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3 WHEATLAND ST - BUILDING INSPECTION II The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code,780 CMR,7tb edition OF SALEM Revised Jamimy EM Building Permit Application To Construct,Repair,Renovate Or Demolish a /,2008 One-or Two-Family Dwelling This Seo-oh Seo—ohFor Official Use O Building Permit Num r. Date Appli Signature: Building Commissioner/Inspector of Build' s Date SECTIO ILWfE INFORMATION 1 1 roperty Address: 1.2 Assessors Map&Parcel Numbers W M EAT ST L 1 a Is this an accepted street9 yes no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' .1 Owner�ofg ord: n _ T� 2 1f" w 9 C-,A7-A q /z, SA1-r-t� MI's 0/g� Name(Print) Address for Servi 898-- 93 — 055/0 Si tore Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building.ffi( Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: Brief Description of Proposed Work'-: o E — LCo/Z A 11 G -r ' o (� t,L. 2 n, CH G -7-QATil Z w 1 SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only (Labor and Materials 1.Building $ Om , 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ cc ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ Ll 0czO t C5, 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Five $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ oco . (A ❑paid in Full ❑Outstanding Balance Due: l�- 6 i SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) 7 7 / y,S p 3 O /2 - XE[�Lot,)c. Uccense/ Number Expiration Date Name of CS(-Holder List CSL Type(see below) 22 iW t 6 K�3c k U-r. rN IA rhe A _ T Description © / g S U Unrestricted(up to 35,000 Cu.Ft.) R Restricted 1&2 Family Dwelling Sr M Ma so OW o r" v3 9 6 0 9 RC Residential RoofingCovering Telephone WS Residential Window and Siding SF FResidential Solid Fuel Burning A Dance Installation D Residential Demolition $'�R!* :>,JIomg Impro ment Jontra y Name or HICRegistrant Name Registration Number re(ii Arssb Tc 0`I` MN rhA b /gY ©3 b�l-1- 639 -06 77 Expiration Date Telephone CTION 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..........°j No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I, Leo-n a r el Pe Uat I',&I- , as Owner of the subject property hereby authorize o to act on my behalf,in all matters relative to work autboAzed by this building permit application. rzr�rcQQ � PeI / �- a o Si re of Owner Date SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION -L' i ,as Owner or Authorized Agent hereby declare that tements and information on the foregoing application are true and accurate,to the best of my knowledge and FrintNaprr.. - °." v� J /2 :sLo leg Si atu �ofOwner or Au oozed Agent Date Date (Signed under the pains and penalties of NOTES: 1. 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.R6 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.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of halflbaths 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" i CITY OF SM.Fbrl, NL-kSSACHUSETTS • BUILDING DEPARTSivi'T 120 WASHINGTON STREET,Sao FLOOR TEL (978)7459595 FAX(978)710-9846 KIMBERLEY DRISCOLL MAYOR THOMAS ST.PMM DIRECTOR OF PUBLIC PROPERTY/BU DING CONMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apolicant information Please Print Legibly Maine(Busine OrganiratioNlndividual): C O R(2 O RA L. C00-S-1— /C, Address: # 1:2 H x G H L A lv`1) 'T A R O/95 5 City/State/ZipMA(3Et=ig- iim A Phone N: 731 6 3 9— n 6 7 7 Are you an employer?Cheek the appropriate box: T of Type project(required): 1. 1 am a employer with— 4. ❑ 1 an a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner. listed on the attached sheet: 7• Remodeling ship and have no employees These sub-contractors have 8. ❑Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp. insurance S. ❑ We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions myself.[No workers'comp, c. 152,§44).and we have no 12.❑Roof repairs insurance required.)t employees.INTO workers' 13.❑Other comp.insurance required.] Any applicant that checks two A mug also fill ma the atxtim below showing thew wmkm'compmo aden policy iermmadon. 'I h matimmen,who submit this of idsvu indicating they am doing all work and then hire outside commcrows mug submit a new affidavit indiening wed =('wnrxaon that cheek ibis box must attached an edditimd short showing that tette of the abmnlrdama and their worker'comp.policy infnuct ioa. I am an employer that is providing workers'compensation imttroneefor my employees. Below is the policy and Job site information. Insurance Company Name'. �� L. n S A) C t Policy q or Self-ins.Lie.M._ CO W C. / 2 9t Expiration Date: 0 S Dti- Z� Job Site Address: 3 W/-IEAT1,J9 7 5% City/StateZir. 5A1—,FM M19 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration ilius). Failure to secure coverage as required under Section 25A of MGL c. 132 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 fore of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do herebynl_y er the pains mud penalties of perJary that the information provided above is true and correct Signature: ('w tis.1//�/n //�/�� Date, 1o� .G D Phone X f29-1- 6 3 7'� 0 6 /1/ Official use only. Do not write in this area,to be completed by city or town offrciat City or Town: Permit/I.icense# Issuing Authority(circle one): 1.Baird of Ilealth 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other.. Contact Person:______ Phone N- CITY OF S.U.&N12 UNSSACHUSETTS BLILDmG DEPAR-nmN''T 120 WASHr4GTON STREET,3' FLOOR TEL (978)745-9595 FAX(978) 710-9846 KI\tBERLEY DRISCOLL MAYOR THOMAS ST.PIERRB DIRECTOR OF Pmic PROPERTY/13UU II IG COWNIMIONER 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 111.5 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 Y transported b : P CM Rign R AL O C. (name of hauler) The debris will be disposed of in : /VoRT-H's-- ./1 R-=wG (name of facility) SWAMOSCoTi' fb SAL.E1\1 Mfl Oi970 (address of facility) � 2�e.�ClozC� signature of permit applicant date dcbri> tldoe