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408 ESSEX STREET - BUILDING JACKET 408 ESSEX STREET l //// n l7uRClilG No. 153L•2 HASTINGS. MN LOS ANGELES-CHICAGO-LOGAN.ON MCGREGOR.TX-LOCUST GROVE.GA U.9J1. APPLICATION ADULT NUMBER ti Trial Court of Massachusetts FOR COMPLAI T JUVENILE )(}{ District Court Department ❑ ARREST A HEARING ❑ sUMM NS ❑ WARRANT COURT DIVISION The within named complainant requests that a complaint issue against the within - Salem District Court named defendant, charging said defendant with the offense(s)listed below. Yf®Bt$tOR$ DATE OF APPLICATION DATE OF OFFENSE PLACE OF OFFENSE- 66 Salem,t Yrtasfllnin 0190 5/28/96 2/96 408 Essex Street NAME OF COMPLAINANT City Of Salem Building Department NO. OFFENSE G.L. Ch. and Sec ADDRESS AND ZIP CODE OF COMPLAINANT City of Salem Sign 3-37 One Salem Green Ordinance Sections 3-38 Salem, Mass. 01970 3-19 2. NAME,ADDRESS AND ZIP CODE OF DEFENDANT John Theodorakopoulos 4Q8 Essex Street 3. Salem,_Mase;. 01970_..-._.—___-__- --- .. . d. COURT USE A hearing upon this complaint application TEO HEA I TI ME OF E RI ONLY—* will be held at the above court address on d AT 7 , t y CASE PARTICULARS E SPECIFIC NAME OF VICTIM DESCRIPTION OF PROPERTY VALUE OR PROPERTY TYPE OF CONtAOLLED NO. Owner of property, Goods stolen,what Over or under SUBSTANCE OR WEAPON ,person assaulted,etc. destroyed,etc. $2k Marijuana,gun;etc. 1 2 3 r d OTHER REMARKS: Failure to Comply to the City of Salem Building Department r SIGNATURE OF COMPL 7I ANT DEFENDANT IDENTIFICATION INFORMATION — Complete data below if kno DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMBER SEX RACE HEIGHT I WEIGH EY HAIR OCCUPATION EMPLOYERISCHOOL .. MOTHERS NAME(MAIDEN) FATHER'S NAME 0 0 s Z Z N 0 O v DC-CR2(3188) APPLICATION ❑ ADULT NUMBER Trial Court of Massachusetts FORCOM'NLAINT, ❑ JUVENILE District Court Department s' ❑ ARREST I '`I HEARING ❑ SUMMONS ❑ WARRANT COURT DIVISION The within named complainant requests that a complaint issue against the within Salem District Court named defendant, charging said defendant with the offense(s) listed below. 65 Washington Street DATE OF APPLICATION DATE OF OFFENSE PLACE OF OFFENSE g 5/28/96 2/96 408 Essex Street Salem, MA. 01970 NAME OF COMPLAINANT City of Salem Building Department NO. OFFENSE G.L. Ch. and Sec ADDRESS AND ZIP CODE OF COMPLAINANT City of Salem Sign 3-37 One Salem Green Ordinance Sections 3-38 Salem, Mass. 01970 -A-39 2. NAME,ADDRESS AND ZIP CODE OF DEFENDANT John Theodorakopoulos 408 Essex Street —� 3. S a-lem,-Mass.-O 19 7-0_..._---------------------_----_ -_-- 4. COURT USE A hearing upon this complaint application DATEOF HEARING TIMEOF HEARING COURT USE ONLY will be held at the above court address on AT I *--ONLY CASE PARTICULARS — BE SPECIFIC NAME OF VICTIM DESCRIPTION OF PROPERTY VALUE OR PROPERTY TYPE OF CONTROLLED NO. Owner of property, Goods stolen,what Over or under SUBSTANCE OR WEAPON person assaulted,etc. destroyed,etc. $250. Marijuana,gun,etc. 1 2 3 4 OTHER REMARKS: Failure to comply to the City of Salem Building Department d SIGNATURE OF COMPLY11ANT DEFENDANT IDENTIFICATION INFORMATION — Complete data below if know . DATE OF BIRTH PLACE OF BIRTH SOCIAL SECURITY NUMB ER SEX RACE HEIGHT I WEIGH EY I HAIR OCCUPATION EMPLOYER/SCHOOL MOTHER'S NAME(MAIDEN) FATHER'S NAME ISEONLY _ + _... ,.:>. DATE DISPOSITION AUTHORIZED BY NO PROCESS TO ISSUE ❑ At request of complainant ❑ Complainant failed to prosecute ❑ Insufficient evidence having been presented PROCESS TO ISSUE TYPE OF PROCESS 0 E. Sufficient evidence presented Warrant 0 ❑ Defendant failed to appear ❑ Summons returnable 0 ❑ Continued to 0 COMMENTS K OC-CR2(3/88) Titu of tittlem, :fflttssac4usetts tlublic 11rapertp i3epartment qeq� Nuilbing Department Mne dalem (green �O 508.745-9595 Fxt. 380 / Leo E. Tremblay Director of Public Property Inspector of Building Zoning Enforcement Officer April 10 , 1996 John Theed©rakopoulos 408 Essex Street Salem, Mass . 