36 WARREN ST - BUILDING INSPECTION fJ The Comntonwcalth of Massachusetts Town of
Board of Building Regulations and Standards
^ � Massachusetts State Building Code, 780 CMR. T"edition Budding Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a �
One-or Tuo-Familt Duelling
This Section or Official Use Only
Building Permit Num Dale Applied:
Signature: O
Buddin Commissioner/ f tidings Date
SE T ION 1:SITE INFORMATION
Property Address: 1.2 Assessors Map 6 Parcel Numbers
L 1 pe y
1.Is 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 n) Frontage I it)
1.5 Building Setbacks(B)
Front Yard I 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: 1.3 Sewage Dip steel System:
/ Zone: _ Outside Flood Zone? Munici I L9'On site disposal system ❑
Public H Private❑ Check if esO w y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record
Na -3Girc� -
Print)
AdAress for Service:
Signature _ Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ Owner-Occupied X I Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units' 17— Other ❑ Specify:
Brief Description of Proposed Work':
gisdetemined-
0 SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use OLabor and MaterialsI. Building f Q d 1. Building Permit Fee: f Indi Standard Ciry/Town Application Fee2 Electrical f ❑Total Project Cost'(item 6)x multipl1. Plumbing f 1. OtherFees: f
4. Mechanical (HVAC) f List:
t Mechanical (Fire fTotal All Fees: f
Su resstonCheck No. _Check Amount:
6 Total Project Cost: f �OO ,/ 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licenssed_Construction Supervisor(CSL) 0 ?
License Number Expintion Date
N.4mc tit Cs . Ilylder J List CSL Type(,cc below)
o GeQf ire f�A�
Add s r Description
re
U Unrestricted(up to 15.000 Cu. Ft.
R Restricted 1&2 Family D%elbn
Si lure �bi M Mason Onl
96,�"�6 q 7 RC Residential a;finjiCovcrmji
Telephone w'S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered His a Imp ovemeot Contractor(HIC) L L
_1 eSe 6Af =,v o n/ d to T
HIC Company or HIC Registrant N Registration Numbers
�;772 4P6 z(F-) Expiration Date
n rc Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.S 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 lssuance of the building permit.
Signed AfTidavit Attached? Yes .......... 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
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are we and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
Si ned under the poins and penalties of perjury)
Noyes:
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 Iff have access to the arbitration
program or guaranty fund under M.G.L. c. 1 S2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I MR6 and I I O.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished bamment/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 hearing system Number of decks/ porches
Type of cooling system Enclosed Open
1 "Toul Project Square Footage" may he substituted for 'Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
M 11 nc 120 WAinINC:I ON SCRrrT • SA IAI. MASiM I It it I'!i 3l't%-
Fri:978-743-9595 • FAX:978.740.9846
Construction Debris Disposal Affidavit
(required I'ur 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:
IdsP � �rAQV,
(name of h r)
The debris will be disposed of in
(flame of facility)
✓✓/n i0 V'T
(addres� od facility)
signatu '{xrmitapplicant
date
Icln isall due
CITY OF S.1L.E.`[, , LkSSAC1iUSETTS
Bt:BDLNG DEPART.IENT
120 WASHINGTON STREET, )sa FLOOR
TEL (978) 745-959S
FAx(971) 740-9&M
KISBEItLEY DRISCOLL THObL%SST.PMRRS
MAYOR DIRECTOt OF PLBLIC PROPERTY/SUILDLNG CONL%rtSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Nettle Idusineas.Ortanizatiory lndnvtdual):� ,/�, G'��n�a
Address: �� le✓��.A e�c� /�2 //�
City/State/Zip: `lQ�o �� O� 96 Phone k: 9'7 Y— 26 51
,►re you to employer?Cheek the appropriate box. Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a gentral contractor and 1 6. ❑New construction
mployees(full and/or pan-time).• have hired the subcontractors
II am a sole proprietor or partner- listed an the attached sheet : 7. ❑ Remodeling
;hip and have no employees These subcontractors have 8. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
(No workers'camp. insurance S. ❑ We am a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
J.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. C. 132.4l(4),and we have no 12. Roof repairs /�
insurance required.] employees. [No workers' 13.9Other BR`R ReW J&S
comp. insurance required.] J� I -
.Any applicant live chocks bus el mull also rill wr Ihr victim below shswitq,1wir workers,eprryenayl"policy infurmallon
'I hvneuwttaa who sulunit this antdsvis indliming they am doing all work and thus him ouiside cattawam~suhmk a tiros amdevis it liuring;tuck
?.mouton that cheek this hors mud attached an 3"liutd Awd showing dr mime of tr Nb Mmi sag and tk k woham'come.Policy infasmdm.
l am as ezployer that is providinif workers'competnsatioa lnsarvisce for my ensp/ayerg Blow/s the Paley andm slh -
informatioru
Insurance Company Name:
Policy N or Self-ins. Lic. N: Expiration Date:
Job Sire Address: City/State/Zip:
,►Hack a copy of the workers'compensation policy declaration page(showing that policy number and esplrsdom date).
Failure to secure coverage as required under Section 25A of MGL c. 132 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 Rix
of up in $250.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the Office of
Inacaugatiuns ol'the DIA for insurance covcragoveritication.
/do hereby errtify under rho pidas and peas s of perjury that As information provided above is true and correes
Win•r t r ' f� r��j -y ci qut : _� �''O
Phone a: 9—
iOfficial use mtly. Do nor write in this area, to be currnpleted by city or rows o/Jieial
City or Tusvn: __ Permit/I.Iccnse M__,
issuing.%uthurily (circle one):
I. Board of Health 2. nuildinli;Department J.C'iiylrown Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: _ _ __, _. Phone N'