57 DEARBORN STREET - BUILDING JACKET {
� . 57 DEARBORN STREET
4�
rfat �o CERTIFICATE ISSUED
DATE Aueast 24, 1993
E' CITY OF SALEM
SALEM, MASSACHUSETTS 01970 BUILDING PERMIT -
a•�D,m CERTIFICATE OF OCCUPANCY
. 16, 93 41-93
wilIAf Bram
DATE y 4B _ PERMIT NOewFwr
APPLICANT IBI ADDRESS l
'�♦1�.�]�L�1��i�� K� IN0.1Ln If TR[[TI IC�4 r,1yN1'S uC3 N]U
ALTMIAATION.S D6EIffd In NUMBER OF ASG
PERMIT TO 1_T STORY DWELLING UNITS
11•If 0E '..."]MENTI NO. IPPOPO]ED USE'
-)i DEARBM 1 D ZONING
AT (LOCSTIONI DISTRICT—
IN0.1 (STPEETI
BETWEEN AND
'CROSS STREET) ICR455 STREET'
LOT
SUBDIVISION LOT BLOCK SIZE
BUILDING IS 70 BE FT, *IDE P• FT. LONG BY FT, IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE JSE GROUP BASEMENT WALLS OR FOUNDATION
'TYPE'
Alterations to attic to create st0rage & clOV2ts
REMARKS:
CAIS. Xd PEWIT To OCCUPY 1445-9595
ml
�
AREA OR xwx
VOLUME ,yam
C.SI[ SDV/VE Ff Cil Ell r•A�
.dilU-n Li"ti�'VA & _'1arsna .jlyte- r,m�rsrw s.�•oeofso oE-Elsei'or<FI-rn nrno�lsa�ls.-rm<no
OWNERTO BEf/10@fC R ES
•E FC SEE REVERSE SID C w CERTIFICATE
ADDRESSft&�lflff?llft'
DEPARTMENTAL APPROVAL FOR CERTIFICATE
` of OCCUPANCY and;COMPLIANCE
qi. 'f,,f$Tatfe filled in byle�ch division indicated hereon
. upW completion 6f,its final inspection;.
BUILDINGS € Permit No. 4 1-93 _
Approved by John 'J Jennings Date .Tune 18 1993
Remarks _ l
6; PLUMBING Permit No.
i
Approved by ! Date_
c
Remarks
I
j
ELECTRICAL' Permit No.
Approved by
John J* Giardi
Date August 13, 1 93
- _.
Remark's—
I
OTHER-- Permit No.
`Approved by_ Date
Remarks I
OTHER " Permit No.
Approved by Date
Remarks
1 BUILDING
PERMITtI
. .r
9 ! F ;,y JOB WEATHER-:kAARD
DATE 19 PERMIT NO.
APPLICANT A.S_ia:{7fsWX1: ADDRESS :%I42:iA i'..1 icejtic
g ` INO.1 ISINEETI (CONT4'S II CEXSf.
PERMIT TO 'Sg ° I_) STORY i'qo' NUMBER OF
DWELLING UNITS
(TYPE 0E uaPROVEUENTI N0. IPR010SE0 USE)
AT ILOCAT10N1 .i:1Es;:E LaI`;^. kD:�::a :'lali b ZONING
DISTRICT
1X0.1 (STREET)
BETWEEN AND
(CROSR STREETI ICROSS STREET)
LOT
SUBDIVISION LOT BLOCK S12E
BUILDING IS TO BE FT. WIDE B+ FT, LONG BY FT. IN HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
ITYPEI
REMARKS:
AREA OR
vOLUME ESTIMATED COST $ �F�}�SVA.r PERMIT S RIIiR 00
-(C'�O�A�IC,'.SOVARE FEET(
OWNER 1CLC"'siX.:� Dacxuuk
ADDRESS .�• ^.�i.."I.'.i'CN[SC; =`.l3EXrF .,1't3' F:;rl BUILDING DEPTA;E:XAT .1. :SF:X'XL•1
dxi "i3 _ INSPECTOR OF BUILDINGS
THIS PERMIT CONVEYSNO RIGHT TO OCCUPY ANY STREET. ALLEY 09 SIDEWALK OR ANY PART THEREOF, ETHER TEMPORARILY OR
► PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY NOT SPECIFICALLY RFRMITTED UNDER THE BUILDING CODE, MUST BE AP.
PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES AS WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINEO
FROM THE OEPAR TMENT OF PUBLIC WORKS. THE ISSUANCE OF THIS PERMIT DOES NOT RELEASE THE APPLICANT FROM THE CONDITIONS
OF ANY APPLICABLE SUBDIVISION RESTRICTIONS.
MINIMUM OF THREE CALL JgppROV EO PLAN MUST BE RETAINED ON JOB AND THIS WHERE APPLICABLE SEPARATE
INSPECTIONS REpU1aED FOa CARD KEPT POSTED UNTIL FINAL INSPECTION HAS BEEN FERMI TS ARE REQUIRED FOR
ALL CONSTRUCTION WORK: ELECTRICAL. PLUMBING AND
1. FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY 15 RE. MECHANICAL INSTALLATIONS,
2. PRIOR TO COVERING STRUCTURAL DUIRED.SUCH BUILDING SHALLNOT SE OCCUPIED UNTIL
ME MBERSI READY TO LATH1. FINAL INSPECTION HAS BEEN MAGE,
J. FINAL INSPECTION BEFORE
OCCUPANCY.
POST THIS CARD SO IT IS VISIBLE FROM STREET
BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS
/Z-
77ARD rF AL H GAS INSPECTION APPROVALS FIRE DEPT, INSPECTING APPROVALS
OTHER CITY ENGINEER 2 V - 2
WORK SHALL NOT PROCEED UNTIL THE PERMIT WILL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS INDICATED ON THIS CARO
INSPE: ]R HAS APPROVED THE VARIOUS WORK IS NOT STARTED WITHIN SIX MONTHS OF DATE THE CAN BE ARRANGED FOR BY TELEPHONE
STAGES 'JF CONSTRUCTION. PERMIT IS ISSUED AS NOTED ABOVE. OR WRITTEN NOTIFICATION.
No. City of Salem Ward
°ccupKs.rJJ'�
�$,g /
APPLICATION
FOR
PERMIT TO BUILD ADDITION, MAKE ALTERATIONS OR NEW CONSTRUCTION
IMPORTANT-Applicant to complete/�all items in sections:1, It, Ill, IV, and IX.
S7 ,D�rrRBoeN $`j ZONING
I. AT(LOCATION) DISTRICT
LOCATION (No.) (sTREE
OF BETWEEN LA2-�FM ONTfi ., n
AND
BUILDING CROSS5REE cnossEl)
LOTL
01—
SUBDIVISION LOT BLOCK SIZE S 00
V S
II. TYPE AND COST OF BUILDING -All applicants complete Parts A-D
A. TYPE OF IMPROVEMENT D. PROPOSED USE-FOR"DEMOLITION"USE MOST RECENT USE
1 ❑ New building Residential Nonresidential
2 ❑ Addition(if residential,enter number of new 12xiOne family 18 ❑ Amusement,recreational
/rousing units added,if any,in part D,13) 19 E] Chruch,other religious
13 ❑ Two or more family-Enter number
3XAheration(See 2 above) of units ............................. 20 ❑ Industrial
21 ❑ Parking garage
4 ❑ Repair replacement 14 ❑ Transient hotel,motel,or dormitory- 22 ❑ Service station,repair garage
Enter number f units ...........................
5 ❑ Wrecking(It multifamily residential,enter number 23 ❑ Hospital,institutional
of units in building in Part D,13) 15 ❑ Garage
24 ❑ Office,hank,professional
6 ❑ Moving(relocation) 16 ❑ Carport 25 ❑ Public utility
26 E] School,library,other educational
7 E] Foundation only 17 ❑ Other-Specify
27 ❑ Stores,mercantile
B.OWNERSHIP 28 ❑ Tanks,towers
8 ❑ Private(individual,corporation,nonprofit
institution,eta)
29 ❑ Other-Specify
9 ❑ Public(Federal,State,or local government
C.COST (Omit cents) Nonresidential-Describe in detail proposed use of buildings,e.g.,food processing plant,
machine shop,laundry building at hospital,elementary school,secondary school,college,
parochial school,parking garage for department store,rental office building,office building
10. Cost of improvement ......................................................... $ r ^ at industrial plant.If use of existing building is being changed,enter proposed use.
To be installed but not included
in the above cost
a. Electrical...........................................................................
b. Plumbing..........................................................................
c. Healing,air conditioning.............................................
d. 011ier(elevator.etc.).....................................................
