Loading...
129 BRIDGE STREET - BUILDING JACKET N 6 ,s3 1 L" (1' I'I The Commonwealth of Massachusetts Board of Building Regulations and Standards Town of Massachusetts State Building Code, 780 CMR, 7ih edition Building Dept Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Fmnil),Dwelling This Section For Official Use Only Building Permit Nu erg/ Date Applied: Signature: /moo'+•J ff Building Commissioner4rnsrector of Buildings Date SECTION l:SITE INFORMATION 1.1 Proreyddr7 r t n g—��'-- 1.2 Assessors Map& Parcel Numbers 1.la Is this an accepted street?yes V no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ill Frontage(R) 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?Check if yes0 I Municipal ❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP[ 2Q1 Owner'of Record: 1" o � Y Cp O I(A ame(Print) Address for Service: Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other Specify:$Tr I P d, Brief Description of Proposed Work': 0Co O IA—, r h CT� SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Offlcial Use Only Labor and Materials 1. Building $ -2_Jl— 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical g ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: l_JZJ 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ ❑ Paid in Full ❑ Outstanding Balance Due: c SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) I Cad el 1, License Number Expiration Date Name ol'CSL- Helder OifX/ List CSL Type(sec below) a V( () Type Description Addressl O o- (L r— Q . d�^ v� U Unrestricted(u to 35,000 Cu. Ft.) J ,J((�,( tom/' - ' R Restricted 1&2 Famil Dwellin Signature M Masonry Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 Regis red Home ImpJ�ovement Contractor(HIC) ( 7 Regist ation Nu ber HIC Company Nalrte or T)Rc t�trant Name Address �� 9790 ���7QG xp rati Date � i Signature. Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 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: OWNER' OR AUTHORIZED AGENT DECLARATION I o,"_ 0� ,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. ( V Q' Print Nam �( Signature of Owner or Authorized Agent Date (Signed under the pains and penalties ofperjury) 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 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 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" PS MllST-BE fiLffniND APPROVED By T44E .LNS,PXTOR PFWR TP A_PERMIT 13ENG GRANTED CITY OF SALEM No. ,H�t• ',�. �\ Date Is Property Located in Location of .! _ the Historic District? Yes_No f Building �9 69tor% yrgeG•wr Is Property Located in the Conservation Area? Yes No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof eroof Install Siding, Construct Deck, Shed, Pool, epair/ eplace Other:Rr:PLnttt- �v+A+Oows�2NplsLooiLL�GRbss vpv*r6 FtRe PRoMcDoN SYsMm PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING TO THE INSPECTOR OF BUILDINGS: The undersigned hereby applies for a permit to build according to the following specifications: Owner's Name 49 f9j r4eq 5r-ggz s`6 0,e- yddress & Phone PD. nK 51 SACL-►"9_VfiA o 12L (�09) �?26 5�38 Architect's Name Address & Phone ( ) Mechanics Name `(g-L"c.T1f 6.' 04//#M 0l2* 4 Address & Phone l7 r4-K(ya SfRC�-V FR+Pm>rdt�dl$>hr PI-Zk- d19o1 What is the purpose of building? M v4ft Fr#pl if.Y D tveLLW 6^ Material of building? WooD AM E If a dwelling, for how many families? 