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37 WARREN ST - BUILDING INSPECTION (2) cP J" GK 11R'1 ggoat The Commonwealth of Massachusetts Board of Building Regulations and Standards 3 1LEM '•lam✓ Massachusetts State Building Code, 730 CMR Revised blur?0/I Building Permit replication"Co Construct, Repair, Renovate Or Demolish a One-or Tivo-Family D+vellit q This Section For Official Use Only Building Permit Number: Date A lied: S Building Olticiai(Print Name). Signature ^ 3 DD t SECTION 1:SITE INFORMATION` I.I Property Address: 1.2 Assessors Nlap&Parcel Numbers /A� i n 1.la Is this an accepted street?yes,___ no. M1lap Number Parcel Nwnber 1.3 'zoning Information: 1.4 Property Dimensions: 1 Lot Area(s It Fronts a It 3 Zoning District Proposed Use q ) g O 1.5 Build Ing 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: 11.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑ Checkif es❑ SECTION 2: PROPERTY OWNERSHIP' 2. Owned o ecord: r +1Iae(Print) S City,State,ZIP ' Nu.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) I$ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief'Description of Proposed\York: r0'P, SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) I. Building S G� d U(/ 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard CitylTgwn Application Fee 2. Electrical S ? ® 00 ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing S 00/) 2. Other Fees: S I. Mechanical (FIVAC) S List: 5.;Mechanical (Fire S Total All Fees:S Suppression) Check No._Check Amount:-Cash:lnunmt:_ 6. Total Projcet Cost: S D 000 ❑Paid in Full ❑Outstanding Balance Due: St✓ MAIL, `7-9H IT To �oNT12hc�Tz MNALGID 3120[tt.\ E s s D Pert 'SECTIONS: CONSTRuc TON SERVICES 5.1 Construction Supervisor Liceue(CSL) CS 1�1y 2eZ / / Ll r / Z���N r S License Number E.g truti n Date / Name ooff CSL[folder / List CSL'rype(see below) / o) Zra o7 ,y�rrG�A+� fypo . Description No.and Street //\� U Unrestricted(Buildings tipto 35,000 cu. 11. J/q a/ °/ o�3 1t Restricted 1&2 F;unily Dwelling Citylfown,Slate,ZIP iIvl Nfasonry RC Rooting Covering WS Window and Siding C/ SF Solid Fuel Burning Appliances t /0/�a �t ma t C nw 1 Insulation Felt hone Enmil add ss I D Demolition 5.2 Registered dome Improvement Contractor(HIC) �P?63-,� / u B ' &�—S [IIC Registration Number Ge Tiro[' n Uate I IIC Cenp;m one ur[II egistran Nam,�J O/ , .J NagSN e S-�P% ! Fs Email address ' City/Town,State ZIP Tele hone Eye i �� 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 .......... ❑ No...........❑ SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PEPAIIT I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNER[OR AUTHORIZED AGENT DECLARATION By entering my name below, I 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. t5al Print Owner's or Authorized Agri s Name(Electronic Signature) Date NOTES: 1. 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 Lint have access to the arbitration program or guaranty fund under NI.G.L.c. 142A.Other important information on the HIC Program can be found at eww.ma.cs. )v:oca Information on the Construction Supervisor License cam be[bond at www.movaoa'JL When substantial work is planned, provide the information below: 'total floor area(sq. It.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. It.) 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;ubstiluted for 'fotal Project Cost" I 4Aassacnuu,l ga4at Oa of F13Iic cia'Js w � Baaia�f 3u".!aFn�fteo;daCons..>_n�Szaraas3a C.>numcnnn supen'kor i d✓' / 0 ? �� � i.;cer..s,cs-( aa12 DANVERS AtA 61923 :�: w10112014 N 0 0 N N m } t CITY OF SALEM, ANSSACHL'SETTS BUILDING DEPARTMENT 120 WASHI dGTON STREET, 3A°FLOOR .. TEL (978) 745-9595 FA-x(978) 73()-9846 KINBFRf FY DRISCOLL LiYOR THOMAs ST.PIFxRE DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\l\11SSIONER Workers' Compensation Insurance Affidavit: Builders/Contractorv/Electricians/Plumhers Ap ilicant Information �+ / Please Print Legibly Nalne (13usine�sGrganiratiowlntlivirlua h l): 44 YRPr�r ?t /iHe L>rJPn?ia� 9U(,tr✓t001i�int / J Address: IO) �i—wv�lTr�B�^f ✓� City/State/Zip: �,.YI ✓ers AM 09a3 Phone N: �9 9— Are you an employer?Check the appropriate box: Type of project(required): 4. ❑ I am a general contractor and 1 \ l.