22 HOWARD ST - BUILDING INSPECTION . � The Commonwealth of Massachusetts Town of
°i
Board of Building Regulations and Standards
la� Massachusetts State Building Code 780 CMR, 7 edition
Building Dept
r Renovate Or Demolish a
Permit Application To
Construct, eat ,
Building P pp � �
One. or Tuo-Fymr l) Du llin g
This Sec+on For O t al Use Only
Building Permit Num ec/J �, ,, e p lied:
Signature: Date �LI/
Building Commissioner/Ins for of uildings
SECTI ITE INFORMATION
1.1 Propert �ddrere�s_s,: 1.2 Asse2sson M� ap& Parcel Nrlmberry, 1
Ma Number Parcel Number
1.1 a Is this an accepted street'?yes_ no
P
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(R)
1.5 Building Setbacks(ft)
Front Yard
Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L C.40,254) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Public)X Private 13 Check if yesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 O„��e 'o Recora� (ln
0 0
Lli n �fl��
��Qrl �=s(�LF�N�lm _..Ldp ` ` �X
Name rint) Address for Service:
Telephone 4609
Signature
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building gr Owner-Occupied� Itepairs(s) c:1 11 ❑ AMilton ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other Specify:
Brief Descri tion of Propos Work: 00
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
ow fee is determined:
I. Building S 1� (���. I. Building Permit Fee: E Indicate h
[3�. Standard City/Town Application Fee
2. Electrical S 3r�t��� ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 5 Q Q, 2. Other Fees: 5
4. Mechanical (HVAC) S List:
5. .Mechamcal (Fire S Total All Fees: 5
Su ression
�,�r� oo Check No. _Check Amount: Cash Amount:__
c
6. Total Project Cost: S 30)fit,.¢/. 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) ^I t\ t
License Number Expiration Date
Nome., S'Hpl er �� �� List CSL Type(,cc below) '
Address Type Descri tion
HD$Rcsidential
estricted u to 35,000 Cu. Ft.)
✓ tricted I&2 Famil Dwellin '
Signature D on Onl
Telephone //''yy'-7 c�l� /ry-� dential Window and Sidinq f R- -S [V 0007 dential Solid Fuel Buri A liance Installation
Demolition
5.2 R, istered Home Improvement L1 b 6 Contractor(HIC) ��/"7G�
6 afll�\C Lr r�/ C�
HIC Companya or HIC egistrant Nalm Registration Number
Address L
/� -7(' n
A 7� �,tJ ? 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
1, 2�b t r7 �j-�j/� (� , as Owner of the subject property hereby
authorize n iS L a nto act on my behalf,in all matters
relative to woj"uthorijed by tu ding ermit application.
1 �-61,
Si namrc oNOwnerate �—'
SEC ON 76: OWN�E�R''�O�R AUTHORIZED AGENT DECLARATION
I, —vv �� ��/ ' Y ,as Owner or Authorized Agent hereby declare
that the statements and information on the foreg6ing application are true and accurate, to the best of my knowledge and
behalf.
f.
Print Name
a , ?Do
Signature of Owher-or Authorized Agent Date
(Signed under the pains and penalties of perjury
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 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 IO.R6 and I I O.R5, 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.) 2tq 'a, 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 ofcooling system Enclosed OPen
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.U1 ESI, �L'�SS.ICHL'SETTS
BUILDING DEPAR-MIENT
120 WASHINGTON STREET, 3so FLOOR
T 1_ (978) 745-9595
F.ax(978) 740-9846
!V\igERI-EY DRISCOLL
MAYOR THODfAS ST.PMRRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO%LNUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Alrplicant Information Please Print Legibly
Nalne tBusimx&Organi:atiomindividuaq: , Y R I %A ry
t -- —
Address: 15 7CA.A-e—
S�
v _
City/State/Zip: / 0JOI - Phone #: sqC)
Are you an employer?Check the appr priate box:
Type of project(required):
L❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2-VJ 1 ata a sole proprietor or partner- listed on the attached sheet : 7• Remodeling
.ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. Q Building addition
[No workers'comp. insurance S. F-1Weare a corporation and its
required.] officers have exercised their 10. Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.TPlumbins 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 chocks full lot must also fill out the When below showing their waken'compensation policy information.
t 1 hwnemoners who submit this affidavit indicating they an,doing all work octad then hitt ouoide contract.must submit a new affidavit indicating suck
!r,,mm;ton that chmil this box most attached an additional sheet showing the name of the sub-contractors and their worker'comp.policy information.
/am an employer that is providing)vorkers'compensation insurance jar my emplayees. Below is the pulley and fob slte
information.
Insurance Company Name:
Policy#or Self-ins. Lic.rr#: Expiration Date:
Job Site Address: oCrlls 5 F 0W 1M) City/State/Zip: D lot / O
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration slate).
Failure to secure coverage as required under Section 25A of MGL c. 132 can lead to the imposition of criminal penalties of a
fine 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 Erne
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ul'the DIA for insurance coverage verification.
/do hereby car ify an er the pal s mrd penaldes ajperfury that the information provided above is true and correct
Sion i ire'
Date: .� � / \ a 120
_ -{� �
Phone
Official use only. Do not write in this:area,to be completed by city or town qiciaL
City or'fuwn: __ __ Pcrmit/License#
Issuing Authority (circle one): -
1. Board of Health 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ Phone#:
CITY OF SALEM
'� ay
PUBLIC PROPRERTY
DEPARTMENT
I I I 't';6'4iI \X W8'4: ".. 4,„
Construction Debris Disposal Affidavit
(rcyuired li)r all demolition and rcnuvation wurk)
In accurdance wth [lie sixth edition of the State Building Code, 780 CMR section 1 1 1,5
Debris, and the provisions of fb1GL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in it pruperly licensed waste disposal I'acility as defined by MGL c
I 11. S 150A.
The debris will betransportedby:
1 arV\kA C�r'i �fR4
Iname u(hauler) �-
I lie debris will be disposed of in
(nainc of facility)
IadJres of fac Jilvl
r
m We of permit applicant
,4 0?6 - apo