61970 RE : 408 Essex Street Dear Mr. Theodorakopoulos : In February, I contacted you in person and requested that you apply for a permit for the existing sign that overhangs the sidewalk on Essex Street . You apparently have chosen to ignore my request and the fact that an insurance bond is required for this sign. Please contact this office within five ( 5 ) days upon receipt of this letter as to what course of action you will take to rectify this matter . Failure to do so will result in legal action being taken against you . Sincerely, Leo E . Tremblay Inspector of Buildings LET: scm cc : Ellen Dubinsky Councillor Flynn, Ward 2 Certified Mail # P91 991 903 ' - ARTICLE P 921 991 . 93 UNE 1 John Theodorakopoulos NUMBER 408 Essex Street Salem, Masa. 01970 t FOLD AT PERFORATION t WALZ INSERT IN STANDARD#10 WINDOW ENVELOPE. , CERTIFIED M A I L f RW PosTACE POSTMARK OR'ATE RETURNSHOW TO WHOM,DATE AND RESTRICTED / a RECEIPT ADDRESS OF DEWERY I DELIVERY O SERVICE CERTIFIED FEE+RENRN RECEIPT WN M TOTAL POSTAGE AND TEES C3OINS RANCECWEIIAG PROVIDE SENT TOS NOT FOP INTERNATIONAL MAIL OO Er, FFSIDER Q a= rc Er John Theodurakopoulosw Er 408 Essen Street wLL a Salem, Hass. 01970 ul- ru 5X }Ro I W� f'a J t+ RS FORM 3800 z # � RECEIPT FOR CERTIFIED MAIL VI wu rnTe E f 4 STICK POSTAGE STAMPS TO ARNCLE TO COVER FIRST CLASS POSTAGE, CERTIFIED MAIL FEE,AND CHARGES FOR ANY SELECTED OPTIONAL SERVICES (see front). 1. If you want this receipt postmarked,stick the gummed stub to the fight of the return address of the article,leaving the receipt attached,and present the article at a post office service window or hand it to your rural carrier(no extra charge). 2. 1 you do not want this receipt postmarked,stick the gummed stub to the right of the return address of the article,date,detach and retain the receipt,and mail the article. 3. If you want a return receipt,write the certified-mail number and your name and address on a return receipt card,Form 3811,and attach it to the front of the article by means of the gummed ends If space permits.Otherwise,affix to back of article.Endorse front of article RETURN RECEIPT REQUESTED adjacent to the number. 4. If you want delivery restricted to the addressee,or to an authorized agent of the addressee,endorse RESTRICTED DELIVERY on the front of the article. R 5. Enter fees for the services requested in the appropriate spaces on the front of this receipt.If return receipt is requested,check the applicable blocks in item 1 of Form 3811. 6. Save this receipt and present it if you make inquiry. ENDER: I also wish to receive the, Complete items 1 and/or 2 for additional services. • complete items 3,and as s b, following services(for an extra fee): • Print your name and address on the reverse of this form so that we can return this card to you, 1. ❑ Addressee's Address • Attach this form to the front of the mailpiece,or on the back if space does not permit. • Write"Return Receipt Requested'on the mailpiece below the article number. 2. ❑ (Restricted Delivery • The Return Receipt Fee will provide you the signature of the person delivered to and the (rORsalt ostmaster for fee: date of delivery. P 3.Article Addressed to: 4a.Article Number P 921 991 903 4 ivh'+ 7 zap ?;r..t:rrp4tis, . 4b.Service Type 40, S.-l.a® Y 6!970 CE If IFITD 7.Date of De t er I i(- 5. 5.Signature ddr 8.Addresse 's *ZOO s ' (ONLY if req ested and fee paid.) 6.Si at e—(Ag n r PS Form 3811,November 1990`. DOMESTIC RETURN RECEIPT United States Postal Service ,,,.