17 1/2 RIVER ST - BUILDING INSPECTION ti
The Commonwealth of Massachusetts Town of
ABoard of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'"edition Building Dept
' r Building Permit Application To Cons t, Repair, enovate Or Demolish a �
One- or A -Fmnil.v Dwellin
Th Section For Official Only
Building Permit N bar: ate I d:G
Signature: / `
Building Commissio er/Ins for of But[ Date
SECTIO TE INFORMATION
1.1 Property A ress: 1.2 Assessors Map At Parcel Numbers
1 %• r
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 ill Frontage(R)
I.s Building Setbacks(R)
Front Yard Side Yards Rear Yard
RequiredProvided Required Provided Required Provided
1.6 Water Supply:(M.O.I,C.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public❑ Private❑ Check if es0
SECTION 2: PROPERTY OWNERSHIP'
2.t Owner'of Record:
Name(Print) Address for Service:
-d/2� ;?z3- �i �l3
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ eparss
Ri ( ) Alterations) 13 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Descri tion of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OMcial Use Only
Item - Labor and Materials
1. Building 5 1. Building Permit Fee: E 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: E
4. Mechanical (HVAC) S List:
5. ,Mechanical (Fire S Total All Fees: S
Suppression)
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S `7 O(�(7 ❑ Paid in Full ❑Outstanding Balance Due:
Com} 16 5-3--
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) / 2
t2e�7' S License Number Expirabo Dale
Ngmc of CSL/- HpWtr
)r- Pv ��vr List CSL Type(sec below)
L/ r
rd c
dress T Description
tion
Qr r, J'e 1rJ U Unrestricted(up to 35,000 Cu. Ft.)
�—�—�— R Restricted 1&2 Fame Dwelling
Signa reM Nlasonry Only
RC Residential Routing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
O / D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
Ga�Ts'i ✓e PS /S9/ 9
H C Company Name or H egistrant ,NN,ame Registration Number
/2L rrnr� �yye2T �zle L
A ress ) q
P1 ✓eP—r a'/� z /7- Xn Date
Signature Telephone
SECTION 6: W RS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.J 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? Ye ..........�� No.........
CTION 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.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, ,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
r(Jr Signature of Owner or Authorized Agent C Date
vv
(Signed under the pains and penalties of r'u
NOTE .-
1. An Owner who obtains a building permit to do his/her o -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 I O.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 basementlattics,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 Cosy'
n�
CITY OF SALEM
jj PUBLIC. PROPRERTY
DEPARTMENT
I ': UI1 r11\II \+.
Construction Debris Disposal .-affidavit
(retluired li+r all demolition and renovation wurk)
In accurdance %0h the sixth edition of the Slate Building Code, 780 CNIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal lacility as defined by MGL c
I 11. S 150A.
The debris will be n':msportcd by:
el �n , r'P✓ ✓i CPS
1 name hauler)
I he debris will be disposed of in
(name ul laclhty)
IIIJdre.Y of I�cllily(
HLIIa1 W l' +r pi nnn al+phc
lalr
CITY OF S.U.F-,,1, 2%LxSSACHL;SETTS
BUILDING DEPAIMIENT
\ �a 130 WASHINGTON STREET, )sa FLOOR
TEL (9714) 715-9595
FAx(9711) 7.40-9846
Ki BERiEY DRISCOLL
MAYOR THOMAS ST.PMM
DIRECTOR OF PLBLIC PROPERTY/84:II.13ING CO%MUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumb
en
Anplicant Information Please Print Legibly
Vatne lllusittcv.Organizatiotvindivishsal):�� �Y//-c H . >�S'
Address: /o/ •.t�r7�.-r�7� ✓�
"99-ACity/State/Zip: v d erS' _ &ej Phone N: dl -7- J"99-
Are
re you an employer?Cheek the appropriate box- Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and 1
mployees(full and/or pan-time).• have hired the sub-contractors 6. C1 New construction
2 1 am a sole proprietor or panner- 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, ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10,0Electrical repairs or additions
required.) officers have exercised their
3.❑ I am a homeowner doing all 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.j t employees. (No workers' U.❑Other S/ .suer r �^f
comp. insurance required.) r�---
•Any applic a a that chain bon at most also fill out the seUim below showing their wmkrs'rompenurion policy infurmatlon.
'I Lwneuwngs who submit this affidavit indicting they ate doing all work and then hue outside conttxtor most submit anew affidavit indicating such.
T.rtracton that cheek this lax most attached an additional shies showing the tame of the subsontreeots and their worker'camp.put icy infemtauea.
I"man employer that Isproviding workers'compensation Insurance for my employees. Below/s(Ile policy and Job std
information.
Insurance Company Name:
Policy #or Self-im. Lie. H: Expiration Date:
Job Sire 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
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the forth of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Ile adviw:d that a copy of this statement maybe rorwarded to the Office of
Invcsttgatiuns of the DIA for insurance covemgc verltieYtion.
/do hereby corifyut r the dins and penalties of perjury that the infarmallon provided above is true and correct
�i •r I ve' Datc. S
Phone 4:
Official use only. Do not write in rho area,to be curnpleted by city or town ojjciot
City or Tuwn: _ Permit/f.lceme p
Issuing Authority (circle one)i
I. hoard of health 2. Building Department 3.Cityfrown Clerk J. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person: . _- ., _ __ _- Phone p•