3 Will building conform to law? ytes Asbestos? lY ID Estimated cost 30,coo o City License # N A State License # 0001 g,�; l)a�) Home lWrovement �vs (" c. 1 ignature of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE P (tS+r cy 65NCR(4L cnT kJOR RtP+�IR tr(ct.t.DN(. L)RYWOLLjmtutoR NoN-S f.,c+ 2Yf�&PR1Rco 05 tic_rt6SSR2 91r,114Qj 4 807-l� ICS02VVcLWG 1 G✓b% !v Comm Cn(ec Sgra M&A o f 206.0 RERooL�RL�PCR�! Ra(�7 GNPRe�ft 5�1��'vD FLooR c69[ss, GRoI46 t=+RC p�e�Tc-cr/�N SySTc-M 1'o eooa &N0 RC-oLA G WJVN06Wg1 a MAIL PERMIT TO: P.O. 0oX 8 Sl��SACC v4 4 01271 No-a `_" APPLICATION FOR PERMIT TO LOCATION PERMIT G NTED APP, VfD _ Ewa INSPECTOR OF BUILDINGS .S r - Oct 29 08 D3:24a p.1 The Commonwealth of Massachusetts �� i• i`� Department of Public Safety 'f„ •J-^,. assachuselts State Litt ildingCode 4780 CNIR)Sevenlh Edition City of Salem 1 Building Perm t Application for any Building other than a 1- or 2-Family Dwelling (This' For Official Use Onto) Building Permit:Number: i ite Applied: 3uilding Inspector. SECTION 1:LOCATION (Please in ' ate Block!f and Lot N for locations for which a street address is not available) a - 4�--/l 90 Nu,and Street City/Town Zip Code Name of Suildinh(it applicable) SECTION 2:PROPOSED WORK If New Constructit.n check here❑or checkall that apply in the twu rows below Existing Building O Repair Alterat on ❑ Addition O I Demolition O (Please fill out and Submit Appendix l) rAre e of Use O Changr of Occupa+ ❑ Other ❑ Specify: uilding plansand/orconstruction doc rments being suppliedas part of this permitapplication? Yes Q No 13 ndependent Structural Engineering P rr[teview required /tr• _Yes ❑ NoDecription of Pn)posed Work: RE LACC CK/S//h66 RI=AR 9f/�S/UC- sr&lRS wrro# 90M 14C—'r*1R D y=c o j R��1L—t�L�7ro Am efGACGtrO S r/3�a SECTION 3:COMPLETE THIS SEC IqN IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Evaluation is enclosed(See 780 CMR 3402.0) 0 Existing Use Gmup(s): I Proposed Use Group(s): r Existing Hazard Index 780 CMR 34: j Proposed Hazard Index 780 CMR 34: SECTION 4: BUILDING HEIGHT AND AREA Existing Proposed Nu.of Floors/Stories(include basement levels)&Area Per Floor(sq.ft.) Total Area(a).ft.)and Total Height(ft.) SECTION S.USE GROUP(Check as applicable) A: Assembly A-I ❑ A-2r ❑ A-2nc❑ lA-3 ❑ A-4❑ A-5 O 1 B: Business ❑ E: Educational ❑ F: Facto F-I ❑ F213 1 IH: High Hazard H-i O H-2❑ H-3 0 H-4❑ H-5 O 1: Institutional I-1 O 1-2 O 1.3❑ 14 ❑ : Mercantile❑ R: Residential R-IO R-2❑ R-3 O R-4 O S: Storage S-1 ❑ 5-2❑ ).1: Utility O 1 Special Use O and please describe below: Special lase: SECTION :CONSTRUCTION TYPE(Check as applicable) IA ❑ IB ❑ IIA ❑ I- r1B Ei IIIA O 11100 IV ❑ VA ❑ VB ❑ SECTION 7:SITE INFdRNIATION(refer to 780 CAIR 111.0 for details on each item) Water Supply: Flood Zone Informati Sewage Disposal: Trench Permit. Debris Removal: Public 9' Check if out<ide Flur d Zone Indicate municipal B' '� trench will not be Lrcenvti fA.p.rat Site 4 Pri gate❑ or indenlifv Zone:.,_- reyurrevd 01,r trench or�fwrifc: i nrrm.ile�aslrm ❑ permit r.crcloxd ❑ j Railroad right-of-way: I Hazards to Air Navigation: Gd I 1Lt!L-A ne t'..nnti�....n 17ov. •. I'r..,...: ! Ap-.hc,1!11v(� i�tilrul-iw'c a�ohtn atrp..rl a n _ppr/n.uh.vt•.t' 1,their ret.et. -rnplvlvd'. ..r l .'"""t tr Ikd.d eni.r.