97 TREMONT ST - BUILDING INSPECTION (2) I rhe commonwealth of Massachusetts
,i Board of Building Regulations and Standards CITY
A � Massachusetts State Building Code, 780 CMR, 7" edition OF SALEM
Revised donuory
Building Permit Application To Construct, Repair, Renovate Or Demolish a /, 2008
One-or Tivo-Fomily Dwelling
This Se•flr n For Official Use Only
Building Prrmit Nu bel: I Date Appf d: l /
Signature:
Building Commissioner/ Spectorof Build' gs Date
SECTION I:SITE INFORMATION
I.1 Property Address: � 1.2 Assessors Ma & Parcel Numbers
P Y 9j 7 Tremo✓3� 5 P
I.1a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water pply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Plaod ne?
Public Private[3Check ifyes Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record•
''ot, u - 2o,p✓� 274 �u,e,, S� . , 4u1e�1
Name Address for Service: T
(77n -710 - F879
Signature Telephone
ECTION 3: DESCRIPTION OF PROPOSED WORK=(check all t at apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) <Afteration(s)<Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work-: e*-1 o✓ /'er+•+ 4 A C-1,
�aCu8+-. oovo,IA ✓oma ire <Z
g� �(ICA,� e,c ��.-�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
t Labor and Materials
I. Building S .. L Building Permit Fee:S Indicate how fee is determined:
00 ❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. ]'lambing S 2. Other Fees: S �//llam` ,l
4. Mechanical (IIVAC) S List: �'7'1 l (/(J
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S�o ❑Paid in Full ❑Outstanding Balance Due:
.i .
SECTION 5: CONSTRUCTION SERVICES
5,1 Licensed Construction Supervisor(CSL) �G
7�
��Dnl a[�nnersc� LicenseNumher spiuuonUatc
Name iT�f CSI.-6, � /G List C'SL frpe(see below)
Address"' Ac I\Ve Description
Il llnresiricteJ u to 35,000 Cu. Ft.
It Restricted 1&2 FamilyDwellin
Sigh 2— M \4asonry Only
RC Residential Rooting C'uverin
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5,2 Registered Home Improvement Contractor(HIC)
I IIC Company Name or IIIC Registrant Name Registration Number
Address
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 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
I, , 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
I, J tp11v1 u Y &VIA v\ as Owner or Authorized Agent hereby declare
that the statemeit[s and in on he foregoing application are[rue and accp t the best of my knowledge and
behalf. _✓�^J �cO /S G'
c�—
Print Nam
Signature of Ow or uthorized Agent Date
Si rued under the
is nd penalties ofperjury)
NOTES:
I. An Owner who obtains a building permit to do hislher 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. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, 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.) Ilabitable 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 he substituted for"Total Project Cost"
CITY OF SM.&M. %Lkss kcHusETTS
• BUMDLNG DEPARTMIENT
130 WASHLNGTON STREET, Yo FLoolt
7)EL (978) 745-9595
FAX(978) 740-9846
KISBERLEY DRISCOL[.
THO
MAYOR .uAs ST.P[P1tR8
DIRECTOR OF PUBLIC PROPERTY/BUtMLYG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 1 l 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit# is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
I 11, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
4
-- -(name of facility)
(address of facility)
si na of pc it applicant
date
dnn�,if J,.