10 WHITE ST - BUILDING INSPECTION (12) ash lot
The Commonwealth of Massachusetts
` Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7i°edition OF SALEM
A Revised Jmurary
\ Building Permit Application To Construct, Repair, Renovate Or Demolish a L :rRhY
One-or Two-Fu Dwelling
This Section or O tc al Onl
Building Permit Number: DatejVlhd
,
Signature: ,
ui d' Commissioner/ sped uildings illlj-�
''}ale
SECTION I:SIT• INFORMATION
1.1 P 7rly AA ryu/ S f 1.2 Assessors Map& Parcel Numbers
1.12 Is this an accepted street?yes no Map Number Parcel Number
I.3 Zoning information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq 11) Frontage(it)
1.5 Building Setbacks(R)
From 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:
Zone: _ Outside Flood Zone?
Public O Private O Check if e30 Municipal O On site disposal system O
SECTION 2: PROPERTY OWNERSHIP'
I Owner'of cord:
W PrL ,da'it /YI
No (Prim) Address liar Service:
azure Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check aB that apply)
New Construction O Existing Building O Owner-Occupied O Repain(s) O Alteration(s) O Addition O
Demolition O Accessory Bldg.O 1 Number of Units Other 45 Specify: T/ . 767
BriefDescriptii ofPropgsed Work,:
'77) C'RPr f- n o Wye) e: �� O✓1
udr
SECTION 4: ESTIMA ED ONSTRUCTION COSTS
Item Estimated Costs: Orflclal Use Only
Labor and Materials
1. Building R57S-0a-D
1. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical O Total Project ost'(Item 6)x multiplier x
3. Plumbing 2. Other Fees: S �(
4. Mechanical (IIVAC) List:
5. Mechanical (Fire
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: 13 Paid in Full 0 Outstanding Balance Dues
s
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) O 6Ga I, Y
M� 1T/ �Aa/n ti License Number Ex tnlion Irate
33 o bfu yler�� �(� )4m el vm M List C'SL Type)see below)�—
�p f Description
U (lnrestricteJ(up to 33,OW,000 Cu.Ft.
/� R Restricted Id2 FamilyDwelling
7,S�7�v� M M (hJ
RC Residential Roulin C'overin
I'depMme WS Residential Window and SiJin
SF Residential Solid Fuel Bttmin A liana Installation
D Residential Demolition
5. �Isstersd Homes Improvemeet Cootraetor(HIC) /�� l7��
// q !c 7/t a /<o
I IIC Comppa��yy,,fN�1ameysHlC Regtst Registration Number
�c /—fGi h-MI-1 t7 1 d/rt� Ali
—5/azro FApiratinh Date
signmure Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.15L f 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..........O 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 -P P2S'f/r1 ah n K to act on my behalf,in all matters
re at to work auth ri by this building permit application.
t
ure of Owner Dale
SECTION 7b://OWNEWR AUTHORIZED AGENT DECLARATION
1 e2S OYN pa H- Co.,C 4, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are We and accurate,to the best of my knowledge and
be
Pr /tim4;l�Oge'/�.i
Sii ra`•luum ol'Owner or Authorized Agent Da(c—TT
7iolal
f
and penalties of 'u -
NOTES:
btains a building permit to do his/her own work,or an owner who hires an unregistered contractor
the Home Improvement Contractor(HIC)Program),will ad have access to the arbitration
nty fund under M.G.L.c. 1J2A.Other important information on the HIC Program and
ervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 1 IOAS,respectively.