11. TOTAL COST OF IMPROVEMENT $ t.r00 r V0
III. SELECTED CHARACTERISTICS OF BUILDING -For new buildings and additions, complete Parts E-L;demolition,
complete only Parts J&M, all others skip to IV
E. PRINCIPAL TYPE OF FRAME F. PRINCIPAL TYPE OF HEATING FUEL G. TYPE OF SEWAGE DISPOSAL 1. TYPE OF MECHANICAL
30 Masonry(wall bearing) 35 5f Gas 40 16,Public or private company Will there be central air
31 Wood frame 36 Oil q1❑ E] Private(septic tank,etc.) conditioning?
32 ❑ Structural steel 37 ❑ Electricity 44 ❑ Yes 45XNo
PL
W
OF WATER SUPPLY 33 ❑ Reinforced concrete 38 ❑ Coal H. TYPEWill there by an elevator?
34 Other-S i 39 Other 42 Public or private company
❑ -Specify ❑ \Y 46 E] Yes 47 TTT�NO
43 E] Private(well,cistern) TTT"````
J.DIMENSIONS
aa. Number of stories .................y.................................. M. DEMOLITION OF STRUCTURES:
as. Total square feet of floor area Has Approval from Historical Commission been received
all floors,based on exterior
dimensions ......................................�!b..................... for any structure over fifty(50)years? Yes_ No_
50. Total land area,sq.e......_r� 0...._S� Dig Safe Number
K.NUMBER OF OFF-STREET PARKING SPACES Pest Control:
51. Enclosed..............................---.........................................
sz. Outdoors
HAVE THE FOLLOWING UTILITIES BEEN DISCONNECTED?
..........
Yes No
L RESIDENTIAL BUILDINGS ONLY Water:
53. Enclosed......................_...._..._...._.................................... Electric:
Gas:
Fun..............�.............._........... Sewer:
. 54. Number of
bathrooms Partial...............I DOCUMENTATION FOR THE ABOVE MUST BE ATTACHED
...................... BEFORE A PERMIT CAN BE ISSUED.
IV. COMPLETE THE FOLLOWING:
Historic District? Yes_ No✓✓(If yes,please enclose documentation from Hist. Com.)
Conservation Area? Yes_ No✓ (If yes, please enclose Order of Conditions)
Has Fire Prevention approved and stamped plans or applications? Yes_ No Z
Is property located in the S.R.A.district? Yes_ No
Comply with Zoning? Yes e/No (If no,enclose Board of Appeal decision)
Is lot grandfathered? Yes_ No_ (If yes,submit documentation/if no,submit Board of Appeal decision)
If new construction,'has the proper Routing Slip been enclosed? Yes_ No e)01
Is Architectural Access Board approval required? Yes_ No ✓ (If yes,submit documentation)
Massachusetts State Contractor License # Salem License#
Home Improvement Contractor # Homeowners Exempt form (if applicable) Yes ✓ No
CONSTRUCTION TO BE COMMENCED WITHIN SIX (6)MONTHS OF ISSUANCE OF BUILDING PERMIT
CONSTRUCTION IS TO BE COMPLETED BY: J V� 1� 93 If an extension is necessary, please submit
in writing to the Inspector of Buildings.
V. IDENTIFICATION - To be completed by all applicants
Name Mailing address-Number,street,city,and state ZIP Code Tel.No.
1. vilket.lae-n Bill S ) 744-23A
Owner or f19O)O
Lessee y� yg -$A4W
1 r rf
2.
Contractor
Builder's
License No.
3.
Architect or
Engineer
I hereby certify that the proposed work is authorized by the owner of record and that I have been authorized by the owner to make this application
as his aWhorized agent and r agree to conform to all applicable laws of this jurisdiction.
Signatur of li Addams L+eq 4eAN ✓/— /� Application date
DO NOT WRITE BELOW THIS LINE
VI. VALIDATION
Building � _ q ? FOR DEPARTMENT USE ONLY
Permit number /J
BuildingUse Group
Permit Isued - 19!
Building Fire Grading
Permit Fee $ eQ G0.-$ Live Loading
Certificate of Occupancy $ Approved by: Occupancy Load
Drain Tile $ 1
Plan Review Fee $
"TLE
NOTES AND Data- (For department use)
PERMIT TO BE MAILED TO: ¢ V- e Y r„ S
DATE MAILED: _
Construction to be started by: Completed by:
VI ZONING PLAN EXAMINERS NOTES
DISTRICT
USE
FRONT YARD
SIDE YARD SIDE YARD
REAR YARD
NOTES
SITE OR PLOT PLAN -For Applicant Use .