�^•^+.e II I I II Official Business PENALTY FOR PRIVATE USE,$300 �Iln�u��ll�lul�ulllumll�l�ulul�l�lnllu�l� INSPECTOR OF BUILDINGS ONE SALEM GREEN SALEM MA 01970-3724 refusal, order or decision. The action of the Building shall be filed annually with the city clerk. Any failure to Inspector may be annulled or modified only by a decision of 4 renew such bond shall be sufficient reason for the revocation of the 5 members of the Board.If the action of the Inspector is of the permit for the sign to which it applies. modified or annulled; the Building Inspector shall issue a ) b, 3-10 SAME.— CERTIFICATION BY SUPERINTENDENT permit or order in accordance with the decision of the Board. OF STREETS, ETC. 3-34 VARIANCES IN SPECIFIC CASES. No permit required by 3-38 shall be effective until the The Board of Appeals may vary the provision of this Or- superintendent of streets,and the city electrician in the case dinance in specific cases which appear to them not to have of illuminated signs are securely fastened so as not to been contemplated by this Ordinance,and in cases wherein endanger persons upon the sidewalk or street. its enforcement would involve practical difficulties or 3-41 SAME — DURATION OF PERMIT. unnecessary hardship, if, in each instance, desirable relief Permits required for signs or structures over a public may be granted without substantially derogating from the sidewalk or public way shall be effective only until revoked intent and purpose of this Ordinance but not otherwise. Any by the Building Inspector, or until the sign for which the decision to vary the provision of this Ordinance shall be permit was required has been removed. unanimous and shall specify any variance allowed and the 3-42 GENERAL PROVISIONS. reasons therefor.Each decision of the Board of Appeals shall No billboards, signs or other advertising devices shall be be filed in the office of the City Clerk within thirty days after erected or maintained on or over the public ways of the city, the hearing and a copy of the decision shall be sent by mail or or on private property with public view of a public way or delivered to the appellant and any other person appearing at public park or reservation, except as may be permitted by the hearing and so requesting in writing. Failure to file such statute,the rules and regulations of the Outdoor Advertising a decision within thirty days after the hearing shall be Authority legally established thereunder, the provisions of deemed to the approval of any variance sought. this code and the ordinances of the city consistent therewith. 3-35 CONDITIONS AND SAFEGUARDS. 3--43 SAME — REPAIR AND MAINTENANCE. The Board of Appeal in granting variances shall set forth All billboards,signs or other advertising devices erected or appropriate conditions and safeguards whenever, in its maintained within the city shall be kept in repair, painted opinion, they are desirable. and in good condition,The Building Inspector may order the 3-36 PENALTIES. removal of any billboards,sign or other advertising device in Any sign owner or owner of property on which a sign is any location where the maintenance thereof constitutes a fire located who violates,or permits a violation of this ordinance, hazard,is dangerous or a menace to public health or safety, shall be subject to a fine of not more than $20.00 a day if the when the use thereof has been abandoned,or the permit for violation continues more than 90 days after(a)the date of the I its use has been revoked by the Building Inspector. notice referred to in 3-29 hereof is given, or (b) continues 3-44 SIGNS IN RESIDENTIAL DISTRICTS. more than 15 days after the date of conclusion of any appeal In any residential district as defined in the Salem Zoning therefrom. Ordinance, there shall