•ed ❑ I. Ye,,�.r N,,(�/ Zia❑ \.. ❑ SECTION BaCONTENT OF CERTIFICATE OF OCCUPANCY ! I rr pc.'f('•w,%ruc1wn: llccupant I oad IV'r I-l.aw _ � 1 dr L.m,rt ( .+.Ip _._1_•a•(.n nr lN.l: _, I)L m.%the btu4tng ronlunm Sprin�Jh•r Sc-dem.': ti;vaaUupulations: l Oct 29 08 03:25a 'w 47 /, p.3 SECTION9: PROPERTY OWNER.AUTHORIZATION Van and A.{drrx; �f I'rulxrte �` er Zip r �� % Citt•/ASwn Nu.atx{Slntit Name(Print} 1'rup¢rt�•CTvher Can ct Intarm itlon: ��� I/YI �..,. •y 7f a o1o1'St-[-=�— one No. Icrlq a-mail address Telephone Nu.(busmec;) Teleph Title )K6 M�y►9— D e7 If applicable,the property'a"-nrr hereby authorizes <CH/yCT'/f C)k4( rvetIZh 17FC-1460 S/ —1 rQ ~tote "Lip Street Address Citt•/Tanvn Name in all matter+rcl,tine to workauthurized bV this bu ildin It a+ licauon. the ,ro sort,, owner^ +ehAlf, SECTION WeCONSTRUCTION CONTROL(Please ftll °ut Appendix 2 (II l+ui Win• 61ec4 titan 13,t)UU at.it-ofrM't�sad +ate and Lon not ulder Construction C,nitroi then check here O and eki+y..tlian to l; 10.1 R ' tered Professional Res onsible for Construction Contm!`� Ren��� 4od.04Me 1 v4 KDR C� CN a-mail iddress Registration Number h rant) Tole+hone Nu. Name eg: /Q�.�' F F9t^'� K4/{A'NI rot A_ Z DisciplineExpiration Date �7 � Qtvr/ S state p Street Address City/Ta,vn 10.2 General Contractor 7f roN7'R e'UNG k1n , Company Name' A•LCA'Yi90�2R - c0o Li a No. and Type if Ap�ltcable 'n� Name�f,Penun Iteslx,nsibl TR C"!•ST cttun r O/�T1�1 /t!b I•/'A'YN �'f.6t"--sLil'=- 1'l� Ci /Town (+ Zip ry >',pgLC 9 fin/. DM Street Ad rasa /(L � f� email address Tale hone No.(business) Tel hone No.(cell) Vrr SECTION 11:WORKERS COMPENSATION A Department t ent of i du trial .a 752. 25C(6 A Wotkecs'Competva[ion Insurance Affidavit from the MA Department of Industrial Accidents must be completed and submitted with this apPlsaston.edaAff'daviPsuliinitoed with thhis is a it will result in li anon? the denial O of the t NonO ce of the building permit. SECTION 1P:CONSTRUCTION COSTS AND PERMIT FEE Estimated Costs:(Labor Total Construction Cost(from Item 6)=S� Item and Materials) $ 00 Building Permit Fee=Total construction Cost x (Insert here 1. Building appropriate municipal factor)_$ 2.Elmirial S 3.Plumbing S Note:Minimum fee=S (contact municipality) 4. Mechanical (HVAQ $ c f Enclose check payable to 5. Mechani at (Other) S 0 (contact munici ality)and write check number hen 6. Total G .t SECTION 13:SIGNATURE OF BUILDWG PERNTP APPLICANT . n l'I . I �G^^NiftrH LCAMoRrt MAaAry6 Nt aGl l of the nhxmati„n contained r, in a tunder the perviltieSW in ©yene d l etmy k vledg Understanding. � of ti ncol n GoL ,f ¢ /� Title Telephone tin. Date I I, t.v F.Pnt and.ihn n.IG7i/��= �/1/3✓n ayb M/7__L_ 6147 7 Mate l Citv; olv n ;Ireel Address Name Date \lu nicipal Inspector to till cut this section upon applic ation approval: Oct 29 08 03:25a p 2 CITY of S.U.E`I, NL-tSS.XCHU5E"I'TS 9L-QJDL%iG DEP.II<TMENT 120W.iSHL`rGMMSTREE ,YoFcooR T zL (979)74S-9595 F.tX(978)74p. W KINJIB EY DRISCOLL THOMS ST.PiEnits MAYOR DIRECTOR OF PL SLIC PROPERTY/gt'Q.DLVC COSL�lrsStO�El Workers' Comptalation Insurance AfIldsvit- BuilderslContractars/Elecc'rx twins L bC" s ucan. .nformatian a itarietvinthvtdtad): / T 0 Ct4/�// �Ir C�ix6 �:L � - Name IUwitw+n sate Atldress: —GnrT"o z c-c: p rDl�f►�iN�F/�w1iwA Phortak bog 768 EJY}88 Citylstate/zi %re you as e,nploywo Creek the appropriate Ito Typo o<project(required$ t. Cl I am a general contractor and 1 6. Cl New construction 1,�1 p a,ees(r l with�.