-1
N
Y
Satem Fvice Department
PNTMEN7 FOR FINAL` Fine P�teventi on Bureau
APOfAPPOINTMENT FOR FINAL -
IN
APPECTION MUST BE 48 La4agette Street INSPECTION MUST BE 3~
MADE AT LEAST ONE WEEK Saeem, Ma 01470 MADE AT LEAST ONE WEEK
(508) 745-7777 AHEAD__._-.
f FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR BUILDING PERMIT
In accoAdance with the pnov44tom6 o4 the Ma44aciva,6ett6 State BuLZdtng Code
and the SaCem F4Ae Code, apptLcatton t.6 heaeby made 4o4 appnovat o4 pFarrh
'and the s441ance o4 a ce4ti4tcate o4 appnovaZ 4o4 a buttdZng pevnit by the
Sa?em F.uae Department. (Re4. Section 113. 3, Masa. State BZdg. Code)
Job` Locat.Lon: l
Owner/Occupant: jjt/1f/CY+�� !r oranl
E-eeat tcat Con t taaato t: 1,47 B6 .fG L
Ftiie Supp4.e64ton Cont4acto4:
SZgnature o4
Appe.cant: tit,<,i,�,r,�- AVG Phone I1: 7 !` 73357
Add e.64 04 City ox
Appt cant: b A, Town:
Appnovae date: li`GJ 3
Ce4ti.44cate o4 appnova a t4 he4.eby g4anted, on appxoved p2.an,6 on 4ubmd ttat
o4 p"ject deta,i.U, by the Saeem Fine Department. Atte pEan.6 arae approved
4otety 4o., .identi4tcation o4 type and .eacation o4 4t a p4,otect4on devtce4
and equipment. AZt ptaA4 ane 4ubjeet to appnovae o4 any othe2 autho44ty
having ju4,i6dZct4on. Upon comptetion, the appt cant on dnata,Z.Ze%(4) 4hatZ
neque.6t an tn.6pectton and/o4, teat o4 the 4.14e pxotRxt on devtce4 and
equ.i.pment. ( ** FOR ADDITIONAL REQUIREMENTS, SEE REVERSE SIDE ** I
New con6t4uction.
P4.openty Zocati.on has no compZ ance w.lth the p4.ovi,6t=4 o4
Chapt" 148, Section 26 C/E, M.G. L.., tetatt:ve- to the
tn4tatatLon o4 appaoved 4.Cne a.Za.4m dev-i.c". The ownea o4
thi,a pe%ope,4ty .t,a 4equt4ed to obtain comp lance ass a
conditton o4 obtatn,ing a SuUdi.n.g Permit.
Pnopetty Zocation 46 4n compti.ance with the p4.ov.t.a.ion4 o4
Chaptea 148, Section 26 C/E, M.G. L.
Expdratl.on date: i
— t'q e 4 F ince .i cf a 2.
Fee due: unde+e 7 . 500 So_ Fes.
FIRE DEPARTMENT CERTIFICATE OF APPROVAL FOR BUILDING PERMIT
In compliance with the provision of Section 113.5 of the Massachusetts
State Building Code, and under guidelines agreed upon by the Salem Bldg.
Inspector and the Salem Fire Chief, the applicant for a building permit
shall obtain the Certificate of Approval (see reverse side) and stamped
plan approval from the Salem Fire Prevention Bureau.
Said application and approval is required before a building permit may be
issued. The Massachusetts State Building Code requires compliance 3
approval of the Salem Fire Department, with reference to provisions of u m w
Articles 4 and 12 of the Building Code, the Salem Fire Code, Massachusetts o p
General Laws, and 527 Code of Massachusetts Regulations. r N
The applicant shall submit this application with three (3) sets of plans, p
drawn in sufficient clarity, to obtain stamped approval of the Salem Fire
Department. This applies for all new construction, substantial p w
alterations, change of use and/or occupancy, and any other approvals au)
required by the Massachusetts General Laws, and the. Salem F.£re Code. z g
Exception: Plans will not be required for structural work when the
proposed work to be performed under the building permit will
.,not, in the opinion of the Building Inspector, require a
plan to show the nature and character of the work to be
performed.
Notice: Plans are normally required for fire suppression systems,
y; fire alarm systems,. tank installations, and Fire Code -
requirements.
