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5 ESSEX STREET - BUILDING JACKET 74520 40% . P4 v �� Co ,o (Cv R N,c e Mlvk APPROVED , 4 �-- --- %U V UL +� .� TY F ntiD LCi AiIC 0 N- 2 - i �^ n� .^RGTECTiCr: r IC N. F F. 'LT$ST'Ar9P:gP:C D1 N.iDF;CD r r(EC'':1JS.h e phl,E'i±ITK THE Fl E CUD-. i v j, r e 4CIP Y: r i \ lS% I'�/4orr ` r- �� �tZ: 2 �� { B;{�,a-- � �� ._ __ ._.. f � � � � � �� ��� - �. x�. ' � .(��' `kh'3 .. .. p��� �_;. �' ;_:, �. :� � � � �� j.. Wim. � I :. +4 ). et y.r- .e.:.yM... q ........ F w ��,�� �� '� / � , i 1 i�r. I O ��• .. .y. i i S[ � t � r i i aY 4 j i e uJ h s t 7 --- I'fie Conumoncvcal(h of iblassarhusclls Y 1" s; '� Board of Building Regulations and St:mJ:lyds Cll'Y OF 'r Massachusetts Slate Building Codc. 7SO C NIR S.\L1:.\I Building Permit ,\pplicalion To C'onslruct, Repair. Renovate Or Demolish a Om-ur Tivu•Panidl-Oat eRin y This Section For Official Use Only building Permit Number: Date Appli .< Building 011lcial(Print Nf ne) Siynutu I)u(c SECTION I:SITE INF R51ATION I.I Property Address: 1.2 Assessors Nlap i Parcel Number S f=cc•r-x ST /v9s9-i/ 9 4/i- oi9 y 1.la Is this an occe fed ..ree.T es 1"' no Nap Number Parcel Number 1.3 Zoning Informatlon: 1.4 Properly Dimensions: /.oniny District I'ropascJ(1$e Lot Area�yio Isy It) Frontage(it) 1.5 Bullding Setbacks(R) From Yard Side Yank Rcor Yard Required Provided Reyuircd Provided Reyuimd provided 1.6 Water Supply:(M.G.1.c. Jo.§)a) 1.7 Flood lone Informatlon: 1.8 Sewage Disposal System: Public❑ Private❑ Zona: _ Outside Flood"Zane? Chock if es❑ Municipal❑ On site disposal$)stem ❑ SECTION3. PROPERTYOWNERSHIPs 2.1 Owner'of Record: FRAezek SL�LC M MA 0797e) N;one(pnm) Uq.Slate.7 p s �ss�x T ���-�y�,�s90 Nu.and Strcel Ielephune F:muil AJdmss SECTION J: DESCRIPTION OF PROPOSED WORK',(check all that apply) New Construction ❑ E.vistiny Building❑ Otvner•Oceupied 11!i l isIsI Alteratlon(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.p Number of Units oL Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIJLATED CONSTRUCTION COSTS Item Estimated Costs: ILabor and .\Lnerialsi O111clul Use Only I. Building S I. Building permit Fee: S Indicate how lie is determined: 2. Iflectival S ❑Standard CiryTuwn Application Fee ❑Tutal Projat Cost'i hens 6).x multiplier 1. I'lunihi'tg S ". Other Fecs: S_ \Iech.miad time — --- •—j"—+-C.--J-� Cune�$ulnl i fPtd .\Il Fces: S __ . .... ._ . n Total Project Cuvt: i �j/s '7 ChaA vat. _...__Check :\muuur. . _....._. C,uh \numunl: ❑ Paid m Full 0 Outstanding llal.mce Due: six'HON 5: ('ONS I'MICTION SFRN'I('F­4 Npiralioll Milt! Ist('"I. t PC ILIllitills tio to 3 .000 N,,� and streetIt ilsoil KC ltoolin Co%vrin WS Window Aid sidin SFT solid II Illimillit Appliances I Insulation l'cic hone ----I—linail_;tdJN_,-4 0 Demolition 41.2 Registered Ilume Improvement Contractor(HIC) ---------1--------- I lic Itt:6111rillion Nuintice E%pirillioll Dow I 11C C0111pall) NJlne or I IIC Iteilkirwu Nimi: Email addrc4s No. Aid Stirclit 3 City/Tow".State,ZIP I' III hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 192.1 2SC(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. yes .......... 13 No.........SECTION .. Signed Affidavit Attached? — 18: 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. �D,1,s Print Uwncr's Nwne(Electronic Signature) I 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. or Noma if.14ttrollm NOTES: I. own work, n;7v; unrcilisteredcontralor .\n Owner who obtains ia building permit to do his her own %yor .or owner who hires an Inot registered in the Home Illiproveillent Cumirlictur(HIC) Program),will LU) have access to the arbitration prograin or guaranty luild under M.G.L.