—a - new hired the sub-contractors y. ❑Remodeling employees(full and/or Past-sitar). ro rieasr ar Partner- listed an the anaohed abates. 2.❑ I am a sack P P Thew subYconhacton have B. ❑I?erttotitioe ;hip and have no employee workers'comp.insurance. 9. O Building addition working for me in any capacity. S. Q We are a corporation and its or additions workers'co6rp.insurance _ atfltNa have exercised hair 10•0 Electrical repairs requirvd.( ri of etwelptian pa MGL 11.0 Plumbing repairs or additions 5,❑ I am r hompawrkemer Doing P-work e. 32.f 1(4),aced we have no 12.0 Roof tcpsirs myad[(\'o workers*comp. .mplM'�.(No worlms' insorame required-( _ 13.Q"OdrR,s., comp. insuratrcetsquirrcd.l •,yt riraal tar ckaraa O0a/1 nor aW fal ad that mina t lre Atrriaa their ratio'mrp1 16M Policy infunsula. r y app auann rhi a ,a�t�xg they nadcitt all wakatd the hiw ataaide eonrtarron r.ar aulrta a ddatr aleltkvi indiarina>� I LatKartara nhO {'.nun-tan tM awil this box nun aaacM4 an rldtkfar Awe ar"04 er naea at thea4evetsfar an/dealt wohra'maP•Pfa1 iefonttaiaa !am an employer that is prenrFAWd workers'campewaarbw buwrwwrrfan my orplaYgt addew fr the pn,b:J annl/ab rlb information. 4 M(Jr4V#(, ltVSv4AN(' C G _ im..urance Company Name: �t - - (� rS is Expiration Dale: g f Yrt l iry K or Self-inn.f,ie.>py: (�� '? a E �t- � � ./ c r Job Sire AdJrss:��! ,v�)p(e c D ��.(ce-✓ eityistaiazip:f�, Yf,4 ©!Z ,%rtegk a copy of the worlters'cempewasdon polity declarations page(ahltwing the ptdley number end nplesdoe.data). Failure to secure coverage as required under section 25A ofMGLe. 152 can lead to the imposition ofcrimimi penalties of e fine up to S 1.500.00 and/or oats-year imprisoamenk as well as civil penalties in that farm of it STOP WORK ORDER and s Fine of up to S250.00 a Jay against the violator. its advisal that a copy of this staterrnKq may be forwarded to the Office or I n.w:ddgatiwra of the MA for insurance covcraga Wrifikation. f r/o herby nrrri/y trnJn rhr priws and [x afPrJur dram the inferwarlaw pra"'d[uyb vac is true,an/t:ur[r[L .n• t r r p y O�ria!ua[only. /M oar write is rbis arras.to be rwnpl[Md by vdy or eel".Ijkint city or rurrn: errmiN.lcenaeMJ_. —. ---- Asuing.whurtly (circle unelt 1. llourd of Ilearth 2. nuAdine department 1. Citylrown Clerk s. Elecrriul Inspector 5. Plumbing Impecior 6. Other Phone s: ... .....:..... Oct 29 08 03:26a p.4 CITY OF SALLM PUBLIC PRoPRERTY DEPART70ENT Construction Debris Disposal Af'iidasit (rryuircd filr all dcttlofidon and renu+Awn work) in aceonlance %%ilh the sixth edition of the State Building Code, 780 CAIR section I i 1 5 Debris, artd tlx prowisiuns of MGL c 40, S 54; Building Permit itis issued with the condition that the debris resuiling from this work shall he disposed of in a pruperly licensed waste disposal facility as defined by Y1GL e I11. S 1511A. The debris w'i 11 be transported by: - tuamc nr'hankr) I he dIebris will be disposed ut'in (ir�rnt u1 Im ny) Ltddre„ „f LI.r luy t +mrwluw•.1 p:nnq .ggdp mt ('A ,Isl,• liziur SACH DRIIIER--' 'LICENSE NCEEER •4r .c#_ f S00235979tz `s oos a 6 P # l 0630 2013 Cb 30 1939w r � v CIASSy REST]HGT SIX 643 M n[ ALL AMORA „UEE t : 7. KENNEfHG 33 Hy WAY` DENNIS MA�'(" 02636 2630 Vl:rtisachusr-tis - Department of P114lic Bared Board of Buildin!