4 CUSHING STREET - BUILDING JACKET The Commonwealth of Massachusetts FOR -
Board of Building Regulations and Standards MUNICIPALITY
Massachusetts State Building Code, 780 CMR,T'".edition USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised January
One-or Two-Family Dw i 1, 2008
1 I This Section For 0 tcial se Only
Building Permit Number: a A ied:
Signature:
Building Commissioner/Inspector o uildings Date
SECTION 14 I INFORMATION
1.1 Property Addjes / 1.2 Assessors Map&Parcel Numbers
IA a Is this an accepted st eet?yes d no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use - - - Lot Area(sq 8) Frontage(R)
1.5 Building Setbacks(ft)
FrontYard - Side Yards Rear Yard
Required Provided Required Provided Required Provided
M 1.6 Water Supply: (M.G.L a 40,§54) 1.7 Flood ZoneInformation: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: ,/ 11� ! 17
re •, a �cno 9a 7 l�
Name(Print) -� Address
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 epatrs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': r-li Z, ( /'I,-M> a-rit i✓ o �/"�
e- C (S
Sn)$,i; c C I /3/a ,t �l C! �c., 5� trtJ a 11 S It
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only.
Item - (Labor and Materials)
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:_
6.Total Project Cost: $ /3 3?W-J0 ❑Paid 'in Full ❑ Outstanding Balance Due:
z
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
tt License Number Expiration Date
Name of CSL-Holder AM
'i List CSL Type(see below)ts 2
31Tiltok Street
Address SalemMA.17Et Type Description
U Unrestricted(up to 35,000 Cu.Ft
Signature R Restricted 1&2 Family Dwelling
A M lvasomv Only
RC Residential Roofing Covens
Telephone ( ' WS Residential Window and Siding
SF Residential Solid Fuel Burning
Y 3 o Appliance,Installation
D I Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company t C RegiIsu-atmnJ Number
Address 61'R h- tSoff Ay mut.
Salem MA 01970 L7 `I t/-?i Y 3 Expiration Date
Signature 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 Issuanc f the building permit.
Signed Affidavit Attached? Yes .......... No ........... ❑
SECTION jai-OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
d U,' --✓1 as Owner of the subject property hereby
.authorize to act on my behalf,in all matters
relative to work authorized
rbbyy this building permit application.
Signature of Owner Date
SEC/TTII�ON/ 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
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.
Print Name
Signature of Owner or Agent Date
Si gned under the pains and pen ahies of a u
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 Improvem ent Contractor(HIC)Program),will not have accessto 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 CNIR Regulations I I O.R6 and I I O.RS,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 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"
J The Commonwealth of Massachusetts
9, Board of Building Regulations and Standards CITY OF
�+ Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Building Official(Print Name) Signature Date
SECTION 1:SITE INFO ATION
1.1 Pro er[y ddres :
SA_ 2- 1.2 Assessors Map& Parcel Numbers
US i/I1Gl
l.la Is this an accepted stre t?yes 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)
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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:` 6 e-rraP)a �p1U�✓aM �4�m TYl � 67
Name(Print) City,State,ZIP
N 0-ybhlNo�sS A �1 _��z 5-iq- 7iya
No.and St et Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description ofPropos d Work': t V,04A 0 Y S rm doors
P SECTION
I--
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ -3o/owQd• 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: )
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ d� 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) /rC 12rn q .
2 1U Q o J mo0C(f,- License Number Exp ration ate
Name of L Holder [l
a-1 J 4 List CSL Type(see below)