not be any sign except as follows: 3-37 SIGNS OR STRUCTURES OVER PUBLIC WAYS. I A.One sign,not exceeding two square feet in total area,at- Sign"s'orstructures over public ways shall, when erected, tached to the building or on a rod or post not more than four be at least ten (10)feet over the sidewalk. Signs or advertis- a feet high and at least three feet in from the street line, and ing devices over a public way shall be at least twenty (20) stating only the street number or name of the occupant or feet over such public way. occupants of the lot,or both,except that in an R—C and R-1 3-38 SAME — SURETY BOND. district, such a sign may also identify professional offices No permit required for a sign over a public way or sidewalk and other home occupations (see Section 5., B. Special shall be effective until surety company bond in the sum of one Permit Uses paragraph 1., A., (4) of the Salem Zoning thousand dollars($1,000.00)conditioned to save harmless the Ordinance as adopted August 27, 1965, and as amended in city from any claims for or by reason of the maintenance of August 27, 1965, September 2, 1969 and August 1, 1972) such sign, and shall be on file with the city clerk. provided that such a display be not more than one 3-39 SAME — TERM OF BOND. I non-electric announcement sign of an area not greater than All bonds required by 3-38 shall be for a term of one (1) 1Yz square feet and attached against the building and not year from the date of permit issuance. A renewal thereof protruding therefrom. 6 7 I C:I*n�o)e of *alem, massacllusetts Public �rapertg Department 1Nuilbing Department (One *alcm (6rcen 500-745-9595 Fxt. 300 Leo E. Tremblay Director of Public Property Inspector of Building Zoning Enforcement Officer April 10 , 1996 John. Theodorakopoulos 408 Essex Street Salem, Mass . 01970 RE : 408 Essex Street Dear Mr. Theodorakopoulos : In February, I contacted you in person and requested that you apply for a permit for the existing sign that overhangs the sidewalk on Essex Street . You apparently have chosen to ignore my request and the fact that an insurance bond is required for this sign. Please contact this office within five ( 5 ) days upon receipt of this letter as to what course of action you will take to rectify this matter. Failure to do so will result in legal action being taken against you. Sincerely, i7 y�Lb �✓i %env'' --�/ Leo E . Tremblay Inspector of Buildings LET: scm cc : Ellen Dubinsky Councillor Flynn, Ward 2 Certified Mail # P91 991 903 OMiI yrilr �0� _ CERTIFICATE ISSUED DATE .. 4/4/91 F' CITY Of SALEM SALEM. MASSACHUSETTS 01970 BUILDING PERMIT AN a4� CERTIFICATE OF OCCUPANCY -7A GATE Feb. 6 19 91 PERMIT NO. 3791 - }APPLICAOT FxNard horr188 ADDRESS 33 GenBBee St., 1244 ... IN0.1 ISTRI[TI ICONIR'S LICENSE) ncq.Tnc FR�n n PERMIT TO RENOVA'PIONS (_7 STORY ___. rlcTlaSIAU L%W DWEBLLROr ING UNITS ITnI on, IurMovwENn NO. IRROIOSEO O!Q AT (LOCATION) 408 ESM SE) mm T M D�STN CT f� � .g m,�* 1x0.1 ISTREETI _ BETWEEN AND ICROSS STREET) (CROSS STREET) LOT SUBDIVISIONLOT BLOCK SIZE BUILDING IS TO BE FT. WIDE P, FT. LONG BY FT. IN HEIGHT AND SMALL CONFORM IN CONSTRUCTION zi t TO'TYPE: r t USE GROUP BASEMENT WALLS OR F0UNDAT ON 'f ITVREI REMARKS: RFNMM-10N EM MM OMS'S PIZZA ~ CALL FOR PEPM1 TO OCCUPY 745-9595 9mN AREA OR VOLUME ' I PIO �mll�4:Sq�50OIRF I{RI b f71 b AI b ST 0.11 OfTI b A l s!/I b S!'rI b CLr b lFl b p91 O'.Tl b!'FI OLtI s!N O T.'EI O m, OWN[P ETot�n �1f=lous - TO BE POSTED ON PREMISES ADDRESS 111 Sheild W8y, Lyn ,MA. - SEE REVERSE SIDE FOR CONDITIONS OF CERTIFLCA&S. A .: E rM � � 4d DEPARTMENTAL APPROVAL FOR CERTIFICATE of OCCUPANCY and COMPLIANCE i To be filled in by each division indicated hereon upon completion of its final inspection. i BUILDINGS Permit No. 31-91 I Approved by,, JAMES SANTO Date 4/4/91 Remarks 4y PLUMBING Permit No. Approved by E Date " Remarks ON FILE ELECTRICAL Permit No. Approved by Date Remarks ON FIT.F OTHER F Permit No. Approved by_ Date Remarks ON FILF I OTHER Permit No. Approved by Date Remarks BUILDING PERMIT JOB WEATH%5.,CARO ESS���,,,�,,.