22 CLEVELAND ROAD - BUILDING JACKET G� The Commonwealth ul'Massaehusens
.� Board ul'Building Regulations and Standards CITY
r M3533ChUSC1ts State Building Code, 790 CMR, 7' edition OF SALEM
Rewrsav/Jarnrwr
Iuilding Permit Application To Construct. Repair, Renovate Or Demolish a '/NAY
One-or Two-Fumdy Dwelling
is Section For Official Use Only
Building Permit u r: Date
Signature:
Huildli Cummiasi tar of Buildings t}ete t '�---
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
� clE��/A>J b Ad-
I.Ia Is this an actt A street? es ✓ no Map Number Parcel Number
IJ Zoning Isformatb ; 1.4 Property Dlmemloas:
tug u�
Luting District Proposed Use Lot Area(sit 11) Fronmge(11)
1.5 Building Setbacks(B)
From Yard Side Yards Resr Yard
Required Provided Required Provided Required Provided
1.6 Water Supph (M.G.L c.ro,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ private❑ Lone. Outs— Check f de Flood CI Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
rNewConstruction
at of Record:
,U (S�#JgAA] a� (r /eve 1AWh 2d .
) Address for Service:
17S- 7y5/
Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
❑ 1 Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) Gr Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ I Other ❑ Speedy:
Brief Description of Proposed Works:
?—CP Aew 96 Z-0/A-)low c t c e ntr
!N W
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lelal Use Only
Labor and Materials y
I. Building IS 1. Building Perrnil Fee:S Indicate how fee is determined:
2. Electrical s ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
J. Plumbing S 2. Other Fees: S L�
4. Mechanical (IIVAC) S List: I - Tr
16
S. Mechanical (Fire
Suppression) S Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S // °
/w 7 ❑Paid in Full ❑Outstanding Balance Out:
SECTIONS: CONSTRUCTION SERVICES
5.1 Llctesed Constructloa Supervisor(CSL) Ta 7 3 3T
I.icerua NumM I:apinliun l}ate
�/-A"V, �iRA1S
Name of 1.'SI.- l lulder y)PK• a LAN List CSL rype(xec t+elowl L)
Or -
A r Ileacri ion
:(Jdre� U unrestricted amity oOelling
R Rnlrieted Id2 Farm Ihvellin
Signature M M Ord
RC Residential Routine Covetin
WS Residential Window and Sidin
felrpllrxtt SF Residenlial Solid Fuel Burning A liamvr Installation
D Residential Demolition
5.2 Ralstere dHe ImprovemeetCoatnclorIHIC) 00 �
��C Regiatrmian umFl ber
I TIC Company ame ur 111C egist I Name
Address a, ZI y 2a 10415 33 Expiration Date
d
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL § 2SC(6D
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 ..........Q� No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
1
to act on my behalf,in all matters
authorize
relative to work authorized by this building permit application.
Si ure of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1 �i•r;f �y.79NS ,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
behalf.
Print N
Sitlnatum of(hvner or Authorized Agent Date
Si under the airo and penalties of pedury
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 730 CMR Regulations I IO.R6 and I IO.R3,respectively.
1. When substantial work is planned,provide the information below:
Total lloors area(Sq. Ft.) (including garage,finished basement/anics,decks or porch)
Gross living area(Sq.FI.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of beating system Number of decks/porches
T)pe of cooling system Enclosed OPen
). 'Total Project Square Footage-maybe substituted Ibr"Total Project Cost"
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527 CMR 4.00 - Form 1A
FP-56A
(Rev.OW10)
Certificate of Compliance
M.G.L.Chapter 148, Section 381
City or Town:^ )A /,' n /
Street Name&Number:
Name of Property Owner: M"
This certifies that a visual inspection of the fuel supply linc(s) for the aboveground heating oil storage
tank was completed in accordance with M.G.L. Chapter 148, Section 38J(d) for the residential property
identified above,and the following equipment was observed and compliant:
17 Each fuel supply and return line(if present) is enclosed with a continuous non-metallic sleeve
❑ Each fuel supply line is equipped with an oil safety valve
This visual inspection and certification of compliance was completed on:
Date: 0"3/.'L /^ -- ----By:(Signature of Oil Burner Technician)
(Print Name of Oil Burner Technician) ,
Certificate of Competency#:
Upon completion of Form I A,the property owner shall receive a copy of the Form and
a copy shall also be submitted to the head of the local fire department or a designee.
This form can he photocopied or reproduced in triplicate.
L # ZOb69bL8L6 96860bL8L6 �aleS 81 EOill-01-ZI