosed_
3 "Total Project Square [dotage may be substituted fir-Total Protect Cott" _ --_-- -
4.
i' CITY OF SM.Elf, AXSSACHLSETTS
1 BUILDING DEPARTNIEDiT
120 W.1SNLNIGTON STREET, 3� FLOOR
TEL (978)745-9595
Ria(973) 7404846
KI\[BERI EY DRISCOI L
MAYOR T l iOMAs ST.PIE.an
DIRECTOR OF PUBLIC PROPERTY/BUnDLNG CO\LMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Leeibly
Namc(0usiiwssy .0rganiratiorufndividual): S V, CO3aS 4-f t3>1
Address: I. AP(7al ooA a v--4--
City/State/Zip:Ltij� M/4- (5707& Phone#- �003 lfob% E6 lo.
Are y u an employer?Check the appropriate hair Type of project(required):
i. l am a employer with 4. 0 I am a general contractor and 1 6. ❑Now construction
employees(Nil and/or part-lima).• have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet t 7. I tfemodeling
ship and have no employees These subcontractors have 8. ❑Demolition
working far me in any capacity. workers'comp.Insurance. 9. ❑Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. C. 152.$1(4),and we have no 12.0 Roof repairs
insurance required.]t employees.(No workers'
comp.insurance required.) 13.0 Other,
'Any appllc:un[hat dtucks box el most also all out the section below showing their workers'compensulon polity inturmatfon.
'1 hwtwuwn m.who sutmil this airdavis indicating char am doing all work and than him outside contractors mug submit a raw amdavil indicting sack
:Contractors that chuck this box must allachod an additional short showing the name of the rubaantracton and[hair workan'comp,policy iniatsnmioa.
1 um an emplayer that Jr provlding workers'compensadan Insurance for my employees: Below&the polls y and fob sUe
information.
Insurance Company Noire
Policy 4 or Sclf-ins.Lie.Cil: Expiration Date6 O
job Site Address: I �4��r/ City/Statr/2ip.
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure covervge as required under Section 2$A of MGL c. 152 can lead to the imposition of criminal penalties of s
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of o STOP WORK ORDER and a line
of up to$330.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Oflica of
Investigations oftho DIA for insurance coveraga verification.
/da hereby certify under the pains uod penalties of per/ury Drat nine hrfurururlon provided above is true mtd correct.
Sinn nlre! ='1>" a-, ' Dare'
Phone;!•
OJJic iul use tiny. Du not write in t/r1r urre,to be completed by city at town ajjUad
City or"ruwn: __- __ Pcrmit/f.leeme ll _
Issuing Authority(circle one):
1. Board of ilculth 2.Building 17cpartinent .i.Citylraw,,Clerk 4. Electrical Inspector 5. Plumbing inspector
6.Olher _
Contact Person: ..- .__.._ _ Phone to:
CITY OF SM1 E\,I, NLSSACHUSETTS
I3uiwL\G DEP.kRTJMNT
�,t'rarF; 120 VUASHNGTON STREET, '3 F7.00R
T EL (978) 745-9595
KIMI3ERLEY DRISCOLL F-LX(978) 740-9846
,NL.%YOR T'H0.%w ST.PIERAE
DIRECTOR OF PUBLIC PROPERTY/BUILDDzG CO\p1ISSIONER
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 1 11.5
Debris, and the provisions of NfGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a property 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
L C I- S L-j-, o�
(name of facility)
GA a
(address of facility)--
signature of permit applicant
date
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