No.and Street 1 Type Description -
1 U Unrestricted Buildings up to 35,000 cu.ft.)
t�V V✓ VV t t 0 R Restricted 1&2 Family Dwelling
CityfTown,State,ZIP M Masonry
RC_ Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I I Insulation
Telephone Email address D Demolition
5.2�_R�egistnered Home Improvement Contractor(HIC)
�P� ( " 4§A- Corr HICRegist�r E a
HIC o -pany Nine odpHhC Rd g'' ` t,N 7 _
�/)11X/��14, Ic�PAI01'U(JP Ucorpa Vim• /l/t�
No.and Street E ail ad ess
q�G �l'NWY19ali
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
A) 1,10194111
I,as Owner of the subject property,hereby authorize e,
to act on my behalf,in all matters relative to work authorized by this buil ing per tit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER[ 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:
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.mass.eovioca Information on the Construction Supervisor License can be found at www.mass.gov/dps
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 halFbaths
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 Cosy'
';20 101
The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7"edition Budding Dept
Building Permit Application
One-ur TConst tilt pveprog novate Or Demolish a
This Section For Official Use Onl
Building Permit N be . Date Applied:
Signature: �z r 2—�, IZ
Building ommtsst /In Buildmp Date
SECTION I:SITE INFORMATION
1.1 Property/yddit Z,y � L 1.1 Anessen Map i Parcels Numbers
L // �LG�/ M Number Parcel Number
1.1 a Is this an accepted scree?yes no
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq illFrontage Ifl)
I.S Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.e0,l se► 1.7 Flood Zone Information: 1.2 Sown st Dktpoul System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Cheek if s0
SECTION 2: PROPERTY OWNERSHIP' y �,
2.1 Owa of eco
i fl)ntl�i .
Name IPrimj' Address far Service•
Signnurc Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) Altention(s) O Addition O
Demolition O Accessory Bids.O Number of Units Other O Specify
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Budding S I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2 Electrical S O Total Project Coat(Item 6)a multiplier x
J Plumbing S 2. Other Fees: S
a. Mechanical IHVAC) S List:
e Mechanical (Fire S Toul All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
it Total Project Cost !;207.00 i 0 Paid in Full 0 Outstandins Balance Due_
SECTIONS: CONSTRUCTION SERVICES
S'.'I�'L�iceroed Construction Supervisor(CSL) Q s7 3?J /�
�[/!( al a M Elective Number E.pt tion Da e
N,yat of esL 7) L is#CSL Type I..Y he low I
AJkesf T Description
J U Unrestricted u to 33,000 Cu. Fl
S R %fa my IR2 FamilyDwellm
.N .Na Onl I,
RC Residential Roofing Covering
Telephone W S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
15.2 Reglstysjd Home Ins ementc. ntra or HIC) j��3� p
/Ccc�� if 4_ / / //�iJ�if
HIC Compann Name or H Rep t ant N ` A /� Registration Number
Addicts / O/9 / l0
(� 9%� Eapirui Dat
SignatureTelep one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. ISL 12SC(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 Allidsvit Altached? Yes..........O No...........O
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 n 04 to act on my behalf,in all matters
relative to work authorized by this budding permit a plicalion.
SignisturofOwner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the beat of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signedunder the gains and penalties of
NOTES:
1. An Owner who obtaina 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 do 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 R6 and 110 R3,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) lincluding garage, finished basemenNanics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
.Number of fireplaces Number of bedrooms
Number of bathrooms Number of half baths
Tvpe of heating vystem Number of decky porches
Tspeof cooling system Enclosed , Open
1 "Total Project Square Footage'maybe suhstimted for Total Project Cosi"
4 CUSHING STREET
City of Salem
BUILDING DEPARTMENT
m
FIELD CORRECTION NOTICE (n
LOCATION j h/ �' >1'lfir: ) // PERMIT NO.
ISSUED TO U ICTAS i> h�'
PERMIT HOLDER AND/OR ALL RESPONSIBILE PARTIES.
NOTICE DELIVERED TO
Upon inspection, violations of the Sec were in evidence
The following orders are hereby issued for their correction:
3"a r� _
Cl
l tr?9
to 'R e4 -t,rr d y O'Ma u a 57.
PLEASE CALL FOR INSPECTION WHEN CORRECTIONS HAVE BEEN COMPLETED. ACCEPTANT
tY` AND APPROVAL BY AN INSPECTOR OF THIS DEPARTMENT IS REQUIRED AND MUST BE CORRECT
ON OR BEFORE
fqv/
DATE BY
INSPECTOR
ORIGINAL