5 CROWDIS STREET - BUILDING JACKET Y
The Commonwealth of Massachusetts
$ ° Board of Building Regulations and Standards CITY OF
( �I Massachusetts State Building Code, 780 CMR SALEM
Revised A4ar 201/
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Wgial Use OnjK
Building Permit Number: ate Applied:
Building Official(Print Name) Signatuie Date
SECTION 1:SITE INFORMATI N
1.1 Propperty Address: 1.2 Assessors tp arcel Numbers
,n c RNJ1DI,S 0-1 S;ALEV\ MAO'l -
1.1 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 ft) Frontage(11)
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:
Public V Private❑ Zone: _ Outside Flood Zone?Check i f yes❑ Municipal L3'On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
I,ARIT6S H, OC-1-03 A&EJES 9A L1 e 1-I^ nq-1
Name(Print) City,State,ZIP
CQOV�I�)S ST 9-18SC14bylc) n,kilttawos�@ Jn Z .(�yrl
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction Existing Building❑ Owner-Occupied K Repairs(s) ❑ Alteration(s) ❑ Addition J9
Demolition Ill I Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work'-: 11 d y' X f eC 'La—
nit 71ev c-f- o e (3 6—C
11 i5Poe('e- ceS .
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 0L) 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees:$
Y,y�� Check No. Check Amount: Cash Amount
6. Total Project Cost: $ (N 0 Paid in Full 0 Outstanding Balance Due:
t ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
No.and Street Type Description
U Unrestricted(Buildings tip to 35,000 cu. ft.)
R Restricted 1&2 FamilyDwelling
City/fown,Stale,ZIPM Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
1-TIC Company Name or HIC Registrant Name
No.and Street
Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.§ 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 .......... ❑ No ........... ❑
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 Xr.—II vC, /'7 L ).et
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 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 IN appI' atiyn�is true and accurate to the best of my knowledge and understanding.
— r`k2�5
Print Owner's or Authorized Agent's Name(Electronic Signature) - Date
NOTES:
1. 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 not have access to the arbitration
program or guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
www.nn ss.2ov_oca Information on the Construction Supervisor License can be found at www.tnuss.�*ov%dns
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 fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost'
MORTGAGE INSPECTION
BAY STATE SURVEYING ASSOCIATES INC. JOB# 42r,30
100 CUMMINGS CENTER, SUITE#316J, BEVERLY,MA., 01915
1�t NOTES:
LOCATION :.SR.LEM.t......!...�R................
1)This is a mortgage inspection survey and not an
r _O instrument survey,therefore this plot plan is for
SCALE : 1" =60 DATE :...j? z.....9.............
- - - mortgage inspection purposes only.It is NOT to
be used to establish boundaries or for the
Q�(' GS 74� construction of any type of improvements.
REFERENCE : c: !?.......(.C.. . ... 2)This survey is based on survey marks of others.
�S X X. .5bQ2"l�•••DIOR�(�-• 3) Bushes,shrubs,fences and treelines do not
QAQ�...... necessarily indicate property lines.
4)Whenever an offset is V+_or less,an instrument
s� ► F(u CD Pp,Ny u c survey is recommended to determine property
TO: .................. .......... Sl ......M.........�..... lines,and any possible encroachments.
The location of the building(s)as shown,either 5)Offsets shown are approximate,and are to be
complied with the local zoning setbacks at the time of used only for the determination of zoning,Not to
construction or is exempt from violation enforcement be used to establish property lines.
action under Mass.G.L Title VII Chapter 40A Section 7 6)In my professional opinion the building(s)are not
located in the special flood hazard zone,as
defined by H.U.D.MAP# 7-S010 Z $'j'-S5
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The Commonwealth of Massachusetts
`i Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CNIR SALENI
�c l
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised.L(nr 201
One-or Tivo-Family Dwelling
This Section For Official Use Only .