❑ I am a employer with b 6. ❑New construction ,..,jniployees(full and/or part-time).* have hired tho subcontractors 2.'iSJ 1 am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling ship and have no employees These sub-contractors have S. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9, ❑ Building addition [No workcri camp. insurance S. ❑ We are a corporation mid its required.) officers have exercised their l0.0 Electrical repairs or additions 3.❑ 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.)1 employees. [No workers' comp.insurance required.] I3.❑ Other •Any applicant ilut checks box AI must also fill out the action bdow showing their workers'compensation policy infli matiun: 'I L,mcuwn,.ns who submit this affidavit indicating they arc doing all work and then hire outside contractors most submit a new affidavit indicating such. =C,mtnctorx shut chak this box must anachsd an additiunal shoul showing the manic of the subtonlnctors and their workers'comp,policy information. I wn on employer that is provldiiig workers'compensation insurance for my employees. Below Is the policy and Job Nile infori nation Insurance Company Vine: __..---- Policy 4 or Self-inns. Lic. H: Expiration Date: Job Site Address: City/State/Zip: Atlach a copy of the workers' compensation policy declaration page(showing the 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 a line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the !'arm of STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of invcstigwiuns otthe DIA Fur insurance coverage verification. I do hereby certify under th pahts whd penallies of periury that the inforvnuton provided above is true and correct. S'„nos t l c - Date: _ J At . Phone,4: Eer wdy. no not virile in this area,to be completed by city or Iowa official n: _.__.. . .__ Pcrmit/I,lccrneX________ hurily(circle arse): BoardHealth 2. Building Dcparbttcnt 3.City/town Clerk 3. Electrical inspector 5. Plumbing Inspector -_son: Phone p: ----_.---_--_ — I y4, CITY OF SOU E1,I, NSSACHUSETTS BLILOLNG DEPARM&NT } 1?0 MQHLNGTON STREET, 3W FLOOR TEL (978) 745-9595 F-kx(978) 7d0-9845 K(JIBERLcY DRlSCOI.L &LAYOa T-IOSLAS ST.PIERItH DIRECTOR OF PUBLIC PROPERTY/8l.'I-Mr,CO.%OtISSIONER Construction Debris Disposal Attidavit (required for all demolition and renovation work) In accordance with tile sixth edition of the State Building Code, 730 CMR section l 11.5 Debris, and the provisions of t1MOL c 40, S 54; Building Permit kk is issued with the condition that the debris resulting from this work shall be I 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by tNIGL c The debris will be transported by: s Gar a (name of ha •r) The debriri/s will bo dispos/ed' of in // O✓/ �7 Slp/��Gr✓ 7�i ti� _. (name of t:tcdity) —�`—' _J�0/'lei, (address o1 tatility) signature of permit ap 'cant — N37, e SearchResults Page 1 of 1 The Official Website of the Executive Office of Public Safety and Secunty(EOPSS) Mass.Gov Home State Agencies Search Results • Select the licensee name below for more information. If your search produced more than one page, you may select page numbers at the bottom of this screen.) • Select the Search for a Person or Search for a Facility button to perform a new search. • Select the Preview File button to view a sample of the fields included in a file you can download. • Select the Download File button to download a text file of your search results at no charge. • Select Public Information Re uest Form for a form to order a data file. Search for a Person Search for a Facility Preview File Download File Name License Number License Type License Status Address BRUERJES EDGAR CS-044412 Construction Supervisor [Active JDANVERS MA 01923 1 ©2011 Commonwealth of Massachusetts Site Policies Contact Us t http://elicense.chs.state.ma.usNerification/SearchResults.aspx 3/18/2014