%:. 14-I.A. Other important information on the HIC program can bit lound at \,\%,% I Information on the Construction Supervisor License can be I ---5. provide the information below: A lien substantial%wrk is planned, I including gauge, finished bascinent.MINs.Jocks or ror%:h) total floor area('4 fl.) Habitable too"'count 6roi0i\ingareaIS4- tl I Number tit hvdrooms Nulliber ofliall'bailli unlb Nlllllherofdccki, por0tes i!,itelli t:d i1or I'oial IIII 01st­ 't1h,litut toi,il ProlcO Is,lumt: ):I it I'hc('ornnwnwealth of Mussachuscus y, },t y Board of Iuilding Regulations and Standards CI IT OF I1fVI ') i7, %3 Massachusetts State Building Code. 730('h1R SALEM l7lvrixdJ ILu 20 Building Permit Application To Construct. Repair. Renovate Or Dena One-or rnu-FuntilY Dw li aelling / This Section For Ofliciul Use Only Buildin Permit Number: Date, ied• Wilding 011icial(Print Name) Signature Dale SECTION 1:SITE INFORAIA ION I. 5 roper Address: `S 7- 1.2 Assessors,Nap dr Parcel Numbers / SSEX I.la Is this an accepted street?yes no Map Number Purccl Number 1.3 Zoning Information: 1.4 Property Dimensions: ' Zoning District Fn po U cU c Lot Area(sq It) Frontage(II) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard ;1133rier uired Provided Required Provided Required Provided ter Supply:(M.G.1.c.40.§Sq) 1.7 Flood Zir on: +1-11 Sewage Disposal System: Prieute❑ Zone: _ Zune? Munici al❑ On site Jis sals snun P N )� 'SECTION2: WNERSHIPIner'of Record:++✓r- �rearzc-k �rint) Z.IPESSt�ST 7YS=�J�U treet Telephone Finail Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) nstruction❑ Existing Building Owner-Occupied 0f Repairs(s) ❑ Alteration(s) ❑ Addition ❑ ion ❑ .accessory Bldg.❑ N of Units_ Other ❑ Spccit'y: scription of Proposed Work=: SECTION 4: ESTIMATED CONSTRUCTION COSTS licm Estimated Costs: (Labor and .Materials) Official Use Only I. Building S I. Building Permit Fee: f Indicate how fee is determined: 1 2. Electrical S ❑Standard CityoTown Application Fee ❑Total Project Cost'(Ilem 6)x multiplier _. x i. I'IumM°g S '. Other Fees: S n 11 \— — J. .\lec11.1nic,11 1111.1('1 S List:_ S. .Vcch;utical IFiry Su+uessionl S Toud .\II Fees: f Muck No. ('heck Anount: C,uh \mount: r. 1'utal,I'ntjcctCast: i - — --- 64 ❑Paid in Full 13 Outstanding Ilalvue Duc: SECTION5: CONSI'RUCTIONSERVICFS 5.1 Construction Supervisor License(C*Sl.) lWile F\piratton Date 11oldcr 1ist0l, 1'.%p: Description Na. and Street ki I hiresirmed illuildit,-3 kl' Ill 35,()00�Lir 11.) It l4c,tricted l&2 Fimil D%w1lin it n n.. "r"rctc' Nia"'ll RC' Rix,fin 0,%crin N&S NVindo%% and Sidin SF Solid Fucl Burning Appliances Insulation fete Fillail address D Dcnxltilion 5.2 Registered Home Improvement Contractor(HIC) Date 111C litegitraiton Nurnt, 1 irutiun I 11C Compaq Name or I IIC Itcgistruru Naing No.and Street Email address City/Town,State,ZIP SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 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 ..........a No...........0 SECTION 7s:OWNER AUTHORIZATION TO HE 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. Print 0%wer's Nanie(Electrunic 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 i s application is true and accurate to the best of my knowledge and understanding. ncr*i or ektithoOcd Agon ai s Nnc(Flectronic Signature) Date NOTES. L An Owner%%hu obtains a building permit to do his,her own work,or an owner\vho hires an unregistered contractor (not registered in the Hume Improvement Contractor(HIC) program),will nu have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be round at \%\k,% 111,1" n o' I information on the Construction Supervisor License can be found at 10\ Ill, \%lien substantial%York is planned, provide the information below: rota) fluor area(sq. tl (including garage. finished basement attics.decks or porch) Gross li%ing area i sq. 11.) Habitable room count Number of firvillaces NU111110 01'11CILIM01115 \unlher of bath rooms Number offialfhallis ocin Number o(decks, porches 1 6 1"!of cooling .'