Building Permit Number: D e.Applied: I I 0-7- 1
Building Official(Print Nmne). Signutur / Date
SECTION 1:SITE INFORMATION
1.1 Property Add ussr 1.2 Assessors Map&Parcel Numbers
I.1 a Is this an accepted street?yes_ no Map Number Puroel Number
-1.3-Zoning Information- I:d Property Dimensions:
Tuning District Proposed Use Lot Area(sq 11) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Itcquired Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal❑ On site Disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ow r of R ortl'�• � C�rt)e,� rlt4A a J!�)
N4ane(Print) q /?—�` City,State,ZIP
f7 .YIYI(G�`7�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK' check, that apply)
New Constr ction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) - Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work-- O.
at
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Casts: Official Use Only
Labor: I �Nlaterials)
1. Ruildin, S I. Building Permit Fee:$ ndicate how fee is Determined:
2. Electrical S ❑Stnttdard City/Town Application Fee-
❑Total Project Cost'(item 6).e multiplier x
3. Plumbing .S 2. Other Fees: S
d. Mcchanical (tIV,\C) S List:
5. Mechanical (Fire
Sum ression) S Total All Fees: S
Cheek No. Check Amumu: Ault:\mount:_
(,. 'total Project Cost: .S ❑ Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
i.l Constru n Supervisor nse(CSL)
1� )/�� � License Number E.rpirr on ate
Name of CSL 11 rry 1 List CSL'rype(see below) �7 _
( �� Type, Description
No. and Street
U Unrestricted uildin s tip to 35,000 cu. Il.)
R Restricted )&2F:anil Dwellin
Cityi Town,Slate,ZIP bl Man
RC Rootin Coverin
WS Window and Sidin-
SF Solid Fuel Fuming Appliances
insulation
"role icon—Crl� e Entail address D Demolition
5.2 Registered Home Im men Contr r(IIIC _
FIIC Registration Numher ,x Ira n Date
n1d2S
murk Name
e ! !� Email address
�33
City/Town,State,ZIP Telephone .
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NF.G.L.e. 152.4 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 IsWanc of the building permit.
Signed Affidavit Attached? Yes ..........d No...........❑
SECTION 7a:OWNER AUTHORIZATION,TO BE COMPLETED WHEN:
OWNE WS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT'
1,as Owner of the subject property,hereby authorize �� ( L'j{��j (r
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER'O AUTHORIZED AGENT DECLARATION
By y name below, I hereby attest u er the pa' sand enalties of perjury that all of the information
con wined in Ills ap true and accur to to the a of kt vledge and understanding.
Print l me 's or Authorized Agent's Name( •Icetronic. Igo lure .to
NOTES:
I. .An Owner who obtains a building permit to o his/her own work,or an owner who hires an unregistered contractor
(not registered in the Flotne Improvement Contractor(FIIC) Program),will not have access to the arbitration
program or guaranty fund under iv I.G.L.c. I42A.Other important information on the FIIC Program can be found at
N%%M I ass.wv' Information on the Construction Supervisor License can be found at w to issaov'dln
2 1Vhen substmttial Ivork is planned,provide the information below:
rotal tloor area(sq. tl.) (including garage, finished basement/attics,flecks or porch)
Gross living-area(sq. f.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type ot'hcating system Number of decks/porches
"type of cooling system Enclosed Open
1. •`Total Project Square Footage"may be substituted for"Total Project Cost"
Co LAU
1 �y
Litt of 2alvni, � 1asgadili5Ett5
s�� �1 epartnunt of Public �Uorks
ANTHONY V. FLETCHER. R.P.E. -
CITY ENGINEER
MaAch 8, 1976
Mt. John Powers
Bu.iEd.ing Inepec.tot
One Sa.Lem Green
Salem, Mabe .
s
Dean Mt. Powers :
I wish to .injotm you that we have approved eewet connection
peAm.ttb jot the 6oeZow.ing :
a) Lot Z-2 (No . 1 Lauten.t Road) .to Megatopotiz Rea-ty Ttubt
bot a bout unit apat.tmen.t bu.iZd.ing.
b ) Lot 48 (neat No . 441 La6aye.t#e S.t)Leet) to Erneb.t R.
l
Betteau bot a three bedroom e.tngte jam.ity dweZZing.
e) Lot 4A (near No. 441 La6aye.t.te S.tAeet) to Etneet R.
Betteau jot a .three bedroom e.ing2e 6am.i.Ly dwetting .
d) Lot 1 (near No . 435 La6ayet.te Sttee-t ) .to Etneet R.
BeK2eau on—a—#hn-e-e—b.e.dtoom singte 4am.i2y dwe ting.
e) Ao-t B (Na 5 CAOwd.ie SS#teex) .to Etnee.t R. Betteau 6o)t
a ahrEe 6�slnoom btirigti 6amiZy dwetti.ng.
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i
't 16 you teoui&e any 6uA.ther .in6orma.t.ion tegaAd.ing .the above,
p.Leaee contact me.
Vety .ttuty youte ,
Ir
A. V. FCexchet, P. E.
City Engineeh
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