Under the provisions of Article 22 of the Massachusetts State Building
Code, certain proposed projects may not require submission of plans or
complete compliance with new construction requirements. In these
cases, provisions of Article 22, Appendix T', and Tables applicable
shall apply. This section shall not, however,. supersede the
provisions outlined in the Salem Fire Prevention Regulations, Chapter
148, MGL, or 527 Code of Massachusetts Regulations. All permits for
fire code use and/or occupancy shall apply for the entire structure;
fire alarm and/or smoke detector installation shall apply to the
entire structure based upon current requirements as per Laws and/or
Codes, but the existing structure may comply with regulations
applicable for existing structures.
Notice: Sub-contractors may also be required to file individual
applications for a Fire Department Certificate of Approval
for the area of their work. Such sub-contractors shall file
an Application to Install with the Fire prevention Bureau
prior to commencing any work for those areas applicable.
" C pop FINp4 t4
1. YMENFOR OtA M t
Form 81X (10/80) AppoisnA N Mu5T E WEEK ItASPE A.1 �S��J JK
1WO£T LENS"
4 P �17........
CITY OF SALEM
BUILDING DEPARTMENT
HOMEOWNER LICENSE EXEMPTION
Please Print
DATE vim'✓ �J, X993
JOB LOCATION 5, 17 P 0-_tiN ST W4 -p I6
Number Street address Section of Town
"HOMEOWNER W 1 t--t-JA14,1 &OWF-i -74S-70-39 G10? 4i82 -47 a3
Name Home phone Work phone
PRESENT MAILING ADDRESS -SAvo- A-f A-tbVL
City/Town State Zip Code
The current exemption of "homeowners" was extended to include owner-occupied
dwellings of six units or less and to allow such homeowners to engage an in-
dividual for hire who does not possess a license, provided that the owner
acts as supervisor. (State Building Code Section 109.1 .1
DEFINITION OF HOMEOWNER:
Person(s) who owns a parcel of land on which he/she resides or intends to re-
side, on which there is, or is intended to be, a one to six family dwelling,
attached or detached structures accessoryto 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 shall be responsible
for all such work performed under the building permit. Section 109.1 . 1
The undersigned "homeowner" assumes responsibility for compliance with the State
Building code and other applicable codes, by-laws, rules and regulations.
The undersigned "homeowner" certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that
he/she willcomply with said procedures and requirements.
HOMEOWNER'S SIGNATURE I,�
APPROVAL OF BUILDING OFFICIAL
NOTE: Three family dwellings 35,000 cubic feet, or larger, will be required
to comply with State Building Cade Section 127.0, Construction Control .
HOME OWNER'S EXEMPTION
The Code states that: "Any Home Owner performing work for which a building
permit is required shall be exempt from the provisions of this section
(Section 109.1 .1 - Licensing of Construction Supervisors) ; provided that is
a Home Owner engages a person(s) for hire to do such work, that such Home
Owner shall act as supervisor. "
Many Home Owners who use this exemption are unaware that they are assuming
the responsibilities of a supervisor (see Appendix Q, Rules and Regulations
for Licensing Construction Supervisors, Section 2.15) . This lack of aware-
ness often results in serious problems, particularly when the Home Owner
hires unlicensed persons. 4n this case your Board cannot proceed against
the unlicensed person as it would with licensed Supervisor. The Home Owner
acting as supervisor is ultimately responsible.
To ensure that the Home Owner is fully aware of his/her responsibilities,
many communities require, as part of the permit application, that the Home
Owner certify that he/she understands the responsibilities of a supervisor.
On the last page of this issue is a form currently used by several towns.
You may care to amend and adopt such a form/certification for use in your
community.
February 11,1992
City of Salem
Fire Prevention Bureau
and
Building Department
Regarding: Alterations to 57 Dearborn Street, Salem
Dear Sir/Madam:
Enclosed are the necessary forms and plans for your review so that a building permit
can be considered.
57 Dearborn Street is a single family home owned and occupied by William Brown
and Marsha Blythe-Brown.
The purpose of the alteration is to alter the current open storage area in the attic to
create storage,closets and drawers and to add venting to facilitate better
ventilation. Lights and outlets will be added as well.
Access to the attic is from the master bedroom via a full set of stairs.
Head height in the attic is G4" at the center peak of the roof. There will be no
habitable space in the attic, only storage.
Please give me a call if I can answer any questions.