_ Re,ulations and Standards Cons'Uuction Supervisor License License: CS 195 Restricted to: 00 # j KENNETH G DALLAMORA t r, 17 FENTON ST FRAM INGHAM, MA 01701 Expiration: 6/3 012 01 1 ('on unlesi„.wr Tr--: 16401 B��� f`'IYdfl `��8t� �L/ds15�r'�3f f t o f swan IMPROVEMENT CONTRACTOR Registration: 117484 Expiration: 1011112010 Tr# 274919 Type: Private Corporation DALLAMORA BROTHERS'CON'.)NC KENNETH DALLAMORA.'� 17 FENTON ST FRAMINGHAM, MA 01701 Administrator �..�� The Commonwealth of Massachusetts c Department of Public Safety \Iassarhu.clls State'Buildin+g Code(78o C\IR) " IfuildingPermitApplicationforanyBuiIdingotherthanaOne-or Two-Family Dwelling (I"his Section-For Official Use Only) Building Permit Number: Dale Applied: -- Building Officiate SECI-ION l:LOCATION(Please indicate Block It and Lot N for locations for which a street address is not available) No.mid Strcet City Town Zip Code Name of Building;(if applicable) SUCTION 2: PROPOSED WORK q Pdilion M \IA State Code used If New Construction check here❑or check all that apply in the two rows below Fxislin); Building Repair Alteration ❑ :Addition❑ 1 Demolition ❑ (Please Ill]ouut,-aonnd submit Appendix 1) Change of Use ❑ Change of Occupancy ❑ Other IRSpecify: @fy/�'-��. .(rl Are building plans.ind/orronstruction documents being supplied as part of[his permit application? Yes ❑ No -- Is an hulependcnt Structural Enginccrir Pecr,Review required? Yes ❑ No 11Z Brief DUScriptionof Proposed ll'ork: 1A1.s`. LV!_vy,Q ,� ✓ — LOGeI t SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION, ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here if an Existing Building Investigation and Evaluation is enclosed (See 780 C\IR i4) ❑ Existing Use Croup(s): Proposed Use SECTION 4:BUILDING IIEIGHT AND AREA Existing Proposed No.of Floors/Stories(include basement levels)&Area Per Floor(sit. ft.) Total Area(sq, ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) :\: Assembly, -I ❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-i❑ B: Business ❑ E: Educational ❑ 1? Pacto F-1 ❑ F2❑ If: Hi h Hu.vd H-1 ❑ H-2❑ FI-1 ❑ li-a❑ 11-5❑ I: Institutional I-1 ❑ 1-2❑ 1-3❑ 1-4❑ �VI: \i cantile❑ R: Residential R-10 R-2❑ R-.i❑ R-4 ❑ / 3: Storage SI ❑ S-?❑ U: Utility❑ _ Special Use❑and please describe below: Special Use SECI'ION 6:CONS"rRUCIION RPE (Check as applicable) IA ❑ IB ❑ I1,\ ❑ IIB ❑ IIIA ❑ [)Ill ❑ 1 IV ❑ I VA ❑ VB SECf'ION 7:SITE INFOR\IA"I-ION(refer to 78B CMR 111.0 for details on each item) Water Suppl : Flood"Zone Information: Sewage.Disposal: Trench Permit: Dcbris Removal: .\ bench wi not be Licensed hispus,d Site❑ Public Chock if outside Plnod Zone❑ Indicate numicipal I'rivatc❑ or indonlily Lunn: or on site cystcnr ❑ rcquin•d or trench or specify: permit is enc lased❑ - ?