2. substantial work is planned,provide the information below:
rs 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 ofcoolingsystem Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
- -- _ CITY QF SALEM �_ -== �-- --
PUBLIC PROPRERTY
DEPARTMENT - - - -
KINtBERlFY DRISCOLL
MAYOR 120 WASHINGTON STREET ♦SALEM,MASSACHUSE TS 01970
TEL:978-745-9595 ♦ FA-x:978-740-9846
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /Please Print Legibly
Name (Business/Organization/Individual):
Address:
City/State/Zip: 6/17 Cl2t 3 f OI LvI Phone 4:
Are you an employer? Check the appropriate box: Type of project(required):
-1. -I-am a-employer-with.2o-ea .-_ 4.- ❑ -I am a general contractor and I _—6.-❑-New-construction
- - - r- - have hired the sub-contractors - - - - -
employees(full-and/oi part=dme). T 7. ❑ Remodeling
2.❑ I am a sole proprietor or partner- listed on the attached sheet.
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [No workers' comp. c. 152, §1(4), and we have no 12.❑ Roof repairs
insurance required.] t employees. [No workers'. 13.0 Other:� eM�
comp, insurance required.]
'Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and their workers'comp.policy information.
I art an employer that is providing workers'compensation insurance for my employees. •Below is the policy and job site
information. / / -
Insurance Company Name: ve h 4S'✓4!- " 4- 'ELT —
Policy#or Self-ins. Lic.#: �o�� L Expiration Date: U 9 Z
Job Site Address: /U t !?/ �T City/State/Zip:J_ �/YI
Attach 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
Fine up to$1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under
the pains and penalties ojperjury that the information provided aabbove .s ttrr a and correct
Signature . !T/l/K�q �flfl�lt� Date•
Phone#' ---
Official use only. Do not write in this area, to be completed by city or town okklaL
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2. Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: — Phone#: —
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IMPORTANT U ENTrrJP � JPJSJ7
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L1 ISSUED BY 5
5 � �f --� Dale of Shipment CI
REGISTRATION o- .
Q® 5/12/2008
5 NUMBER (7 ,. w —Jinious�ines iruC
EVANSVILLE, INDIANA 47725 Tent Identification C
PI-00.1 va aP °r MANUFACTURERS OF THE FINISHED 046f8268 j
S TENT PRODUCTS DESCRIBED HEREIN — �J
5 This is to certify that the materials described have been flame-retardant treated
ray (or are inherently noninflammable) and were sDpplied to:
Lj 657150
5 PETERSON PARTY CENTER INC C�
5 139 SWANTON ST ZI
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5 WINCHESTER MA 1890J
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5 Certification is hereby made that: r�
The articles described on this Certificate have been treated with a flame-retardant approved
S chemical and that the application of said chemical was done in conformance with California
5 Fire Marshal Code. All fabric has been tested and passes NFPA 701-99, CPAI 84, ULC 109.
5 Serial # S
8020500C(2)
5 Description of item certified: 5
5
rl E$TA TOP 20X40(I PC)SNYDER 5
5 Ho//102397oA 5
Flame �etardant Process Used Will Not Be Removed By 5
Washing And Is Effective For The Life Of The Fabric
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SNYMEG NFW PHII„ADE Slgned:I,PHIAOI1 ��'� / (�`.-q'of Applicator of,Flame Resistant Finish ANCHOR INDUSTRIES INC.
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Aco�D CERTIFICATE OF LIABILITY INSURANCE
T1-I!S CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON TF,'E CERTI �HOLDEE�Tr,:S
CERTIFICATE DOES NOT AFFIRMATIVELY OF. NEGATIVELY ALIEND, EXTEND OP. ALTER THE CO`iERA.G=_ C., TH-
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C -. T.;6 CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A COf.TRACT EET!Ctr-N THE ISSUING o IEP.(S
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IMPOR T'f;T: If Ina cerli;ica helder is ar ADDITIONAL INSURED, the poCcy( esl ^'_>t tee o_r s If SUEROC-�.0.' IS _
the terms aid cer.d:b ons of t�-po!r-y, cerzln pclic ws may require an endorsors-n:. :,sL-'en-r;c,t`.s ceT. i_�,c do . __ r � •-
c Ert!fica:e herder in lieu of such endcrsenert(=). -
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