57 WARREN ST - BPA 09- 104 INSULATION The Commonwealth of Massachusetts
Board of Building Regulations and Standards FOR
F Massachusetts State Building Code. 780 CMR, 7th edition Ml1NIcl h,�l.l'I 1'
U
Building Permit Application To Construct. Repair, Renovate Or Demolish a Rcrisrd Janoan
One- or T o-Family Dwelling i =tNl3
n
This Section For Official Use Only
Building Permit No r: Date Applied:
v Signature:
B g mmissiuntr/InspVtorof Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Add�e�s� La�n(1r'ot� p { �7 1.2 Assessors Map
& Parcel Numbers
P Y s:7 1
i.la 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 ft) Frontage(li)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Requ ired Provided Require) Provided Required Provided
1.6 Water Supply: (M.O.L c.40. §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al ClOn site disposal system ClPublic❑ Private❑ Check if yes❑ P p" y
SECTION 2: PROPERTY fOWNERSHIP' -
2.1 Owner\jt �r
Name(Print) /� Address for Service:
S02 Carer I ga�
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work : 14
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ r
❑Total Project Cost (Item 6) x multi tier x
3. Plumbing $ 2. Other Fees:
4. Mechanical (HVAC) $ List.
5. Mechanical (Fire $ Total All Fees: $
Suppression)
Check No. Check Amount, Cash Amount:
6. Total Project Cost: $ — 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name uf'CSL- Huller List CSL Type(see below)
Type Description
Address
U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
RC Residential Routing Co\'erinit
Telephone WS Residential Window and Stdin
SF Residential Solid Fuel Burning. A llnlmce IIbIJl dnull
D Residential Demolition
5.2 Registe o m o t Contractor (HIC)
HIC C or HIC a is Registra
AJtiot Nm ber
ess z �_)� ��
TLJ ExP ira to ate
Signatu Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. 9 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 f 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
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. r
7
Si nature of Owner Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
I ,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.
Print
sigilfaCufe of Own r or Authorized Agent Date
(Si ne under the pains and penalties ofperjury)
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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and I IO.RS. 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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. '-Total Project Square Footage" may be substituted for"Total Project Cost"
FROM : Kll IBLY FRX N0. : 6033629675 Jul. 10 200B 10:05PM P4
HOW,IMPROVEMENT CONTRA('I'
S14d,haninlxnl and Ins ttllW by:
Branch Nam.:_ 7T�N DaW: r/J/ (I TI ID A1,1](it.Scniccs.ire:.
Tom— d/bAt '1'In home Uepnt At-I Innw Scrvims
345A G,eunwnod Stru:l,Wo ooslel MA 01607
.Branch Number. 3 l .Job#• '�YJtr„" 'full F=(800)657-1182; Fax:S08 756-2K59
° SJ.].5-M,Aa 1&1 M ii...ne'd Cy a."",kcis�'!324Y9�
Installation Address: J / Si Q///r/
L1ty State Zip
Last 4 Dieler of Driver'$
Pnnehxcr(v9: Lk.9&4 ".MWYr: Work Phone: Hone Potion:
Home Address: "-- --
(If di&ntit from Installation Address) City State lip
E-mail Address(it)receive updates ant promotions fmm The Home Depot):
Project Information: I(WeNou("Purohnsor"),the owners of tho pmpurly laneu:d at the abovo installatilm addmss,nlfcr to
contract with TM At-Houro Services,lie ("Notre Ihpuf')to furnish,duhvor and arrange far the imllallation of all rmlcdals
as described on the attached Spx Sheet# ,inuorpomted heroin by tefctuns,and made.part hereof.
Home Depot resi,mcs the right to cancel this contract it,upon reinspectitnr M'the Jab,Home Depot determines that it
cannot perform its obligations due to a structural problem with the home,pricing errors or because work required to
complete the job was not included in the Spec Sheet or Contract
DEPOSIT PAYMENT OPTIONS
' (tivalee[mfirM viceti¢atioo:loA/or crditaprw,valj
CONTRACT AMOUNT $ •! 7� I. c;ax�t+,t�,xn;e.xc:na:a:o.u+v,„rul sorv�tnoav clNor
�sde ry,.dhm m Ttu rralr�r>aPnp.
tLESS DEPOSIT $ 2. Ccau C,ra+•.. yr caner ra o ra.Px�� wiem-Curie One se
_--BALANCE DUE 2/ vix, M:Isrcral Discover Arrcr�nn P.,grresa
crx c-cs�.:r:.:7..avIv i� ]is liov:c llept Chime lmprtrvelmml.rxvn The DPrtt D¢Wt Crerlil C'.aM
tMinimuar 259:of C.ittract Amount due upon CI New Areouot ❑Erixdaq Accuuat (H1I.Y HO('C ONLY)
AVallahb Credit-$
Indicate Payersent Method For .ccry.}'tr�-ff� &emu t" •r7 a ____
It
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NOTIrr'• Annrm A'V:Sr.TVe'A" a!v a rnvrn•r•rrtar5 ' .A .. e I——
AND ....,.,.
.. .clr,TaT Of a nsS CV NTRACT
<16-08,ev4-2-07 46C MNC-Branch He Ylt Cudome!' Pink-Selea Cohsultsn!
CITY OF SALEM
rs PUBLIC PROPRERTY
DEI'AR'I'�IENT
'.1 'I: I_: U J 1;". .., '.11.111r11\II \I, \t.\ \ ., I . • .I'/ -.
III /'3 'J i I;-); ♦ I \\. 'i'.V 'A_ •ti 4,,
Construction Debris Disposal .affidavit
(re\IuiIcd lix all demolition and renovation \vurk)
In accordance %%ith the sixth edition of the State Building Code, 780 C NIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit 0 is ISSUcd with the condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
ar l rcl
I name of liaukr
The debris will be disposed of in
�Z
(name uf�ity)
Iuddres. of fu'ililvl
\ILI alUl l' of prnnit applicant
�al