19 OLIVER ST - BUILDING INSPECTION (
The ('onununsaCa llh of Massachusetts
Iloard of Building Regulations and S;anJards Lt IR ---
j.`o� `7 + MdSSaultusCrS State Building Code. 7S1) (AIR. 7"' eJitiun Mt \'I( II' \1 I I 1
13uildine-
Permit Application To COI1SI11CL Repair. Renin ate Or Demolish a R, ,nrJ.Lrnrr,u i
i I
One- or Til')-h. Doelliri,q /. _oe;S
phis Serliun or fhrial Use Only —'
Building Pumit Number: -- -1
_ ate .-\ppbed: __ Q
IiwlJmg Coni s.unier/ In.pe 1 BUlld Ings
_SEC'T'ION 1: SITE INFORMATION ------- - --
1.1 Property Address:
1.3 Assessor-s-—Map . Ptrecl Vunbcrs--------_. ---- - _-
I.la Is this an _accepted sucet:' esno bis i_N1.1b
p y P s Pa;cel ..\'un:hrr
1.3 7oning Information: i 1.4 Property Dialensiors:
jZoning District . . ('Prn.used Use
Lot Alca U4 �1) Fl Unlage illi
IS Building Setbacks (ft) --�
1
From Yard Side Yards ------I
Rear Y;A
Required Pnry ided ---i
� i � Reyu neJ _ Provided Requited Pn,aJrJ I
1.6 Water Supply: IM.G.L c. 10. §511 L7 Flood Zone Information: 1.8 Sewage Disposal System: {
Public❑ Private❑ Zone: -- Uutside Floud Zone:' ---�
Check if yes❑ Municipal ❑ On site disposal syaam ❑
_SECTION 3: PROPERTY OWNERSHIP'
- J
fir' ir�a `9 D/�'� �✓ �f 3:0
;� Print l Address for Service: j
t —
Signsurc ---phone 1J _519
— Telephone I
SECTION 3: DESCRIPTION OF PROPOSED WORK (check as that apply) —I
—r----- I
New Cunstructiun ❑ Existing BuilJing ❑ Osaner-Orcupied C) 1 Repaus(s) ❑ Aheratnmis) C7 \Jditiim O
�-- -�
Demolition ❑ Accessory BIJ9. ❑ Number,rf Units— Other ❑ Speedy: i
Brief Description of Propose(1 Work1: - Q
SECTION J: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs:
(Labor and Mattrialsl Official Use Only
I. BuilJing $ I. Building Permit Fee: S. Indicate hum tae a determined
'. Electrical g ❑ Standard City/Tuwn Application Fee
❑ Total Project Cost'(Item G) r multiplier s
\. Plumbing g _
'. Other Fees: S
1. :blechaniral (HV:\C) 5 List
5. ,Mechanical (Fire — J
.Su) ression) b Taal :\II Fees: S -
y Check Vu. — C'herk :\mount (',uh :\m�uuu:
v -Total Project Cost y / DSD I ❑ paid m Full -- -- -
❑ Outstandim' Balance Due
f
4
SECTION 5: CONSTRUCTION SERVICES
A
5.1 Licensed Conslru•tion Supervisor IG• .) - /ej / ��� ___ 010
L_icrc,n>c lNltFiiihcr I`yn r.iwm Dalt �� '�-.• '
siame of ( Sl-- I htWrr 1 AL �,- Lt,t CSLI\pr t,rc htlow 1_
Tv e option
JJrtS,
( l'nrnli'rt ltd u t m :9.1N10(-u 1'I ___�
4j R RnlrrcteJ IS:' 1 ,1111111Vl.so
ltunutura \I Re—,,J nt lv —+
RC Re,iJtnoR�l uuhnc('ut itmc
- \1'S Rt.iJ:
feltp tone
� T 1F Rt aJtnudl S,thJ Fuel BUMM"
lJYJ1 D Rt.tJtntidl UrmuLuoti —{
5.2 Registered Ito to 1 (pro menl C'o'ntractor IIIICI
la6 '' Reguliauun Nunihrr
Ii IC""Companyantc o
Vr F C Registrant ?1:rt 6 .
Aessddr .aper int Dat, —.—
Ttlephunc
Signature
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. S 25C(61)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to parade
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes .......... CI 13 —
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
iU e • as Owner of the subject property hereby
I. --- -- _ to act un my beh:df, ht all matters
autht Nlzc
relative to w•.n k authorized by this but permit application.
—�--
Sing,litule ut Owner
SECTIO NERC OR AUTHORIZED AGENT DECLAR>�TION
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 �7_ ----
Datc
Signature of Owner or:\ t Dazed: gent
(Si ned under tlhe pains and l,enalties of e(u .)
NOTES:
nregisleied contractor
I. An Owner who obtains a building permit to do his/her own work, or an owner who hires .111u
(nut registered in the Home improvement Contractor (HIC) Program), will Wait have access to then and nnn
program or guaranty fund under M.G.L. c. 11"_'A. Other important infiirmation on the MC Pn,gram and
Construction Supervisor Licensing (CSL)can be titund in 780 CNIR Regulations I I0-R6 and 110 R5. icspccu,.cly.
' When ,ubstantial work is planned, provide the information below:
Total thrurs area(Sy. FLi (including garage, finished basement/atncs, decks or porchi
Habitable room count
I Gross living area (Sy. Fl,) Number of hedroinns -- ------
Number of tireplaces Number of h.tlt/baih -
I Number of bathrooms Number nit decks/ pi,rehcs ---
fvpe of heming System — --
Type of cooling system — --
}. `Total Project Square Footage•' may be ,ub,ututcd for -rota) Proleet Cost"
CITY OF SALEM
PUBLIC PROPRERTY
' DEPAR'I'L1ENT
;II r • 1u1 %1, Mt1 . . :I'1 :
I11
)_N '4 4.'I F"C ♦ I \X 'i',Q '4i J,.
Construction Debris Disposal Affidavit
(iciluired lbr all demolition wid renovation work)
In accurdance \%itlithe sixth edition of the State Building Code, 780 CMR section 1 11,5
Debris, and the provisions of MGL c 40, S 54;
Building Permit H is issued with the condition that the debris resulting from
this work shall he disposed of in it pruperly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
The debris will be transported by:
1r
I��I l� < c 1*t�
lname tit hauler)
the debris will be disposed of in
G�� 5
luJlnr u( aulmy)
IaJdre.. ul I�cllitvl
♦IL'IIJI W l' nt prnnrt apphcJnt
JIC