26 WILLIAMS ST - BUILDING INSPECTION C Y
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code 730 CIvIR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dtivelfing
This Section For Official Use Only
Building Permit Numbert . Date?cpplieds ,
Building Official(Print Name) Signature,-- Date,
SECTION 1: SITE INFORiINIATION.
1.1 Property Address: / 1.2 Assessors Map & Parcel Numbers
1.1a Is this an accepted street? yeses 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)
Ffont 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: 1.3 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2;` PROPERTY OWNERSHIP''
2.1 OwnertofRecord: a
✓a A P
Name(Print) City,State,ZIP
6�,'C4 / /Aeat r'2cLnff7f gig
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK''(check all that apply)
New Construction ❑ Existing Building Cl Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work Z: N i 1<✓a arc Y c r.
Gt_Ar� ��.fr/•f ./ jic�.r 'Q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only..,
Labor and Materials
1. Building 1. Building Permit.Fm S Indicate how fee is'determined;
2. Electrical S ❑ Standard.City/Town Application Fee -
❑Totat Project Cost',(Item 6)x multiplier x
3. Plumbing S 2 ,Other Fees: S.
4. Mechanical (tIVAC) S List:
5. Mechanical (Fire $
Suppression) Total All Fees: $_
Check No. Check Amount: Cash Amount-.
6. Total Project Cost: S I ❑ Paul in Full ❑ Outstandim; Balance Due:
4� ouo��
,I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
5 e Ue r S I/ License Number Vxpiratitin Date
Name of CSL Ilolder -�
List CSL Type(sae below)
72 Type Description
No. and Sheet
U Unrestricted(Buildings u to 35,000 cu. [t.
g!/( �_/l%Ul • < 0� J R Restricted 1&2 Family Dwelling
ity/Town, State ZIP ivI M:tsonr
RC Rooting Cuverin
WS Window and Siding
SF Solid Fuel Burning Appliances
�� ����_ �� Y.✓t ru.vr-t 7/� / I Insulation
Tele hmte Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
P e ,y_ j� •PcO IIIC Registration Number .epic:, ion Date
FLIC Company Name or III , Registr•nt Name
—add, w<��i✓
No. and Street Email ress ress
Ci /To>w�e, ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L c. M. § 25C(6))
Workers Compensation Insurance affidavit mast 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 BE 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(!Eleceiic�Sign, ire) Date
SECTIO, 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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires an unregistered contractor
(tot registered in the Home Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. ld?A. Other important information on the IIIC Program can be found at
www.mass.�>oviuea Information on the Construction Supervisor License can be found at Nvww.rnass.,wv:'(IL
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) _(including garage, finished basement/attics, decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fit ceplaccs_ _ Number of bedrooms -- _ —
Number of bathrooms Number of haI0baths
fype of heating .system ---_-- -- Number of decks•/ porches ----_-- --
fypeorcooling .sy,lem_ - -- _ Enclosed--------Open- --
1. " total 1'rolect 5qu:uu Footage" uray be substituted fur-'fatal I'roiect Coa
i CITY OF SM.EE\,i, NLkSSACHUSETTS
• BUILDING DEP 1RTMEINT
' p• 120 WASHINGTON STREET, 3m FLOOR
TEL (978) 745-9595
FAX(978) 740 9846
KID fBFRT F.Y DRISCOLL
MAYORTHOb(AS ST.PIERteB
DIRECTOR OF PUBLIC PROPERTY/BUIIDRVG COSLUISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t Ilicant information Please Print i e ib1
Name(BusinossOrkinizatiorvIndividual: P
Address:
City/State/Zip: cQ�j'e4 tea ,#:
r
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractors
2.V I am a sole proprietor or partner. listed on the attached sheet t 7• [3 Remodeling
ship and have no employees These sub-contractors have 9. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9, ❑Building addition
(No workers'comp, insurance 5. ❑ We area corporation and its ME] Electrical repairs or additions
required.] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LE] Plumbing repairs or additions
myself. [No workers'comp, C. 152, 91(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers'
comp, insurance required.] 13.❑0ther
•Any appiicunl dtar checks box Bl must also fill out the section blow showing their workeli olicy informan compact"don policy}I lomeowtw:n who submil this anidivit indicating they arc doing all work and then hire outside contractor must submit a new affidavit indicating such.
=Conlr for that check this box mast aaached an additional sheer showing the nome of Ihraubarontraeon and their worker'comp.policy infommtion.
lain an employer that Is providing workers'compensation itrsarance for my employers. Below Is the policy and Job site
information.
Insurance Company Name:
Policy 4 or Self-ins. Lic. 4: Expiration Date:
Job Site Address: City/State/Zip:
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
tine up to S 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 S230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Oflice of
Investigations of the DIA for insurance coverage verification.
I do hereby certi under the pains and penalties of perjury that the inforatatlon provided above is true and correca
Si,• a tlire; Date: ) Q J
Of/icral use only. Do nor Ivrire in this urea,to be campleted by city or town aJjrciaL
Citynr,rown: Permit/i.1ceme#
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.City/rown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Otiter.�...
Contact Person: _----_,___ Phone 4:
CITY OF SALEM, NLksSACHUSETTS
BuamNG DEPART) &NT
130\V.A,SHINGTON STREET, 3° FLOOR
TEL (978) 745-9595
F.As(978) 740-9846
K.I\I13ERLEY DRISCOLL
;�L.%YOR T-10.% s ST.PlE Ria
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COSLMISSIONER
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 NIGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be 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)
I he debri will be disposed of in
---a _
(name of facility)
(address of facility)
signature of permit applicant
date
�cbnvi�'.L n: