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7 WOODSIDE ST - BUILDING INSPECTION (2) h qw - 1 4P 9150 2S-0­" µ The Commonwealth ofMassachoseus CITY a Board of Building Regulations slid Standards �' Massachusetts State Building Code,'.80 ChiR SALENI Peiwed itar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-orTivo-Fanfihrlht2jling _._. This Section Fot'OlTicialuseonl}'�- Building Aertiiit'�unther; - Date_Apu Btulduzg Offieia tAi::t Vainej ig Date SECTION:1.SITE I:�'FO TIOA 7 A o dddr 12.assessors flap R Parcel lumbers ... 1.1 Proert-.�1 Ste• - olBS—n j 1_1a Is this an accepted street'_yes no Map Number Panel VSnnber 1.3 Zoning Information: i 1.4 Property Dimensions: Res rr+a1L �` y q�-�/ D •i; Zoning Dis•:uct Proposed::se ?� i Lot Arza.(sq ttj fimnteae(A) ..................................................................................................................i.....................................................................................................:..................... 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Rtquirzd prucided Required Provided Rsgcimd Proeided •.-_:..-..-_...-..--..-._..-._.i-----------------------------------------i--....................._-......._'.......--------- -----.-........-.-.-.-..1------..-..-._.....-.._-_......-.. i 1.6 W t Sapp(.,.(M.G.L c.40,§S4) j 1.7 Flood Zone Information: 1.8 Setraae Disposal System: /gr 1 Zane: Ontside Flood one' / i Po Iic® 1%vim❑ — Chzok if"so..............._„__ ----� SECTION Z:: PROPERTY OW\ERSHIPl .......... .. ................................. .:::::::. 2.1 Owner'of Record• iio6�✓� E �'asLt�✓n2 �C Trust Sz�ivv . /i)/ 6/970 Nacre(knit) Ci:y,State,Z 7/) i)Lde SG. 97f-7yY 52 / 6p332@I/er/fan , ✓I�� j Ni.and Street Telephone Emaii Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ ; Esishne Buiklsg : OxAezr-0ccupied Repairs(s) ar' : Altaatmn(sj O Addition ❑ Demolition ❑ Accessory Blde.0 i Number of Units ( 's Other D Specify. . . ..._._.,..,..._.,.-._...._,._.:.. - .______----._..__......._. ---------------------------------------- ...... .__..: Brief Description of Proposed Work': Ren/ace �aZ`Z'ers-;F:jPC Kr a nn 11 Pei i SECTION 4:ESTT§IATT31 CONSTRVCTION COSTS Estimated Costs -: Item 61I'1clall se0nh _____ _ -----(Labot_andDlate, ak) ___-_:_ _____----- I Building i Building Permit Fee::5 Iuoieate how,ee is detefltitaed. S ---- Q Stai.dard CityTayyv Application Fee 2.Lectrical 3.Vlumbina S r. Other Fees: S 1 4.Mechanical (H`'AC) S List: S.Mechanical (Fire 5 Suppression) ------ -- — Total All Fees:S Check Igo. Check Araocnt: Cash Amotsci: `i 6.Total Project Cost: S I-Sd0 i QPaidie,Fu€1 ue: ©QutstatidingBalanceD 5.1 Constraction Supervisor License(CSL) Lic=wNtunbcr Expiration Dale Name d CSL Folder List CSL Type(see below) .................. ........ . No.and Savet :T ::::: ::: ::::: 1, : : Dmcfipuon:,:::., ...................................... I Ir, (Buil I ................................................ 10 Restricted 1&2 FmiAlv Dw Citv-Toumt state,Zip M Masonry . RC. Roofing Covering .......................................... Window and Sidine ------—-------—--- SF Solid Fuel B-Purig Appliances Telephone EMM11 address D Demolition 5.2 Registered Homeimprovernent Contractor(HIC) h:C Registration Nurnber —Evuai..,Dare i HIC Cornpmn-v Name orIUC Regis uNeau No.mid Street Email 2&lress CitViTovvil-State.ZIP .... ................... -------- ---------------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 ........13 -------------------------- SECTIaN Ia-:0WNER At7f[ORIZAITION TO:RF COMPLETED WfiiN.. ............ Oi �M'SAG -U1 FiNT.OR.C.0N.".TRACTOR APPLIES FOR B LD11q'GPF1UN1IT ............... 1,as Owner ofthe subject property,hereby authorize to act an my behalf,in all matters relative to work authorized by this building permit application. Print Ovmer'%Name(Elmuotilc Signature) Date -------- - --- --- - -- - - - - - - - - - - - - - .. ....... - - - - ------- - - - - - - - - - - - - - - I By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information Contained in this P application is true mid accurate to the best,of my knowledge and understanding. -,V te-y' Print Oicmer's or Authorized Agent's Name(Electronic Sianar—) NQqTqES:. . . . .. . . 1 An Owner who 6otahts'a-building to do Iiis;her--0xXM-work,m- M- -ow-Mer- �410 hires an unresistered contractor (not registered in the Home Improvement Contractor(HIC)Program' %,H nal have access to the arbitration program or guaranty fund under NLG.L.c. 142A.Other important information on the HIC Pro-jam can be found at mm2w.maas§oS%o,^a Inforniaticm on the Construction Supervisor License can be found at x�e kwmiass.gov.Mvs --------------------- --------- 2. When substantial work is plarmed,pros ide the mrotmation below. Total floor area(sq. IQ (including garage,finished ba&ernenvattics.decks or porch) Gross living area(sq.ft.) Habitable room count I Number of fireplaces -INTumber of bedrooms Number of bathrooms; Number of half baths Type of heating system Number of decks!poiches Type of cooling system Enclosed ......................................................................................... ...................... 3. "Total project Square Footage"may be substituted for"Total Project Cost" CITY OF SOU E211, NIASSACHUSETTS BUILDING DEPAa'n1LNT • p t'_O WASHINGTON STREET,)m FLOOR T L (978)745-9595 FAX(978) 740-9846 KI.NIBERLEY DRISCOLL MAYOR THOMAS ST.P>FM DIRECTOR OF PUBLIC PROPERTY/11L DLNGCONWISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumben Applicant Information Q Please Print Legibly ga Name(Bush -&ornizatioNindividual):_/_)Q.be¢g-r L j�> ere rhZ t Address: / 4)oedsi rdl e- sr City/state/Zip: 416MIO Mir 0/4 7a Phone#: 9 7f-74/f-gi L 69 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a craployer with 4. ❑ 1 am a general contractor and 1 employees(full and/or pan-time).• have hired the subcontractors 6. ❑New construction 2.Q I am a sole proprietor or partner- listed on the attached sheet. 7• ❑Remodeling ship and have no employees These sub-contractors have It. Q Demolition working for me in any capacity, workers'comp,insurance. 9. Q Building addition [No workers'comp.insurance 5. ❑ We are a corporation and its quired.l officers have exercised their 10.❑Electrical repairs or additions 3.Lld I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or addition myself.(No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' I3.(]ff Other ej Lt✓ comp.insurance required.] ;Any applicant that checks boa®1 must also all out the section below showing their wmken'compassion policy information. Itmwowmeo who submit this affidavit indicating they are doing all work and then hire outside cmttracton must submit a new affidavit indicating such. 'Cumncton that chuck this box must anached an oMdunid sheet showing aw name of the sub comroewn and their workers,comp.policy infarmitiw. l am an employer that is providing workers'compensation Insurance for my employees. Below b the palI and Job sire information Insurance Company Name: Policy#or Self-ins.Lis#: 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 15Aof MGL c. 152 can lead to the imposition of criminal penalties of a fine 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 itt= of up to S250.00 a day against the violator. He advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. l do hereby ccee/rr�tifyy under rthhee paai/n�Js and penaties of peiJury that the information provided above is true and correct Similire• 7MitMirif� (�Jq��Dis�✓r� Date: Phone# 97 � �7yN- 9289 Official use only. Do not write in this area,to be completed by city or town offiWaL City or Town: PermIdUcense# Issuing Authority(circle one): 1. Board of Ileallh 2.Building Department 3.Cilyffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other, Contact Person: Phone#: CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT 120 WASHNGTON STREET 3m FLOOR TEL. (978) 745-9595 F KIMBERLEY DRISCOLL FAX(978) 740-9846 MAYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER HOMEOWNER LICENSE EXEMPTION PLEASE PRINT: Date / 2 - S — /3 Job Location `7 LJ "J , j f�e ,M fif Home Owner Address 74g,2r)d s? W,v S �— s Present Mailing Address The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two Units or less and to allow such homeowners to engage an individual for hire that does not possess a license, provided that the owner acts as supervisor. DEFINITION OF HOMEOWNER Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use and/or farm structures. A person who constructs more than one home in a two year period shall not be considered a homeowner. Such "homeowner" shall submit to the Building Official, on a form acceptable to the Building Official,that he/she be responsible for all such work performed under the Building Permit. The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and other applicable by-laws and regulations. The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department minimum inspection procedures and requirements and that he/she will comply with such procedures and requirements. HOMEOWNER'S SIGNATURE p APPROVAL OF BUILDING INSPECTOR CITY OF Sa71.F1 , �'I.xSS.kCHUSETTS BuELDNG DEPARTMI NT 130 W 1sHiNGTON STREET, 3'o FLOOR d TEL (978) 745-9595 FAX(978) 740-9846 KIJIBERLEY DRISCOLL bIAYOR THobw ST.Pmna DIRECTOR of PuBLiC PROPERTY/Bt:nnmr.COMMSSIONER Constru ction 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 MGL 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 l 11, S 150A. The/ldebris will be transported by: W?�rf / Izrtzi�- �1 w ✓l� - (name hauler) The debris will be disposed of in : (name of facility) (address of facility) signature of permit applicant a- — �-I date debriulTdw