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&\ Commonwealth of Massachusetts
City/Town of Salem
Certificate of Compliance
Form 3
DEP has provided this form for use by local Boards of Health. Other forms may be used, but the
information must be substantially the same as that provided here. Before using this form, check with
the local Board of Health to determine the form they use.
This is to Certify that the following work on an On-Site Sewage Disposal System
Important:When
filling out forms ❑ Construction of a new system
on the computer, ❑ Repair or replacement of an existing system
use only the tab ® Repair or replacement of an existing system component
key to move your
cursor-do not -
use the return Has been done in accordance with Title 5 and the Disposal System Construction Permit(DSCP):
key.
14-1 July 30, 2014
D
� DSCP Number DSCP Date
Roy Zaller
Facility Owner
1 Eleanor Road
Street Address or Lot#
Salem MA 01970
Citylrown State Zip Code
Designer Information:
Name Name of Company
Signature Date
Installer Information:
Milt Hamilto Preventative Septic and Drain
Name Name of Co any
C- r�/� _
Signature - Date
Use of this system is conditioned on compliance with the provisions set forth below:
No additional conditions
The issuance of this certificate shall not be construed as a guarantee that the system will function as
designed.
Larry A Ramdin Health Agent
ApTroving Authority
SignatufQ,, Date
t5form3.doc•06103 Certificate of Compliance•Page i of 1
The Commonwealth of Massachusetts RECEIV
Board of Building Regulations and Standards INSPECT IOI ALES
W
\\� Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Deq�t3
syr 127 05
One-or Two-Family Dwelling L„� � 5 A
This Section For Official Use Only
Building Permit Number: Date Ap 7-V- ZO `/
Building Official(Print Name) Signature -
SECTION 1:SITE INFORMATION
/ 1.1 PropertyClPano(1!AddresrZs•o4r� 1.2 Assessors Map&Parcel Numbers
� I
1.1 a Is this an accepted street?yes no Map Number - Parcel Number
1.3 Zoning Information: 1 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 Reqjjj1:T 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 if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: /t
PcAit1l �QM wt4M S461-1S461-1 !/.,. A 011-70
Name(Print) pp II /City,State,ZIP---1
E (eanofYfot�ljnB�SZ��O�, GgM
No.and Street Telephone Email Address
SECTION 3:DESCRIPT1O -OE PROPOSED WORK!�(check that apply)
New Construction Elup ei d -Existing Building Owner-Occ ± rs s) ❑ I Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2: CoM (pt( rr-moo4l ot Cly/` f cC
QI 0 l_r 164a r Cm d rQ,1A>,trV& got o P tie i, C t, 11--t4f dr g0pl1 a Ce S
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 1. Building Pemut Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costr(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire
Suppression) $ � Total All Fees:$
6.Total Project Cost: $ '' O 00 Check No. Check Amount: Cash Amount
r ❑Paid in Full ❑Outstanding Balance Due:
Cl.L r—Ey2 �, U ,
a
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
Q -SI Aq�Z ;�! List CSL Type(see below)
No.and Street l Type Description
U I Unrestricted(Buildings up to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/I'own,State,ZIP M Mas
onry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Bunting Appliances
I Insulation
Tele hone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name HIC Registration Number Expvation Date
No.and Street
Email address
Ci /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...........Cl
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
/ to act on my behalf,in all matters relative to work authorized by this building permit application.
Dnn JEL 14AMM IJ q -tf - zo/g
Print Owner's Name(Electronic Signature) Date
/ SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
.J 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.
%PJEL- NAMVvAni qr-y - Zorn
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dors
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"maybe substituted for"Total Project Cost"
I