80 R WHARF ST - BUILDING INSPECTION ?�4 - d��0�'b ro3 �
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7 h edition OF aJ ERemedEM
Building Permit Application To Construct, Repair,Renovate Or Demolish a 1,2008
One-or Two-Family Dwelling
This Section For Official Use Only
t� Building Permit Number: Date Applied: 2 22 'j
Signature:
41*
Building Cot imissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1 �p�eSty flddress„S /uN r 1.2 Assessors Map&Parcel Numbers
1.1 a is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: IA 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 Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public PI Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: -
ht'r-
Name(Print) Address for Service:
Signature%' Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work : i
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 $ ❑Total Project Cost'(Item 6)x multiplier
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ '
Suppression) Total All Fees:$
�i,,r�.- Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ }c u�/��� 13 Paid in Full 0 Outstanding Balance Due:
CITY OF S.1I.&M, NLUSACHUSEM
Bl:MDLNG DEPARTSMNT
120 W.t5H1NGTON STREET, 3"FLOOR
TEL (978) 745-9595
F.►)t(978) 740.9SM
KIJBERIEY DRISCOIl
MAYOR THOMU ST.PD>eUS
DIRECTOR Of PL BLIC PROPERTY/RI:ILDLVG COSMUSSIONER
Workers' Compensation Insurance A111davit: Builders/Contracton/ElectrlclaniVPtumbers
ltsnllcant Information Please Print Legibly
Valnalllwimv.Orynuariorrlm4/r�ldual): /�Gtil�wtr
Address:
cily/State/zip: Phone
►re you ao employer?Cheek 1ho appropriate box:
Typo of project(requlrea
1.Q 1 am a employs r with 4. ❑ 1 am a general contractor sad 1
rocsycve(full and/or past-time).• have hired the atbcoraracter 6. ❑New construction
y�2.L17 1 am a sake proprietor orpartner- tilled an the anschad district. : 11 7. Q Remodeling
ship and have no employee Then subcontracwes have Al. Q Demolition
working for me in any capacity. worker'comp.insurance. 9. Q Building addition
(No worker'comp insurance S. Q We are a corporation and its IO.Q Electrical repair or aeltliniom
required.) olAeas have exercised their
J.❑ 1 am a homeowner doing all work right of esemprion per MGL 11.Q plumbing repairs or additions
myself.(No worker/comp. C. 132.f 44)r and we have no 12.0 Roof repairs
insurance required.)t .mplayee.(No worker' I).❑Od1er
comp insurancerequire&J
•Any appetaa Iht Charlie bsn e1 tiara Allier no aw IM aaia belle abrwiaq their vakara•canpndir perky inAw"wedon,
'I I.wewawm who submit this aMldert iediadne May m Joins sit weakens than like memiee eeanuom Ind sulank a rive aMditii indkriq euek
T.wwrernon ahem cbetk Ibis time n1lse stiath d ea 3deleiml+M sMwiay she rena or dso wde,,e sMn sad Ihek w—ba ,ramp.Policy infasmaara.
I oar an emrphryer that bt psavidbaR werters'roarpeasadam lieseremeojer may tarploytes Ot/wr hr Ihf pNley ewd/oI sloe
ireforte ail"
Insurance Company Name:
Policy a orSelf•ins. Lie. p: Expiration Dar:
rub Sire Address: City/StatdZip:
.►mach a copy of the workers'compensation policy declaratloa page(Allowingthe policy oumMr and sxplraHoa data)6
h'ailum to secure coverage as required under Section 23A of MGL a 132 can lead to the imposition of criminal penalties arm
fine up to S 1.500.00 and/or ono-year imprisonment,as well an civil penalties in the farm of a STOP WORK ORDER and a Hsu
Of up to S250.00 i day against the violator. Ile advised chats copy of this statement may be forwarded to the Oayten of
InYC)Ilaallans al'dte MA for insurance coveralls veritieaiiam,
l do hereby Car /y under rho pins and penaldcs al crimpy that the inlaratolae provided above is true and carrrea
�SIZZ
OQicial use only. Do rat write im this area,to be.arreplerd by city or town olpe-iml
City or fuwn: YcrmiNl.lcrnte e
hsuing.►uthorily (circle une):
1. Iluard sitllvullb 2. Huildlny) Department J. C'ilyfrown Clerk J. ftecrrical Inspector S. Plumbing Inspector
6. 01 her
L•,ntacl Person: __ _. Phone e•
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) f4941 -0 ZD `0
4 V' lyd&41, License Number Expiration Date
Name of CSL- older List CSL T see below r/�'
/01 /l/�,-� �G� �- t�� Type( )
Address Type Description
U Unrestricted(up to 35,000 Co.FL
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
! RC Residential Roof Covering
Telephone �'7d��, ,��� — WS Residential Window and Siding
cc SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 istered omejmprovement Contractor(HIC) d—%ff
HIG Company Nor HIC,Registy nt Nam / Registration Number
65 � a s G<j
Address xpiration Date
Signature Telephone
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 .......... 0-" No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I Try, . �J ,�wtrai 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
yf" SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
I, �a✓„ i/' / <�`��G 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 me 1-2-
Signature of Owner err Apffiinifed Agent Date C
(Signed under the pains find penalties of )
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.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basementlattics,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"maybe substituted for"Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
'W: HIF.1 !'NM '';II
\I`.,"I/ I'f)�'.,it ll.\1::�,N�l'N ErT 1•\I I'\f, St.KiAt It :I I : :I'/
IEI:'/7tl-N 7iY$ 978-7449846
Construction Debris Disposal Affidavit
(required I'ur.tll demolition mid 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 he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
(
name of hauler)
The debris will be disposed of in :
p,ame of ocl ,ry)
(address of facility)
l.�
,gliP re Ixm,it applicant
dote