Sincerely,
William Brown
Home 745-7339
Office (617} 4824703
APPROVPD L � 4/77C- S7 G
Sub,�!ct to approval by ray Oth-r
h - ing luriscictian. �! 4 c /� (r a
r n.L�ni rs�
w ar s7 ��7Y�aIr.N 'r/� or
if LSF
s� i ,r .r4-L-& ti, i'h o/976
a= 2'J -/i
P
,bdOtiJ �
� � J
r /kms
G//avoM . dit/miv��
s�b��
tt
sz� The Commonwealth of Massachusetts RECEIVED ITY OF
Board of Building Regulations and Sta RECTIDNALSERVCESC lTYO
I Massachusetts State Building Code,780 CMR SALEM
IV Revised Mar 2011
(\I Building Permit Application To Construct,Repair,Renddl MlabolA as: 4
One-or Two-Family avalding
' This Section For Official Use Only _ -
1 Building Permit.Number:
.Building Official(Print Name) - Signature Date
{!1\ SECTION 1: SITE INFORMATION
1 it �� perry Addr�ss: 1.2 Assessors Map&Parcel Numbers
lIT'^ ��hlat7�
L l 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 11) Frontage(it)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: Outside Flood Zone?Check if yesl7 Municipal❑ On site disposal system ❑
SECTION 2 PROPERTY OWNERSHIP'
2.1 Orvner'of Record:
( I't q
Name(print) / L City,State,ZIP p n
l�ek��orvt 5f y7�^ SO(9 �2� 1 LCOraw a 4nna La7m
No.and Street Telephone nail Addless
SECTION 3:DESCRIPTION OF PROPOSED WORIe(check all that apply)
New Construction Existing Building 17 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Cl Addition l7
Demolition ❑ 1 Accessory Bldg. ❑ N nber of Units I Other ❑ Specify:
Brief Description of ropose 12-
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only -
(Labor and Materials
1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Coati(Item 6)x multiplier x
3.plumbing $ /..
2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Su ession $ Total All Fees:$
S� S Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ ' ❑Paid in Full ❑Outstanding Balance Due:
p. 'J
SECTION 5: CONSTRUCTION SERVICES
5.1 nConstru/ction Supervisor /License(CSL) C S f 9 (o Y 4 mil
I ��
1)�jVt�G( s�t..1q 7_4 ,� LicaiseNumber Ezpimi on e
Natne folder
NF ,r— List CSL Type(see below) r,
No.and StreetA ' k .Type Description
U Unrestricted(Buildings u2 to 35,000 cu.ft.
R Restricted 1R2 Frunily Dwelling
CityRown,State.ZIP M Maso
RC Roofing Covering
WS Window and Siding
5 /� SF Solid Fuel Burning Appliances
I
Qv-C-s>��nc �7 �t�J7'Qi Insulation
ele hone Email address Co^A D Demolition
5.2 Registered Home Improvement Contractor(HIC) r S Lq S
� / 7
�. �^ Pn HIC Registration Number Ex irat' nDate
HIC Company Name or HI Re istrant. Mile
.ZV,e ��� �d c�'4r a 5G .✓ td_ z 17 /oe .
No.and Street ,�ru
�JTs�0 S milady ss
City/Town,State.ZIP Tel hone
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
I,as Owner of the subject properly,hereby authorize VI S L
to act on my behalf,in all matters relative to work authorized by this building petmiYapplication.
t
Print 0%vvcr s Name(Electronic iguatute) ate
SECTION 7b:OWNERi 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 inthis application is taste and accurate to the best of my knowledge and understanding.
/
I q S,a ( 1—c='/
Print Ot+�or Aut orizeTAgcr s Natne(Electronic Signature) III T lbate
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
w1vtiv.41ass. og vtoca Information on the Construction Supervisor License can be found at wwlk.rnass.gov/das
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
Nmuber 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"
l2'r.lot: Back -- W 4 sgt~'fi
„ f } jVhiylitMuvV} co l0au Sb.lbsls(Ct
/ f d
d'oWlas hf U1066 (bs } 'L4 f%'1tAN,c IBOO Ibs, eA&A
I
'• T loadreo auli asSv�M� S°iI - 7100 lbs `s��
i v ; `ova
• , . t Z°xjS"r IC$"Joist )CIO IAQsjff 'ZI of Cs.�auJl
• f � V I _' _ _ T � f i
I ,
JJ
cavc
I ,
• � I � � 1 F �llt(
i f I
• T
2X Oki
,
i 6"diA v�ila�
• - x2 ' II I
• �' v5s' ! glari dam( r t !
I I ,
(1 ,
I
1
1 ,
I 1 Skl�s r
I r .. + I 1 �beu.Un , r ben�ln bev4ch '
i
4 1
I
i i 1 1 1
p f I
i
1
i
i i I
44
r f �
4