4 TURNER - BUILDING INSPECTION ,\ Jzk The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
It Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One- or Tit o-Family Duelling
This Sect n For Official Use Only
Building Permit Number: Date Applied:
U--G�'
Signature: BuildingCom sioner/ to tidings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map At Parcel Numbers
X 41 rvrn P a- Sa Bin
Map N
!.i a Is this an accepted street?yes_ no }_ umber Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Lot
Zoning District Proposed Use Area(sq R) 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,§54) 1.7 Flood Zone Information: 1.9 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private E3 Check it Xes13
SECTION 2: PROPERTY OWNERSHIP'
�/ 2.1 Owner'otRecord: u �.waC
CLnerC I Ra :, F`P–�' lL3
Name(Prjn Address for Service:
Si�ure
Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
XNew Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition 13Demolition [3 Accessory Bldg. 13 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building E pbb I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical a 1 200 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 4,Dprj 2. Other Fees:
4. Mechanical (HVAC) S List: /
V 5. Mechanical (Fire 5 Total All Fees: 5
/\ Su ression
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: S ❑ Paid in Full ❑ Outstanding Balance Due:
2(S
SECTIONS: CONSTRUCTION SERVICES +
5.1 Licensed Construction Supervisor(CSL)
—!J8gSi7!f-
Expiraoon Date
onDate
O�tr�� Q�9A7 �' License Number
N,Imc of C Hplder �I !/ �V/� List CSL Type(sec below)
"1 (f
. / d.4on Sf 6,,A1eh i y
Address T Description
U Unrestricted u to 35,000 Cu. Ft.)
Signature R Restricted 1&2 FamilyDwelling
M Mason Onl
7��" '�i RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered HomeImprovement ontractor(HIC)
r s Ptr
XHIC Comp me or C Registrant NaAe Registration Number
Addr-sc S� Mss dl�ti r� lac+ a/9!ft 0/ 1 1 �„Z fl/C, _
A•y JJ.t_,� Sof{. 7`f',5• S' 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........... O
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
�/ OWNER'S A/GE/NT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, �,P,/4A yzz , as Owner of the subject property hereby
authorize2.o 4 424 z to act on my behalf,in all matters
relative to work authorize by this building permit.application.
Signature of Owner _ Date r 1
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
I. Few ,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
�1 behalf.
/\ �0&eA Fe,�
PrintNa log
+
Signature of Owner or Authorized Agent Date
Si ned under the pins and penalties of peru
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 110.116 and 1 W.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"
CITY OF SAI,E.N1, L%L-1SSACHI:SETTS
BUILDING DEPART.%t&NT
\ �a 120 WASHINGTON STREET, 3se FLOOR
TEI_ (978) 715-9595
F.kX(978) 740-9846
KINfBERI-EY DRISCOLL
,MAYOR THOMAS ST.PtT:RR13
DIRECTOR OF PUBLIC PROPERTY/BUILDING CO.\L\RSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information /� Please Print Legibly
Nalne (0usimstvorsaniratiomindividual): 6feo/Or' t� Uary/'
Address: 1 1.✓Zdrion S 5/
City/State/Zip: Phone N: JOS ' 7).S- 6W
Are you an employer?Check the appropriate box: Type of project(required):
1.0 I am a employer with 0� 3 4. 0 I am a general contractor and 1 6. 0 New construction
employees(full and/or part-time).* have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet : ?• RfRemodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. workers'comp.insurance. 9. Building addition
[No workers'comp. insurance 5. 0 We are a corporation and its
required.] officers 10. Electrical repairs or additions
officershave exercised their
3.0 1 am a homeowner doing all work right of exemption per MGL 11. Plumbing repairs or additions
myself.(No workers'comp, C. 152, §1(4),and we have no 12.E Roof repairs
insurance required.) t employees. [No workers' 13.0 Other.
comp. insurance required.]
Any applicant that chwW box ill most also fill out the section below showing their workers'compensation policy information.
}I I.wnwuwnera who sulmtit this affidavit indicating they are doing ail work and then him outside contractors must suhmit a new affidavit indicting suck
:C,nnratom that chick this box must attached an additional shed showing the name of the subtoninsoon and their workers'comp,policy information.
I am an employer that it providing workers'compensation Insurance for my employees. Below is file policy and fob site
information. /
In.surance Company Name: t!t p Yofr/,f, IL06
Policy At or Self-ins,Lia#: 74 14/�r F V 7 /ittQ Expiration Date: 09
Job Site Address: TdJPP1F.d City/State/Zip: ga1o&7 MA
Attack a copy of the workers'compensation polity 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 S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a Jay against the violator. Be advised that a copy of this statement may be forwurded to the Office of
Investigations of the DIA for insurance coverage verification.
1 do hereby eertify under thatpains and penuldes of perfury that the btformadon provided above is true and correct.
�iizna tie: ���� Dote:
Phone'l: / 60W • 71S• lti�
Oficial use auly. Do not write in rho area,to be completed by city or town official
City or Tuwn: PermitfUcense Al
\uthorit
Issuin -- - — -- -
g. y(circle one): ---
1. Board of Ilealth 2. Building Department 3.City/rown Clerk 4. Electrical Inspector S. Plumbing Inspector
6. Other
Contact Person: Phone#:
CITY OF SALEM
4j. PUBLIC PROPRERTY
DEPARTMENT
'J; 'i'8.'4_ ',i4..
Construction Debris Disposal Affidavit
(required lirr all demolition and renovation work)
In accordance \\ith the sixth edition of the State Building Code, 780 CMR 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 pruperly licensed waste disposal facility as defined by MGL c
I 11. S 150A.
Thedebriswill be hansported by:
��
eSt 656-614 T-e'CA Cfra /)7e//f
Inan of'haukr) /
I he debris will be disposed of in
,411r'Y.._CIL—_ky S l i .
(name of lacilav)
Iddruss of Iacillly)
L'IWIulc 0
1pc mit applic.int
dal?
3/4"= I '
0
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