408 JEFFERSON AVE - BUILDING INSPECTION Y , .
The Commonwealth of Massachusetts Town of
}, Board of Building Regulations and Standards
!3� Massachusetts State Building Code, 780 CMR. 71"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a ! '
One- or Avo-Fandl'v Dwelling
(1 This Section For Official Use Only
�c Building Permit Number: �/ Date Applied:
Signature: ��""-11 � � ( 6
Building Commissioner/Inspector of uddings Date
SECTION l: SITE INFORMATION
1.1 Pro erty Add s:
AVE, 1.2 Assessors Map& Parcel Numbers
�� 'S���•er5o�
I.Ia Is this an accepted street'. yes ✓ no.
Map Number Parcel Number
1.3 Zoning Information: 1. prtv Dimensions: �r
U ( n (SFT (a f
Zoning District Proposed Use Lot Area(sq ft) Frontage(n)
LS Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided =RcquiredPTOvidedProvided1.6Wate Supply:(MGLc.40,§54) 1.7 Flood Zone Information: em:Zone: Outside Flood Zone? l system ❑Public Private❑ Checkif es❑SECTION 2: PROPERTY OWNERSH------------
2.1 wner'of Recor� 9t.0
me(Print) Address for Service:
gnature
Tel
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ ;Numbe;rofUgnits
=Other
Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials -
1. Building S 'kDOD. f0 1. 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 (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
6.Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES ^
5.1 Licensed Construction Superviso`r'(CSL) n Q q �. 00219 // 10
r�� L W S14A y 1L iLcrC7nsr/Number Expiration Date
N�mc of L-Holder s 14,C7List CSL Type(see W-ow)--U—
Address T Descri tion
U Unrestricted u to 35,000 Cu. R.)
Signature R Restricted 1&2 Famd Dwellin
C' M Mason Onl
15 RC Residential Roofin Coverin
Telephone WS Residential Window and Sidi-
SF Residential Solid Fuel Bumin Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: RICERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 25C(6))
Workers Compensation Insce affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the de of the Issuance of the building perm' .
Signed Affidavit Attached? Yes...... .... 0 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`building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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
beh f.
Ayl_ ylmha, �f'resa frlL��^
Pnnt Name U
i
Signature of Owner or Authorized Agent Date
(Signed under the pains and 2enalties ofperjury)
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 nor 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 1 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"
ti
l
CITY OF SALEM
,,. PUBLIC PROPRERTY
DEPARTMENT
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance %%i[I the sixth edition ofthe State Building Code, 780 CNIR section 111.5
Debris, and the provisions of vIGL c 40, S 54;
Building Permit A is issued with the condition that the debris resulting front
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debris will be transported by:
ALY,t si or, CP1 -In L
(name of hauler)
Ilie debris will be disposed of in
(name of facility)
laddress of lacilitvl
signatuic of panmt al ant
51,Q / O
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