�.,� DATE Feb. 0 . -^i'�9.�� 9.1� PERMIT NO. APPLICANT i�i4 morrSHB ADDRESS ticTEE St.1,Heyem'' I NO.) (STREET) (CONIR-S LICENSEI ��I�Ay�A( TTw�t�c oocc NUMBER OF PERMIT TO iSA�n/Y V I—) STORY S•-_'� DWELLING UNITS (TTR 01 IMVROV EEENTTJ �-sN+OO.. nLon (PROPOSED USE' 408 L 911U '' uww zwo �OSTR CT e AT (LOCATION) ISTRCETI 1X0.1 BETWEEN AND ICROSe STP[[il (CROSS STREET) LOT SUBDIVISION LOT BLOCK S12E BUILDING IS TO BE FT. WIDE BY FT. LONG BY FT. IN HEIGHT AMC SMALL CONFORM IN CONSTRUCTION TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION InvEl R1Im11'iON kM HUDIEEW'S PIZZA REMARKS: CA" lit pFSwX1 io OOCM 745-9595 AREA OR ESTIMATED COST J PERMIT S 20.00 _ VOLUME �CU81C/SQUARE EEETI S /Ij TIfPvilr� EI4iY• Tj�Y3C1N.LJ�'701C1U8 OWNER BUILDING DEPT. C ALS. 111 Sheild WAy# Lyrm,m. BY 1 ADDRESS — INSPECTOR OF BUILDINGS THIS PERMIT CONVEYS NO RIGHT TO OCCUPY ANY STREET, ALLEY OR SIOE�y/ALK OR ANY PART THEREOF. EI:MER TEMPORARILY OR PERMANENTLY. ENCROACHMENTS ON PUBLIC PROPERTY NOT SPE CIFIC A CLY PERMITTED UNDER THE BUILDING CODE, MUST BE AP- Poo. PROVED BY THE JURISDICTION. STREET OR ALLEY GRADES A5 WELL AS DEPTH AND LOCATION OF PUBLIC SEWERS MAY BE OBTAINED FROM THE DEPARTMENT 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 APPROVED PLANS MUST BE RETAINED ON JOB AN" THIS PFRM ETS APPLICABLE RED SEPARATE F09 INSPECTIONS REQUIRED FOR CARD KEPT POSTED UNTIL FINAL INSPECTION HA$ BEEN ALL CONSTRUCTION WORN: ELECTRICAL. PLUMBING AND L FOUNDATIONS OR FOOTINGS. MADE. WHERE A CERTIFICATE OF OCCUPANCY IS RE- MECH aNI C AL INSTALLATIONS. C. PRIOR TO COVERING STRUCTURAL QUIRED.SUCH BUILDING SHALL NOT BE OCCUPIED UNTIL MEMBERSIREADY TO LATH1. FINAL INSPECTION HAS BEEN MADE. S. FINAL INSPECTION BEFORE OCCUPANCY. POST THIS CARD SO IT IS VISIBLE FROM STREET BUILDING INSPECTION APPROVALS PLUMBING INSPECTION APPROVALS ELECTRICAL INSPECTION APPROVALS IV - ROARD!]F HEALTH GAS INSPECTION APPROVALS �j FVSEDERT. IN EC INGA PR L$ X A .14'0' I �t11 0 �� • I 31boll-11 /V' OTHER CITU ENGINEER Z Z ✓(/ WORK SHALL NOT PROCEED UNTIL THE [PERMIT ERIT WILL BECOME NULL AND VOID IF CONSTRUCTION INSPECTIONS NSPCAN CTIAO ARRANGECATED D FOR BYTELEPHONE IARD INSPC: JR HAS APPROVED THE VARIOUS ORIS NOT STARTED WITHIN SI% MONTHS OF DATE THE OR WRITTEN NOTIFICATION. STAGES of CONSTRUCTION. IS ISSUED AS NOTED ABOVE. d 66 3Q .a The Commonwealth of Massachusetts Department of Public Safety F Massachusetts State Building Code(780 CNIR) n Building Permit Application for any Building other than a One or wo-Family D e ling '1 (This Section For Official Use,Only) Building Permit Number:' Date Applied Building fII ial SECTION 1i LOCATION(Please indicate Block# and Lot#for locations fo hicti astreet a di of available) �/Ok t'ssex 56 Scle� WSJ ONt5 No.and Street City/Town Zip Code >d<e of .uilding(if applicable) - SECTION 2:PROP09ED WOR Edition of MA State Code used If New Construction check here❑or eck that apply in the two rows below Existing Building❑ Repairik Alteration ❑ Addition❑ I Demolition CILKease fill out and submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ 1 Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No ❑ Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑ Brief Description of Proposed Work: c c .l wl�,e o Ilel.,� d �rE SECTION 3i COMPLETE.THIS SECTIONIF EXISTING.BUILDING.UNDERGOING RENOVATION;ADDITION;OR CHANGE IN USE OR OCCUPANCY J. Check here if an Existing Building Investigation and Evaluation is enclosed(See 796 CMR 34) ❑ Existing Use Group(s): Proposed Use Group(s): SECTION.4:BUILDING HEIGHT AND AREA.