10-1 WEATHERLY DR - BUILDING INSPECTION (2) r KIN Commercial and Other than One or Two Famil
° The Commonwealth of Massachusetts RECEIVED
`t Board of Building Regulations and Sta
'j �:CTIOPIAL SERlIC
Massachusetts State Building Code, 780 CMR Edition NIQ
Application to change use,construct,alter,renovate,repair or dem 41
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4 I( i- s Nv✓,
n Building Permit Number: Date of application
Signature AV-2
Buddm Commissioner/Lac ns ectof Date
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` — 1.1 Property Address:
1.2 Assessors Map&Parcel Numbers
1.1 a 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(ft)
1.5 Building Setbacks(feet)
Front Yard Side Yard Rear Yard
Required Provided Required Provided Required 9 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?
Check if yes ❑ Municipal❑ On site disposal system ❑
1.9 ZBA Special Permit 1.10 Old &Historic Commission 1.11 Conservation Commission
Date Bled N/A ❑ Date filed N/A ❑ Number 40- N/A❑
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2.1 Owner of Record:
-�>ATKIC1A Q rt�ONNE� /(/� / G✓EY+-ri/EzrL �s�,
Name(Print) Address for Service
D&-5 90-a66�
Signature of Owner Tele hone
'�.�.n• Y4.� "�
New Construction❑ Existing Building❑ Alteration(s) ❑ Addition ❑ Repairs(s) ❑ Demolition❑
Change of Use ❑ ❑ Change of Occupancy❑ Other ❑ Specify:
Description of Proposed Work: j�(.:aAGI�� ��-(/EST �-�(l a�.t�
,
' .
Item Estimated Costs
(labor and materials) Tkis Section For Official Ilse Only
I. Building $ Building: $10/$4000
2.Electrical $ goo ae B'uilding+Pl'umbing: $12/$1000 wilding+Electrical: $13/$1000�
�e Building+Electrical+Plumbing coin ined: $I5/$1000
/
3.Plumbing $ � c-
6
Total project cost(labor and materials)$
4. Mechanical (HVAC) $
5. Fire Suppression $ Fee multiplier from above$ $1000
6. Total Project Cost $ o'u `� Permit Fee$ Receipt Number
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.aka g�. F M
deV<" "ti.5.."a` ..e}' :U F `.,d ,H . ti^i Y 'urx; .i
5.1 Construction Supervisor License(CSL) KK t
J'141� x f I• License �037�� Expiration Date747- �
Name of CSL Registrant -T Description.
30 �Eu%tq-/l /�,,. Unrestricted(up to 35,000 Cu.Ft.)
Addresses R Restricted 1&2 Family Dwelling
// � r•Z�9 M Masonry Only
ure RC Residential Roofing Covering
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WS Residential Window and Siding
Telephone SF Residential Solid Fuel Burning Appliance
D Residential Demolition
5 Home Improvement Contractor Registration(HIC)
---I'IGE5Ct S(CJU OEty rVC"' Registration 6 Expiration Date
HIC Company Name or HIC Registrant Name
30 S67-_�Wn cJ T
Addres
Signature
Telephone
HEM
Worker's Compensation Insurance affidavit must be completed and submitted with this application.
Failure to provide an insurance affidavit may result in the denial of a building permit.
Signed affidavit attached? Yes ❑ No ❑
a -
I, D Cep e , as Owner of the subject property,hereby authorize
s by�ldc� t application. to act on my behalf in all matters relevant to work
au tied thi per
e � ✓� /—/y—/S
Signature of Owner Date
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a
aMIT. 1 .Erlwa
1, /y twg(t t J)/K , as Owner or Authorized Agent,hereby declare that
the sta s an in oing application are true and accurate,to e best of my knowledge and belief.
Mgnature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 I IO.R6 and I IO.RS.
When substantial work is planned,provide the following information:
Total floors area(Sq.Ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(Sq. Ft.) Number enclosed of decks/porches
Habitable room count Number open of decks/porches
Number of bedrooms Number of fireplaces
Number of bathrooms Type of heating system
Number of half/baths Type of cooling system
QTY OF SALEM, MASSACHUSE M
F
t_ ) BUILDING DEPARTMENT
120 WASHINGTONSTREET,3wFLOOR
TEL.(978)745-9595
K8OERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER
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 111.5 Debris,
and the provisions of MGL c40, 5 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
ra*A )'ix'e, Y
(name of hauler)
The debris will be disposed of in:
(name of facility)
Y4'v
(address of facility)
Signature of a licant
Date