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0002, 0004, 0006, 0008 CELESTIAL WAY - BUILDING PERMIT APP The Commonweahh of Massachusetts Town of a s Board of Building Regulations and Standards Massachusetts State Building Code, 780 CMR, 7 edition Building Dept oBuilding Permit Application To Const epair, enovate Or Demolish a One- or 7 umih Du ellit Thi action For Official U e Only Building Permit Number D to pli d: Signature: Building Commissioner/Ins for of Buildings Date SECTION 1: INFORMATION 1 Property Address. 1.2 Assessors Map& Parcel Numbers � i� ' Ma Number Parcel Number Ila a is this an accepted street?yes_ no P ' \� 1.3 Zoning Information: 1.4 Property Dimensions: �J Zoning District Proposed Use Lot Area(sq R) Frontage(R) 1.5 Building Setbacks(D) 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? Municipal O On site disposal system ❑ Public O Private❑ Check it yesO SECTION 2: PROP R Y OWN IPt Name(Print) Less r Service: 9 _ 81J 3� -�1� Signature - Telephone SECTION 3: DESCRIPTION OF PROPOSED WORKr(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition O Accessory Bldg. Number of Units_ Other ❑ Specify: MDe;cnption of Prposcd ork': C! SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building E I. Building Permit Fee: S dicate 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: $ 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Total All Fees: S Suppression) Check No. _Check Amount: Cash Amount: 6. Total Project Cost: E `��0© ❑ paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) �e /7 1 / /1� pva License Number Expiration Date N,gmc of C L 1191de Li.a(CSL Type tsee below) AJ es ve � � C44,1eV T Descn tion r U Unrestricted(up to 35,000 Cu. n, R Restricted I&2 FamilyDwelling M Masonry Only J RC Residential Roofing Covering lephone IF Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5� a Istere Home y t� ntr tor(HHe�� H �C9m Nan o C is nttNN, Qgy�O Reeg�istt/rationNumber Expiration Date Signature Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 property hereby authorize to act on my behalf, in all matters relative to work authorized by this building permit application. Signature of Owner Date SECTION 7b: OWNER OR AUTHORIZED AGENT DECLARATION I, Vll A✓y�/ 5 ,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 be Prin / l O Sig ure of Owner or thorized Agent Date Si under the pains and penalties of perjury) NOTES: I. P 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.RS, respectively. 2. When substantial work is planned, provide the information below: Total floors 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"may be substituted for"Total Project Cost" CITY OF SALEM �. , PUBLIC PROPRERTY ' DEPARTMENT I1C W,oKo.%r:Ial,SKALET•Snit.w•MAM.w IIt of n51`i7: . G:I,y7i•.'IivS'+3 •1 ox 9711•h1: -1x46 - Workers' Compensation insurance Affctla--it: Builderslcontractors/Eiectricians/Plumbers % ilicant Informrlion dPlleea's_e' PPrint�Leeeeiibiv —rte Vdtnc l0o.uw�ss)r;tanualinwlnds.�.Iwll: �i14�1L1S ����'i.c��J �7YY'/!/!G-'��'�^N�����K/ _ -yam �. Address: Gy�,��! u�l�o � &i�7 �t7� Ciry.�c:ur./.ip' �'r+rf1 �dr0 1-20 I'hunei': (3' .\fe 1 on an employer:'Check the appropriate box: 'l')PC firpnejawc(raiuired):. - 1.L7 1 :em a employer with 13 4. Q 1 ant a general cauuaetor and 1 /i. 0 New construction cnlploycea(full.endsur part-tine).• have hired the sub-contracture 2.0 1 ant a sole pmpricux or partner. listed on rhe anachcd sheet �• C1 Remodeling . - ship and have no cmployLes These sub-contractors have a. 0 Demolition working for the in any capacity. 'workers'comp. Insurance. 9. 0 pudding addition INo workers'cutup. insurance S. 0 We arca corporation and its required) officers have exercised their 10.0 Electrical repairs or additions I 0 1 am a hnmapwn.a doing 411 work right of exemption per MCL 1 I.0 Plumbing repairs or a ldititlns myself.INo tuorkers'cutup. C. 152, §1(3),and we have no 12.0 Roof repairs insurance reuired. r aecs.nploy [No workers' `I J 13. Utiler comp. insurance rcyuind.J 0 •tn. .•itphcud else chcckr.bass Ill maal alio lilt wn the wubwe twWw rlmwina their n'wkui auntpanaatiun puliry snliutmalwn. 'I tutncuwnenwhtt suboYl this amdavir indiuein„tha,arc duuyl ell.Turk aeW ghat him"Usle contractors mrW.ulvna a new arr ma it iredicd.n t:u.:h. T..uencnan shot cluck this box mval anwhad an aeddiunal,J tsl.6uwina Ih sumew of tln eahiOnlraalatx and shelf wurkmi rasp,potecy mfmmadem. lain un enrp/ajer phot fit providing workers'rompentarfon insarnnre for niy employers, Below/s the pu/fay and job ifs, infurnrution • rI /� In..uranccCpmpauy Vame:__��z�i/ �`��j� �p,5�/i�11�---GC/J_� r i'olicy is utSelf--ins. Lic. it: dQ04 ��t�� l / -... - Eepirauon Date::_ 5"o.403 Job liro addresv: 001,9 piio�0 _C'ny;Slalei"LIp: ;iITIG/�/��1 !!(/ .\naeh a copy of the workers'compensatlon policy declaration page(showing the policy number and expiration state). Ivdure w wcurc cooerage as required under Section 25:\%;l'JIGL c. 152 can lead to the imposition of criminal penalties of a - rine op to 51.5110.00 and/or one-year'inrprisonmcnt,as well as 6%d penalties in Ile form of a STOP WORK ORDER and a fine Of tell r0 5250.00 a day againsl the Violator. lie advised that a copy of this elatcenent Inay b< larw arded to the office of . In�:.nyaunro ul :hc UTA for in.w:u:cc co�:rayr• wrilis.rr:on. - /Ju ben•Ay e.•rrifv turltcr r/ paint and penuhfet fdrer lhar rhe infurnna/lon provided abo , isfr atilt correct. I'1,.•c • :r_ --�-3-1113 - i/Qia'iu/use mdy. Dd nor urire in rhir urru,ru Ae ruuephred by airy or rorve a//iriuL I f R!, or fawn: __. Pcrmial.iccnce M. L.uing.\uthurirv (circleonc): - I. IF.ard of llarlll, !. Iloaldio' I)cpartisle tit .1.Cith.'fuwo Clerk 4. Llevric.d lu.pecror 5. Plumbing Inspector 6.04nr Cu lilac[ i'cnun: I'llone q: CITY OF SALEM .J PUBLIC PROPRERTY DEPARTMENT `'j I,, Ardll\......C S1?II t . ..,11 \l. \1,.,�, _. , � : .I•� _ • Ili v'•y.y;:i9•,; • 1 %X:';7N '4_•,ii,, Construction Debris Disposal Affidavit (required lur all demolition and renovation work) In accordance t, ith the sixth edition of the State Building Code, 7SO CNIR section 11 1.5 Debris, and the provisions of MGL c 40, S 54; Building Permit N is issued with the condition that the debris resulting from this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c. I It. S 150A. The debris will be transported by: �4�U1�O.t�Z �dg� 9.s8-3 X07 Ituunc o!'hauler) - 'I he debris will be disposed of in (mune ut I'acili y�� Unklres.ut Iii litvl SpA - 101itule atp:mlit apphrant x/A AD/ ,late