0017 MARLBOROUGH ROAD BPA -10-795 ROOFThe Commonwealth of Massachusetts
CITYBoardofBuildingRegulationsandStandardsOFSALEM
Massachusetts State Building Code, 780 CMR• 7'"edition
v\
j Revised Jontu.ry
Building Permit Application To Construct, Repair. Renovate Or Demolish a 1. 200
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number/Date Applied:
J /
Signature: tl
Building CommissionerLffispectorof Buildings Date
SECTION 1: SITE INFORMATION
I.0pet=r77.4x® G'/
1.2 Assessors Map& Parcel Numbers
T
1.1 a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Informatio 1.4 Property Dimensions:
t
Zoning District Proposed se Lot Area(sq 11) Frontage(tl)
1.5 Building Setbacks(R)
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:
Zone: _ Outside Flood Zone?
Public Private Check if es
Municipal On site disposal system
SECTION 2: PROPERTY OWNERSHIP'
2.1 0 nertof ecord:
l3 C c ress7 IN
Name(Print) Add for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction Existing Building Owner-Occupied Repairs(s) 1 Alteration(s) Addition
Demolition Accessory Bldg. Number of Units_ Other ify:8
Brief Description of Proposed Work'-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item
Estimated Costs:
Official Use OnlyLaborandMaterials
1. Building S 7 I. Building Permit Fee:S Indicate how fee is determined:
Standard City/Town Application Fee
2. Electrical S
Total Project Cost(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire
S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S'01Q'aQ CTU 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) o7 a
ratio )ale
Name of CSI.-I folder
S
List CSL Type(see below) JW
r Descri Lion
Add s U UnresuicteJ u w 35,000 Cu.Ft.
R Restricted I&2 Famil Dwelling
Signature M Mason Only
yI/RC Residential Routing Covering
relephone WS Residential Window and Siding
SF Residential Solid Fuel Homing Appliance Installation
D Residential Demolition
2 Regi tered ome nprovement onlractor(HIC) All 7 7 G
i LL—
I C C parry a or f IIC Registrant N ey
Regtst tion Number
7
Jd ss (xpir ton Date
Signature relephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.¢ 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.
Signed Affidavit Attached? Yes.......... 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 to act on my behalf, in all matters
relative to work authorized by this building permit application.
Siumnum of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1V?4 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.
P int am 2d
Si ature of Owner or Authorized Agent Date
Signed under the pains and penalties of '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 Improvement Contractor(HIC)Program),will nrl have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 1 10.R6 and 1 IO.RS, respectively.
When substantial work is planned,provide the int'ornation below:
Total floors area(Sq. Ft.) including garage, finished basementiattics,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of hal"aths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.U.E.ti[t AXSSACHt;SEM
XMDLVG DU.%ATNW iT
110 W.13HINGTON ST%W. 1'e FtooR
T1t1. (978) 745•9595
F.%x(978) 72496"
KI.',CBEA"V C)UWOLL 7NO"ST.PMUM
MAYOR DII Wmill oP PL BLIC PROPEATV/DUBDL4G CO-%LbrSSSCL%ER
Workers' Campoesation Insurance %Md4Vi1* guilders/Contraclor%iElect/iclens/Plumbore
k t llcant Infnrmatlots
L1
Pleeao hint Leilsbr
Vatrtelurnne,.a,{,a.aeanln r.,mrllr 7ZOLAL
Address ;?
1-s V PP A n a S-
City/StakJZip. in
Are y u awpMysr!Chneh approplaa best Type a/proiss(ra9rlre/):
am n cmpleyw with 4. 0 1 am a ganaal conciarlar and 1 r~ Now construction
ctnployes(Adl anNor peat-anr).e have bird the at eerraracters
I. 1 am t sole prsprieter 6r paartw6
limed an the astachad A"= 7. 0 RemgMling
hip and have no employes These su comnssen have e. 0 Demolitia s
marking for me in any capacity. WOrke1a'comp`inaaraaca 9. 0 Building addition
S. We die
N leas'comp inwraatp mod I0.0 Eieeraical repairs or additionsorlkwahewexercised[link
3.0 1 am a homeowner doing all work rija of exemption per MOL 11.Plumbing npain or addWsns
myself.(No workers'comp. c. Ia-11(4),well we hm no 12.0 Roornpain
insttratee raquind j emp',) , LNe workers' 12.0 Other
Cornµin ur m4Nhad.l
nee appttod ihr dtala bra al Intra alw tW ur sr gets bnMe Atwiq deir wa,lam'eanpe todon pOo inermWaa
I I.rvwrwrsa who Submit ak aAldwn idtedne are an at4a w we*Mal"hla euaids cewemmm~mbaa a new alndwa intlurms Oak
anMM"dr.bwh ibis bw mw aowW as adettwrl dtem r..us dr moan of tin eAeraawmm ed iheb wwbes'mrT pd4y iaenwaYa
ate ow ray/ayal rA16/rrW/Gr/teerears'etwPrn ssdte/wrmaswJir nq tiap/erees etAsrr 6/iNos/hp nw/alb
informed"
Imurance Company Name:
Policy 4 ur Self-ina.Laic i /d 2— C3 Expiration Date 7
lob Sits AddrCaa 7/ -,j ( /440fi'/9 AV City/StaWzim 1
nscb a cop of rho werhan'composanWn psWy dedonli n pop(sMwing tb pNley w---read ssplrselae daft). _
Failure to amen covernp as required under 9ectien 25A or NOL e. 132 can land to the imposition oreriminal psnaldee are
fine up to S l jo0.00 and/er onayear imprisonmem•as will as civil pearltis in the fare of a STOP WORK ORDER and a floc
Of up to 3250. day anima t the violator. lie adviwd shot a carpy of this atatent na may ba rarw4cled to flat OI'Jleo or
In.c>uaatiuna, onlArw insurance coverapvcnfkafioa
b hrrrey r ana/rr the pr has on/ Ashlra o a Aor tAo ' jararedw Pnvilyd u1e it Ira rn1.'wrrd
Date:a
P•nre a: d
O/frrid Ytr rnI/t ne not wr%Mir Mix rrrq a e..YrwO/ird ey fits av urw a//hirf
city or rutvn: eermidUcente/__.
lauint.%uth.rty (circle in*):
i. uard u(IleaUb I. Mudding Department /.City/rown Clerk f. Electrical Gtrpector S. I'lumbint Impactor
6. Other
i
l„nfact reran: 2 -,pliant 0:
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
MII1 ' 11N. 11
I.CTA-411.1.n!V51Nkl•r •11I\I, tit. ItVI,•.PI
rrl '/7111.70.1!699 1 \t:J7•1a?'lIINI
Construction Debris Disposal Affidavit
required lur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I I L5
Debris, and the provisions of MGL c 40, S
Building Permit q is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility, as defined by MGL e
lt1. S130A.
The debris will be transported by.
1 nalrle ul hauler)
The debris will be disposed of in :
11111.J a
n; rut au my
I .Inn.d4N L r
taa
ALL jile'LL ,
Isnalure of lk-c"111 applicam
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dale