`,-',! -- Existing Proposed No.of Floors/Stories(include basement levels)fir Area Per Floor(sq.ft.) Total Area(sq. ft.)and Total Height(ft.) -SECTION 5:USE'GROUP(Check as a licable)k A: Assembly A-1 ❑ A-2❑ Nightclub ❑ A-3 ❑ A-4❑ A-5❑ 1 B: Business ❑ E: Educational ❑ F: Facto F-1 ❑ F2❑ H: High Hazard H-1 ❑ H-2❑ H-3 ❑ H4❑ H-5 ❑ f: Institutional 1-1 ❑ I-2❑ 1-3❑ I-4❑ M: Mercantile❑ T R-Residential R-111 R-2❑ R-3❑ R-4❑ S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as applicable) IA ❑ Ill ❑ [IA ❑ IIB ❑ IIiA ❑ IIIB ❑ IV ❑ VA ❑ VB ❑ SECTION.7:.SITE INFORMATION (refer to 780 CMR 111.0 for details on each item) Water Supply: Flood Zone information: Sewage Disposal: Trench Permit: Debris Removal: Public 1{ Check if outside Flood Zone GA Indicate municipal 9 A trench will not be Licensed Disposal Site❑ Private❑ or indentify Zone: or on site system❑ required 0 or trench or specify: / fL permit is enclosed❑ - Q Railroad right-of-way: Hazards to Air Navigation: CIA Historic Commission Review Pro —'S": Not Applicable❑ Is Structure within airport approach area? Is their review completed? or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑ SECTION 8:CONTENT,OF CERTIFICATE OF OCCUPANCY Edition Of COcle: Use Group(s): Type of Construction: Occupant Load per Floor: Does the building contain an Sprinkler System?: Special Stipulations: I t `SECTION 9:,PROPERTY OWNFR AUTHORIZATION . . . , Name and Address of Property Owner � i pMwljvS f/zza 961: Name(P t) No.and Street City Town Zip Property Owner Contact Information: Title Telephone No. (business) Telephone No. (cell) e-mail address If applicable, the property owner hereby authorizes �1 79ca res bsev✓� /S' ,$�..,w- � apt VVV_' 5 5 Q141 � Name Street Address CityCity/�� State Zip to act on the property owner's behalf, in all matters relative to work authorized by this building permit application. SECTION 10:CONSTRUCTIONCONTROL Please fill in&A` , endlk,2 If buddui ,less than 35,000 Lu'of enclosed''s ace and or not under Comstruc5oh Control then check here:Erm ski Section lo.l 10.1 Registered Professional Responsible for Construction Coritrol.`i Name(Registrant) Telephone No. e-mail address Registration Number Street Address City/Town State Zip Discipline Expiration Date 10.2 Generaalll Contractor-a t Company Name :7i- L.Acr ra-zip. !(1t69q Name of Person Responsible for Construction License No. and Type if Applicable /5- .17Pr ti024 a'Ae_ jl "xv �tl 4-?sf_S� aP/5� Street Address City own State Zip fW- LAS 3-ro l � Telephone No. business Telephone No. cell e-mail address ' SECTION II:WORKERS<t7(JAPENSATIONINSUPANCE'AFFIDAVIT M'.QL.cc152. 25C6 A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit. Is a signed Affidavit submitted with this application? Yes❑ No ❑ • -'SECTION 12c.CONSTRUCTION'COSTS AND PERMIT FEE ,.; Item Estimated Costs: (Labor and Materials) Total Construction Cost(from Item 6)=$ 1. Building $ ls'Oe> •oo Building Permit Fee=Total Construction Cost x_(Insert here 2. Electrical $ appropriate municipal factor)_$ 3. Plumbing $ 4. Mechanical (HVAC) $ Note:Minimum fee-$ (contact municipality) 5. Mechanical Other $ Enclose check payable to 6.Total Cost $ Z coed , W (contact municipality)and write check number here SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT-'- 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 tothe best of any knowledge and understanding. >/ c,tye' I 1 / �SZ 3SG1 9 17 Please print and sign name Y� � Title Telephone No. Date /S I1pw/P✓�u 11Ac, t f �' ^r�� Street Address Town State Zip Municipal Inspector to fill out this section upon application approval: Name. Date