\Stein -.0'en 1. "focal Project Square Foola.ge"lnaN he suhstitiacd l'or fowl Project Cost" � L *_ , The Commonwealth of Massachusetts CITY OF 00 Board of Building Regulations and Standards SALEM Nlassachusetts State Building Code, 780 CMR Revised Slur 2011 lJ Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Family Dwelling This Section For Official Use Onf Building Permit Number: Date Applied v . Date MIAbuilding 011icial(Print Name) Signature, o C?�w SECTION 1:SITE INFORMATION' N 1.1 Property Address: T 1.2 Assessors Map At Parcel Numbers rn S q L I a Is this an accepted street. yes � no Map Number Parcel Number -U �2 1.3 Zoning Information: 1.4 Property Dimensions: N tos t Zoning District Proposed Use Lot Area No tl) Frontage(11) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required Provided Requited 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 es❑ SECTION 2: PROPERTY OWNERSHIP'" 2.1 Ownert of Record:I— /\+Q �P {r7 / rr� 0 /9 -7 0 ./ i�r �Jne(Print) City,Stare,ZIP �% SSPx S T No.and Sireet Telephone Efisbil AJJnsg SECTION 3: DESCRIPTION OF PROPOSED WORKS(cheek all that apply) New Construction❑ Existing Building If Owner-Occupied 9' Repairs(s) ❑ I Altemtion(s) Addition ❑ Demolition ❑ 1 Accessory Bldg.Cl Number of Units I Other ❑ Specify: Brief Description of Proposed Work': SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials 1. DuilJing S I. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical S ❑Total Project Costs(item 6)x multiplier x 3. Plumbing S 2. Other Fees: S d.`lechanicnl (HVAC) S List: 5. \lechanical (Fire S total All Fcas�S — Su ress,on Check No. Check Amount: Cash Amount: 6.Total Project Cost: S o20 006 . ❑Paid in Full ❑Outstanding Balance Due: Tnra,> SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) Type - Description No.and Street U Unrestricted But lJin s tip-to 35,000 cu. ft.) R Restricted 1&2Fanil Dwelling Citylfown,State,ZIP M Masonry RC Rocifinst Covering WS Window and Sidin SF Solid Fuel Burning Appliances i^' 1 Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) ' HIC Registration Number Expiration Dade IIIC2Comp:my Name or HIC Registrant Name No. and Street Email address City/Town, State ZIP TA hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.$ 251C(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........... O SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED WHEN. OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize 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'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. P 'tt Owner's or Authortzed Agent's Name(Electronic Signature) Date 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 Lipol have access to the arbitration program or guaranty fund under M.G.L.c. 1 d2A.Other important information on the HIC Program can be found at rvww mars,eov:'ocir information on the Construction Supervisor License can be found at www.nrass.eov:'dns 2. When substantial work is planned,provide the information below: 'total floor area(sq. ft.) (including garage,finished basementlattics,decks or porch) Gross living area(sq. 11.) Habitable room court Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches rypeofcoolingsystem Enclose) Open ]. '"I'otal Project Square Footage"may be;ubstiluted for"'fatal Project Cost"