3 HENRY ST - BUILDING INSPECTION 1,7
The Commonwealth of Massachusetts
wn of
Board of Building Regulations and Standards To
Massachusetts State Building Code, 780 CMR, T"edition MEN
Building Dept
JJ Building Permit Application To Cons ct, Repair, Renovate Or Demolish a �
One- or Tit o- nihy Divelling
This Section or0fli I Use Only
Building Permit Num n:! ate Applied: {
Signature:
Budding issioner/Ins ildings Date
ECTION I:SITE INFORMATION
1.1gProperty'"
ropppe tyyAddddress:j 1.2 Assessors Map& Parcel Numbers
1. rAJ
1.Is Is this an ac opted street?yes_ no Map Number Parcel Number.
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(D)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: Outside Flood Zone?
_
Public❑ Private❑ Check ifes❑ Municipal❑ On site disposal system 13
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: z ,/�,y
Name(Print) n Address r ervice: KK
x"94 - ��� -
Signature Tel hone
SECTION J:DESCRIPTION OF PROPOSED WORW(cheek all that apply)
tExisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition
Demolition ❑ I Accessory Bldg. ❑ 1 Number of Units_ Other ❑ Specify: (\
Brief Description of Proposed Work=: �1�1
1�lzEGT w b IJ/Tr 0/ `
SECTION 4: ESTIMATED CONSTRUCTION COSTS tt\'
Item
Estimated Costs: Ofllclal Use Only
Labor and Materials
1. Building S 415 Java . Building Permit Fee: S Indicate how fee is determined:
r ❑Standard City/Town Application Fee t)
2. Electrical ❑Total Project Cost'(Item 6)x multiplier x
}. Plumbing S 'fJ-0 2. Other Fees: S i
4. .Mechanical (HVAC) S List:
5. .Mechanical (Fire S Total All Fees: S
Suppression)
qz
�y Check No./06LCheck Amount: ash Amount:_ p
6. Total Project Cost: S Qb� / ❑ Paid in Full ❑Outstanding Ba nce Due: v
4�-
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SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
r,/ "R�'�"�' ((` J' Linnse umber Expiration ate
Ngfmc oCSL- H Ider J V
f //;YC� �D �ry�'{-t; List CSL Type(see bcluwl
Address r �� MDV
Description
Unreancted u to 75,000 Cu. Ft.)
Restricted 1&2 FamilyDwelling
Signature Slason Only
Residential Roofin Covering
Telephone P/ 7 Z i� 3 1 Residential Window and Siding
if/ 7
esidential Solid Fuel Burning Appliance Installation
esidential Demolition
5.2 Registered Home Improvement Contra for(HIC)
f +�� 1.1 AA P R �r� 7
HIC Company Name or 1 Registrant IQame Registration Number
1 _
Address 2//6 /ate d 9
6Z 7 0 2 Z3 'Expiratidh Date
Signature �— Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 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
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. j
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, ,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.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of fu
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 fW 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 110.R6 and I I O.RS,respectively.
2. When substantial work is planned, provide the information below:
Total noors 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
J. 'Total Project Square Footage'may he substituted for"Total Project Cost"
CITY OF S.0 .M. AxSSACHI;SETTS
BUILDING DEPARTMENT
120 WASHINGTON STREET, 3m FLOOR
TFL (978) 745-9595
FAX(978) 730-98U
KINtgFAi FY DRISCOLL
MAYOR THOMAS ST.PEEM
DIRECTOR OF PUBLIC PROPERTY/gl'fLDING CO\L%aSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / n Please Print Leeibly
Natne (IlusincS Organization lndividud): /,/(J`/�it/!X
Address: A6 2 2
City/State/Zip: !- -smr'a-�,° IVA ell Phone #:1'6 to /7 2S %-;? —vg31.1L7
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time).* have hired the sub-contractor 6. C3 New construction
2.[GA'atn a sole pmprietm or partner- listed on the attached sheet : 7• ❑ Remodeling
ship and have no employees - These subcontractors have S. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9• ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.] of10-C] Electrical repairs or additions
officers have exercised their
3.❑ 1 am a homeowner doing ail work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
comp. insurance required.)
'Any applicant that checks boa M must aim rill out the sectim below showing their workers'cumpenyviun policy infumusiom
'I himeuwnpa who suhmil this affidavit indicating they am doing all work argil then hire outride cenrrack"mum submit a naw affidavit indicting such.
. '("ommrton that cheek this box mum attached an a"no of sheet showing the name of rift subavnrractom and their workers'comp.policy information.
/am an employer that Is providlnr workers'compensadon Insurance for try employees. Below Is the policy and Job slte
information.
