33 WILLIAMS ST - BUILDING INSPECTION (2) 1 '
The Commonwealth of Massachusetts
Board of Building Regulations and Standards To
wn of
of Massachusetts State Building Code, 780 CMR, 7"edition ammm
t Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
or Tuo-Famih-Duelling
Th's Section For Official Use Only
Building Permi Nu r: Date Applied: 77
Signature:
Building Co issionaf/ eetor of Buildings Date
SECTION I:SITE INFORMATION
ST 1.2 Assessors Map& Parcel Numbers
I.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 tt) Frontage 01)
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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 � ner'of Record
) L/I er(-Record;-) 33 111,4� f 5'7
Name(Print) Address for Service:
y99-- s-3 D 6,13
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
FDemolilionEo
ew Cons Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Accessory Bldg. ❑ Number of Units Other ❑ Specify:
rief Description of P/r�oposed Work=: 2 cO T!'�[. r n T orG -c,
—7��
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
L3Plumbing
s I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
lectrical s ❑Total Project Cost'(Item 6)x multiplier x
s 2. Other Fees: S-
4. .Mechanical (HVAC) 3 List:
S. .Mechanical (Fire $
Su ression Total All Fees: s
Check No. 'Check Amount: Cash Amount:_
6. Total Project Cost: s ",S1p, too ❑ paid in Full ❑Outstanding Balance Due:
J
i
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) t/j ZZ 3 � 9-2 0- 0al
rl/9s L¢cnsc Number Expiration Date
N,mc of CSL- HplJer A /7 List CSL Type(xc below) l)
1�G�t �G�C�G 1 / V``� T Description
Addres�� lei m�
U Unrestricted u to 15,000 Cu. Ft.)
R Restricted I&2 FamilyDwelling
Signature M Mason Only
RC Residential Roofinx Covering
phone WS Residential Window and Siding
!�''� SF Residential Solid Fuel Burning Appliance Installation
OO C� -1 D Residential Demolition
5.2 egistered Homf Improvement Contractor(HIC) /16 O 3 Z
L9741� 2 7 l� NoC e ' t 7--4 nc
HIC Company Name or HIC Registrant Name Registration Number
It, r
Addrcu ZO 1
Expiration Date
S' ature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.S 2SC(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........... ❑
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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 ae 4 rn el 2 (.9- l y N" S , 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. /l
r (y .vat'
Print Name
Si ture of O er Authorized Agent Date
(Signed under IF pains and penalties ofperjury)
NOTES:
I. 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 ny1 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 110.116 and I IO.R5, respectively.
2. When substantial work is.planned, provide the information below:
Total floors 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 halfibaths
Type of heating system Number ofdecks/ porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for 'Total Project Cost"
CITY OF S.0 .M. AxsSACHL-SEM
BUILDING DEPARTMENT
120 WASHINGTON STREET, 3m FLOOR
TEL (978) 745-9595
F.ut(978) 740-9M
KINtgEgI EY DRISCOLL
MAYOR THOh1AS ST.PIEM
DIRECTOR OF PLBLIC PROPERTY/BCILDLNG CO%LNRSSIONER
Workers' Compensation Insurance Aflidavit: Builders/Contractors/Electricians/Plumbers
Annlicant Information Please Print Legibly
Name (Busim�Orsvtiratiomindsvldual):1 q-62✓�4 ¢ /S�/L�/ 6,h S7 -/iC
Address: 2 1.lz TL c, erg GT reG'
City/State/Zip: S/i �d M Phone #: '9
Are you to employer?Check the appropriate box: Type of project(required):
I.Q I am a employer with 4. Q 1 am a general contractor and 1 6. Q New construction
employees(full and/or part-time)." have hired the subcontractors
2.Q I am a sole proprietor ar partner- listed on the attached sheet : ?• ❑ Remodeling
,hip and have no employees These sub-contractors have g. Q Demolition
workingfor me in an capacity. vorkm'comp.insurance.
Y P tY• 9. Q Building addition
[No workers'comp. insurance 5. LCU We are a corporation and its 10.❑ Electrical repairs or additions
required.] officershave exercised their
J.Q I am a homeowner doing all work right of exemption per MGL t 1.0 Plumbing repairs or additions
myself. (No workers'comp. C. 152,§I(4),and we have no 12.Q Roof repairs
insurance required.] t employees. iNo workers' 13.E] Other
comp. insurance required.]
.Any applicant that choelts Dos el must also fill uut The section below Showing their worlaro comi",gh,policy infdmutlon.
r i f.wneuwttm who submit this anldwit indicting they ars doing all work art/then hire outside eenm,,s ra total submit a new alndavit indicting wee
-C.nnra un,that chuek this box mud attached an additiwwl Wham showing On Te me of the wb.eontraetars and their worhaa'rump,polity,infmmodon.
l um an employer that Is providing workers'compensaton Insurance for my employees, Below/s the pollcy and Job site
information.
Insurance Company Name:
Policy A or Self-ins. Lie. H: Expiration Date:
Job Site Address: City/State/Zip:
Attack a copy of the workers'compensation policy declaration page(showing Ike policy number and explrstlon 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 51,500.00 and(or one-year imprisonment,as well an civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Invcsltgations ol'the DIA for insurance coverage verification.
I da hereby certify 7
Joe the ins and penalties of perjury that the information provided above is true and correca
�n ter Date: Is? — 1)
Phone '29
— Si S'- I-(-9'7
nfcial use dnly. nu not write in this dreg, to be completed by city or town o/JkiaL
City or ruwn: _ Permit/I.Icense q
Iuuing Authurily (circle one):
I. Iluard of flealth 2. Building Department J. City/town Clerk J. Eltctrical irnpector 5. Plumbing Irnpeetor
6. Other
CuatactPenon: _. .. __. _.. Phone#•
.A CITY OF SALEM
=r sy APUBLIC PROPRERTY
DEPARTMENT
.1
III v'y.'13. i;.,; • l ;\ "',A '4 1,.
Construction Debris Disposal Allidasit
(re\Iuircd li)r all demolition and renoc:uion \voi k)
In accordance \\ith the sixth edition of the State Building Code, 7S0 CNIR section 1 1 1.5
Dcbt is, and the provisions uf'AGL c 40, S 54;
Budding Permit t) is issued with the condition that (he debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal lacility as defined by AGL c
I1I. S 150A.
The dchris will bee�transportcd by:
� �(qq � (s /Y `c"S
Inamc ut holder)
I he debris will be disposed of in
W0,!' 1 L 5/ a �/ n S
cc (name ul I'auhly)
lG ra.,�sc a-ff ?<f AW 4f �
1•IJJrcv. u(I.Icllitvl
a�n Vi • pernuf .yglhranl
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