31 FORRESTER ST - BUILDING INSPECTION �$ 2Sbo cK2 .3rS
The Commonwealth of Massachusetts CITY OF
!� Board of Building Regulations and Stand5� RECEIVED SALEM
qY1 Massachusetts State Building Code, 780CI1 ECTIONAE_ SE �� yrrr101!
:Building Permit Application To Construct, Repair, RenovafP,'p NDemolishOa
One-or Two-Fanily Dwelling LLUU 55
This Section For Official Use Only
1 Date A
In Building Permit Number: PP
Building Otlicial(Print Naive) .__ Signature '. ,. - Dat
t SECTION 1:SITE INFORiIVtATION'
IL L �per�ddress: 1.2 Assessors Map&Parcel Numbers
_ ppl o. RC2 ST
I.In is this an accepted street9 yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District -Proposed Use - Lot Area(sq It) Frontage(R) -
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard-
ReygimJ Provide) ;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 a
Public 0 Private O - - Check if yeqrl.
SECT[ON2: PROPERTY OWNERSHIP)'
2.1 Owners of ecord: _ S�! ` O' d�7PJ
!Yh/�-2 � /IY�d'er� �c
me(Print City,State,ZIP
?/ �/LesTe.2
No.and Street telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all Mat apply)
New Construction❑fixisting Building O Owner-Occupied ❑ 1 Repairs(s) Altemtion(s)A Addition O
Demolition O I Accessory Bldg.0 Number of Units_ Other 13 Specify:
Brief Description of Propos Itt
Ale L F
s A- 4 " -C o n �gT�P
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building Permit Fee:$ Indicate how fee is Determined:
1. Building S —` ro 0
O Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3.Plumbing - S P Qlher Fees: S Inx',>
4.Mcclumicai (HVAC) S - List: �/
5.i\Ixhanicd (Fire -
Su ressiun)
i 'fatal All Fees:S
Check No. Check Amount: Cash Amount:
6. Totai Project Cost: S Bd O Paid in Full ❑Outstanding Balance Due:
M(Jt LA--0 It t2b
ova A
SECTION 5: CONSTRUCTION SERVICES
5.1 Cunstruction Supervisor License(CSL)
/, ;ys ff License Number Expiration Uale
Name of CSL Holder L
- (�
A e S1Z J(I/r7d/ List CSL Type(see below)
Type. - Description
No. and Street
,q U Unrestricted(Building!tip to 35,000 cu. Il.
/✓J C $ {?�r/ ! R Restricted I&2 Famil D.vellin
City/rown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
S I Solid Fuel Burning Appliances
1 I Insulation
Telephone
1 &nail address D Demolition
5.2 Registered dome Improvement Contractor(HIC)
HIC Registration Number Expiration Dane
I IIC Company Name or HIC Registrant Name [�
b / 1
No.and Street Email address
Cit /Town State ZIP Tele hon!
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L w 02.g 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 Is4uance of the building permit.
Signed Affidavit Attached? Yes .......... No...........O
SECTION lap OWNER AUTNORIZATIOI`GTO BE COMPLETED N'WHE
OWNER'S AGENT OR CONTRACTORAPPLIES FOR BUILDING.PERMIT'
1,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.
�?i16�,2�
Print O� en's Name(Electronic Signature) Date
SECTION 7b:OWNEW 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
tJt I—Cr 6,u I �c-(f ;-
Print Owner's or Authorized Agent's Nana(Electronic Signature) Dote
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 W have access to the arbitration
-t
program or guaranty fund under�LG.L.c.T4 --Oilier Importon�imfoirnaFion onrhe H1CTrogmmcan bortoimd at- -— —-
�rww mass eov'oca Information on the Construction Supervisor License can be found at wtvtv�os
2. When substantial work is planned,provide the information below:
'notal floor area(sq.ft.) N (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
.1. "Total Project Square Footage"may be substituted for"Turd Project Cost"
071'OF SALEA MASSAaiUSEM
BmDnvGDEPAKnffm
120 1WAStmvTcNS7=T,YOFLom
L(978)745.9595.
PAX(978)740.9846
RIMBERLEYDRISQ7LL
MAYOR 9kMis STREM
DutEcroROFpuRucPROPERTY/jiugDmO S4oi1=
Construction Debris Disposa/Affidavit
(required for all demolition and,renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and theovisions of MGL GL o40, S 54; Building Permit g is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 156A.
rThe debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(add ess of facility)
Signature of applicant
Date
The Commonwealth ofMassachuse&s
Depattinent oflndustria ,4eadents
1 Congress Street,Suite 100
Boston,AM 0211 4-2 01 7
UW www.mamgov/din
Workers'Compensation Insurance Affidavit.Builders/Contractors/Elecdicians/Plmnbers.
TO BE F11-ED WITH THE PERIVD'1TING AUTHORITY.
Applicant Information Pleaseftint jAdb
Name(Bosmess/Oigrmiiati.on/Individual): /J&4
Address: BSO-0-eL� J¢—
City/State/zlp: Dj:LJ Ja-2s m0 Phone t(
Are you an employer?Check the appropriate box: Type of project(reorifted):
a employer with _employees(ful)anNorpart-tim).4 - 7. Q New construction
2.Qlam asole propriourorparmernhipand have no empbym working formem
soY capm+tY•[No t'vakais''eonrp imteaace requited.] 8. 0 Remodeling
3.01 am a homeow�doing all work myself.[No worker'comp.insmmce required.]t 9. 0 Demolition.
4.Q Ism a homeow�non will be hiring contractors m conduct all work m my property. 1 will 10 0 Building addition.
enure that all contieams either have workers'compensation insurance or are sole 11.0 Electrical repairs or additions
pmpeieturs with ro employees.
5-F])am a general cannoneer and r have hired the m&oontife[me listed on the attached sheet. 12.�Plttmbing repairs tic additions
7Lese aub•c tnwtots have employees and havew13.0
orlho'comp.insman+1 Roofrepairrs(��
6.0re We area corpoiatim and its offices have exercised their right of airemption per MGL c. 14.0 Other l.J.-ti/
-4 tzmj4
152,1)(4),and we have no employees.[No workers'moap:msmmm required.]
*Any Wiliam that chedm box#1 must also fill our the section below showing theb troikas'compmmpm pnliny
t Homeowners who submit this affidavit indicating they are doing all work and that hie outside coubauma must i in A new affidevit indicating such.
1Contracturs this check this box must attached an additional ahem showing the mmeof the subcavmsgors and slme whether or not them emitim have
employees If the subconnacfma have employ-4 they,must provide their wwkas'comp.polirym®-
I am an employer that isproviding workers'compenaadon insurancefor my emplgyees. Below is tbepo/iry and job stile
injonnatlon. Q &%z—Insurance Company Name. Stn, RV S //�$(,/�/�CQ_ �Qr /t/q zy-V•�`
�.
Policy#or Self-ins.Lic.#: -- Expiration Date: - -
Job Site Address: 3 I Fod1/2eS I rpt city/swamp:
Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiradon date).
Failure to segue coverage as required under MGT,c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil,penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations.of the DIA for insurance
coverage verification.
I do hereby certify
t /uAderrAepain nand ppen/ae
alllies ofprjury that the inform ation pro vided above is true and correct.
Signature, �i1/V1 / .9n t c !� Data: /�r
Phone#:
Oficial use only. Do not write in this area,to be completed by city or town oozaiaL
City or Town: Perndt Ucense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
ContactPerson: Phone M