Insuclnce Company Name:
Policy M or Self-ins.Lie. p: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
f ne up to S 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$250.00a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
/do hereby certify under tpain emldes of perjury that the btfwmmlorr provided above is true and correct
Chin. t tr
pate'
t. t
Phone 4: / 1
Oficial use only. Do nor wrier in this area, to be completed by city or town officiaL
City or Tuwn: _ Permit/I.Iceme p
Issuing Authority (circle one)!
1. hoard of llealth 2. BuildinL Department 3.City/rown Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
(:Intact Pcrson: _ .. - -- -- Phone p•
CITY OF SALEM
PUBLIC PROPRERTY
�..I• .� DEPAR'I'�1ENT
IAC \\ r,i p`a.. ",\:ill ! • \\II \I, \1 \ .\ •. I . • .I _
II I •I'N.'14.14N t \\ 'i'$ V_ 'ri 4�'
Construction Debris Disposal .affidavit
(required litr Lill demolition and renovation work)
In accordance \%iih the sixth edition of the State Building Code, 780 CNIR section 11 1.5
Dvbris, and the provisions of:bIGL c 40, S 54;
Building Permit N is i5Slled with the condition that the debris resulting front
this work shall be disposed of in it pruperly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
. )_/PWA/d__
1 lcame of haultr)
I he debris will be disposed of in :
(namr of laeilrly)
I.IJJre,. ut'I�cllily)
'W lull• .11111 11J 11 -
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MICHARL P. ANTO INO .
REGTSTERFD.L.AND,STIRVE 'OR
';I LEDGEBROOK AVE. -
S'TOLKGHTOt N,IASSAC1-IUSETTS'0?072
PHONE/FAX (781),3= -4550
6/7
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PROPOSED HOUSE ADDITION AT
3 HENRY STREET
SALEM, MASSACHUSETTS
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1. GENERAL NOTES A-1
2. EXISTING FIRST FLOOR PLAN A-2 z
3. PROPOSED FIRST FLOOR PLAN A-3
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4. PROPOSED FRONT ELEVATION VIEW A-4 o
5. PROPOSED REAR ELEVATION VIEW A-5 0
6. PROPOSED LEFT ELEVATION VIEW A-6 Q cn
7. PROPOSED FOUNDATION PLAN S-1 �w�=
8. PROPOSED FLOOR FRAMING PLAN S-2 0wv
9. PROPOSED ROOF FRAMING PLAN S-3 +I z EXISTING HOUSE o�N
10. CROSS SECTION VIEW S-4 7n _~�
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GENERAL NOTES: :' 3�3 U n
1. HE CONTRACTOR OR OWNER IS RESPONSIBLE FOR OBTAINING AND PAYING FOR ALL PERMITS REQUIRED FOR THIS PROJECT. ��y�/�9 0
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OF IDri co2. ALL WORK SHALL BE PERFORMED IN ACCORDANCE WITH THE COMMONWEALTH OF CURRENT MASSACHUSETTS STATE BUILDING CODE (780 CMR) w
AND OTHER APPLICABLE CODES. ! TU1l�N �,I W N
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3. THE CONTRACTOR IS SOLELY RESPONSIBLE FOR MEANS, METHODS, TECHNIQUES, SEQUENCING, SCHEDULING AND SAFETY FOR THIS PROJECT. ` W.4%M Q a
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4. DIMENSIONS ARE NOT GUARANTEE, THE CONTRACTOR SHOULD VERIFY ALL DRAWING DIMENSIONS BEFORE PERFORM WORK. 6I i5/ w
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5. THE CONTRACTOR SHALL WARRANTEE HIS WORK FOR A PERIOD OF ONE YEAR FROM THE DATE OF FINAL COMPLETION. o
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6. THE CONTRACTOR SHALL REPORT ANY DISCREPANCIES BETWEEN DRAWINGS SPECIFICATIONS OR FIELD CONDITIONS TO T DESIGN IMMEDIATELY. N
7. CONCRETE AND REBARS STRENGTH SHALL HAVE MINIMUM OF 3,000 PSI AND 60,000 PSI RESPECTIVELY PAM NUY
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D T o E PROPOSED HOUSE ADDITION AT RENSION
27 PROSPECT AVENUE 3 HENRY STREET
N RANDOLPH, MA. 02,368 617-797-6637 �, am TM SALEM MASSACHUSETTS.
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I 27 PROSPECT.AVENUE �: � 3 HENRY STREET
cn RANDOLPH, MA. 02368 617-797-6637 DAM'
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I 27 PROSPECT AVENUE NRY STREET
ry RANDOLPH, MA. 02,368 617-797-6637 pan TM SALEM. MASSACHUSETTS.
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