36 WEST AVE - BUILDING INSPECTION s
The Commonwealth of Massachusetts CITY OF
/}(,�, �.• Board of Building Regulations and Standards
Massachusetts State Building Code,730 CNIR Sd Xfar RavisedMar20/!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One.or Tivv-Family Dwelling
This Sact on ForOfficial U nl
Building Permit Number:.." Date
Building Official(Prtnt Nime) I, Signatur e
SECTION l:SITEINFORMATION
1.1 Property Address: 1.2 Assessors Nlap& Parcel Numbers
�q 26 Ir, ,)4 &e .%10-n1 I YMA
1.1a 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(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required r 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❑ On site disposal system ❑
Check if yesO
SECTION Z; PROPERTY'ONYNkRSFIIPt
2.1 Owneri of Record:
t��ndr�rc i�rehtne� t zzct 1 M,- OIY'70
Name(Print) City,State,ZIP tt -
�Sio wPS c}
� Ave 'iP�-S��'F',5)6 �tf[Fnbt-14ii �Y4�ao.Ct :
No.and Street Telephone Email Address
SECTION 3: DESCRIPTI N OF PROPOSED W RK''(check a that apply}
New Construction ❑ Existing Building Owner•Occupied Repairs(s) Erl Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
YP PIkP 'i5�t�9 Y_tlt2
SECTION 4: ESTINIATED CONSTRUCTION COSTS-",.
Estimated Costs:
Item Official Use Only
Labor and Materials)
1. Building S DOO 1. Building Permit Fee:S' .Indicate how fee is determined:
�. F.Icctriatl 5 ❑Standard.CityCPown•Application Fee `
❑'fatal Project cost'.(Item.6)xmultiplier x
3. Plumbing S / 2. Other Fees: S
1. Mechanical (IIVAQ S List:
5. Jlechauical (Fire $ /
!'oral All Fces:3
Check No. _Check Auwunt: Cash auwmit__
e, I'mal Project Cost: S I DD 0 ❑ Paid in 171111 0 Outstanding tlulsnce Ohio: __-- -- -_
SEC'f1ON 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number — Expiration Date
N:une of CSL I!older
List CSL'Type(set below)
No. and Street M
Description
stricted Buitdin s u to 13,000 cu. lt.
icted 1&2 Famit Dwellin
Cityfrown,State, ZIP nr
n Covering
ow and Siding
Fuel Burning r\ppliancos
tionTele hone Email address lition
5.2 Registered Home Improvement Contractor(111C)
HIC—Registration Number Expiration Date
I IIC Company Nome or IIIC Registrant Name
No.and Street Email address
Ci /Town,State 'LIP Tel e hone
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 DE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, 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.
Print Owner's Name(Electronic Signature) - Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
vcontained in this.application is true and accurate to the best of my knowledge and understanding.
Print owner's err Autll riled:\gent's N,uno(Electronic Signautro) Date
NOTES:
1. An Owner who obtains a building permit to do his/her own work,or:m owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(H[C) Program),will nor have access to the arbitration
progr:un or guaranty find under M.G.L. c. I42A. Other important information on the HIC Program can be found at
www m;us.cuv=ora information on the Construction Supervisor License can be Found at ivwiv.mas .^aiv�IL
IF2. lb'hen substantial work is planned,provide the information below:
I tlour area(. R.) _ __ _(including guragt, finished basemenVattics, decks or porch)
dross tiving;urea(sy. I labitable room euwtt —
Numberoftireplacci--_- ----- Numberotbedrooms
lumber otballuoonts - Number oflmlfbailis -----_-- --
-- - —
I'cpu of heating systcut .. -----._-- Number otdecks/porelics
I\peof Cooling ;y„lem Enclosed-- open
l i. "I,ird I'nq�a 1yu.iro I�not.�,e" in.iy he snb;tihit, l t;,r 'I„r.il I'rujc.( l'o;t"
l
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CITY OF 5.1[_E.ti[, ANWS.lmusFT s
8[:[t0LXG DEPARTNtE` r
V4/."j4C4GT0N STUIM 310 FLOoit
{ T'EL (978) 143-9595
f<IS[OE2LEY DRISCOLL FU(973) 7-10-934-5
,b Ckyoa 11'0-sW Sr PtExu
DI TECM10F Pt:t7L1C PR0PERTY/8t:(LDLYG COSt�[[S5IO.V ER
Construction Debris Dispasai Aff1davit
(required for all demolition and ronuvation%vark)
In accordance with the sixth edition of the State Building Cade, 730 C1dR section 111,5
Debris, and the provisions of tMOL a 401 S 34;
Building Permit is issued with the condition that tha debris resulting from
'his wurlt shall be disposed of in a properly licensed waste disposal raaility as defined by NIGL o
I 11, S 150A.
The debris will be tr'mspartcd by:
�, -.satin �t��tiold 'l
The ticbris will bt:disposed of in :
Ai_L BOA �YnG
(nama of Clctlil/)
10—It i11111 l
;Corot:o(permit applie.t
3 —.._—
i
CITY OF S.U-ENf
PUBLIC PROPERTY
DEPARTMENT
V 11>♦AalJtSi ti� r
'AAVUS
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HOMEOWNER LICLNSB E.Xj..MFrjO,V
Ptew print /r
Daq�' /T
lob Location , 3(p Wo l Ai, I �c Mewl
Home Owrser Address , fir. tl e s+ A✓:�1, xAr4
HomsOMwTelapboas 9-7g,�y_R
PreseenMaiUngAddress �( M1c }_ �„ e_�- -- A• A n1970
The current eserapdon o/"Homaowaffe was extended to include owner-oeeupieid
dwellings of"" Units or ten asd to allow such homeowner to enpp m irsdividual for
hit who does riot Possess a liteas4 r ovidod that the owner Atli as aupa W*W.
DERNMON Op HOM80WNE3t
Persons) *be owns a pared of land on which hdshs resnldes or Intends to redd@6 on
which there is; or is intended to bob a ors or two &Wly dwell6sg, Attached or detached .
strnctuM wcessory to.arch use usd/or/Arm atructurea A Parson who conaMMU more
than one home far a two year Period,shall not be considered a homeowner. Such
"homeowner 'iW submit to the Building OQkiA on a form acceptable to the Building
Oi feial. that hNshe be responsible for all such work performed Permit under the Building
The undersigned "homeowner"urma regwnsibiiity for compliuses with ths_Stats
Building Code and other applicW@ bylaws ud rg Wsdons -
The undersigned "homeowner cefsilfes thu he/she undentAnds the City of SAlem
aBuilding Deparmsent minimum inspection procedures and requirements and that hdshs
.vill comply with said Proctsdures uad requirementu
HOMEOWNERS S1G.VA TIRE
kPPROVAL OF 3UILD1VG OiSPECTOR
See Other site far state code