� 11miruadright-of-way [lizards to Air :Navigation: 1. i I „,:,.. Nnt :\pl+lira hlr I Is;Iruc lure\vilh in airpa rt a1,pfaa1,h area' Is[heir I iew completed' or C on.ent lu Budd ear lu,ed ❑ I 1 cs ❑ nr No Ga/ l es❑ ,N:i SEC"[ION 8:CONI ENT OF CFlt I IPICATE OF OCCUPANCY G 111111011 of COLIC _ l.e Croup(,). _ I\pe of C0111trtic inn: rUrrupant Load per I'Ln,r . Pol, the building Lonlaiu,in�prinlder Sv stein?: /`/IV. <por ial}lilnil.ltinns: s SECTION 4: PROPF.R'I'Y OWNFR AU'ITIORIZAIION iA�.unc and AdJ ass ut Property Utvner �� _ cC -51��� �C.C � 05/�b� m_j_ ©lQ-Z.�-- Nanto(Print) No.and Street City/Town T Zip PropeitV Owner Qnttaet htformabon: M��i ���rJ12Cid,� ,Sos'3�6 �' 3S_RmGr K(9lCDAt��9ary I'tlle relephune No. (business) Telephone No. (cell) c-mail address It applicable, the properly owner hereby authorizes Name Street Address City/Town State Zip to act on the property owner's behalf, in all matters relative to work authorized bV this builkling, permit application. SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2) 'If buildin•is less than 15,o00 cu.ft.of enclosed s•ace and or out under Construction Control then check here❑and skip Section 10.1) 10.1 Registered Professional Responsible for Construction Control Name istr. tt Scle hors No. e-mail address Registration Number c' 1-6 // � ) U CaasV-.1P.'& 2 30 61 reet Address City/Town Stale Zip Discipline Expiration Date 10.2 General Contractor Noy MCq/ Con pang Name Erg J919PLC/J-Moe4- L>60 I ? Name of P rsun Responsible for Construction License No. and Type if Applicable Street Address City/Town State Zip �/ ezn e (2 owl Telephone No. business - Telephone No. cell e-maii address SECTION 11: tit 11«jjl, t.0 mu•r��,N I10N IN',, I AI 111'AVI I M.G.L.c.152.9 25C 6 A Workers'Compensation Insurance Affidavit from the NIA Department of Industrial Accidents must be completed and submitted with,this application. Failure to provide this affidavit will result in the denial of thept.�uance of the building permit. Is a signed Affidavit submitted with this application? Yes(?r No ❑ SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE Item Estimated Costs: (Labor and Materials) Total Construction Cost((rum Item 6) =S I. Building S Building Permit Fee=Total Construction Cost x_(Insert here P2. Electrical S appropriate municipal factor)=$ 1, Plumbing, 5 I. Mechanical (HV:\C) S - Note: :\lininuun (ec=5 _(contact n—'/��� S. \Ictimoical Other S ^� Enclose check payable hp _ n. Total Cost 5 rjV� (contact municipality)and write check number here ------,-- ___ SECTION 13:SIGNA"IUBE OF BUILDING PERMIT APPLICANT RV entering my name below, I hereby attest wader the p s,m I p na It*cs of perjury that all of the infurmetiun annaincd in this application is true and accurate hi the hest ot.any t vl nlg, u uulerstandifig, _ I I sv Ipri tt uxl .if;n norm title -rvlcphonc NP Uatc m� --- titre) Addrss City/ I'mN n c ip Municipal inspector to fill out this section upon application approval: Nano -..PAv 3� CA, RECEIVED The Co onwealth of Massachusetts ICES W Department of Pubic Safe%jnri13 A �plicafilon achusetts State Building Code( N � Q 1 Building Permit for any Building other than a One-or Two-Family Dwelling O _(This Section For Official Use Only) .--� Building Permit Number: Date Applied: Building Official: SECTION 1:LOCATION(Please indicate Block It and Lot#for locations for which a street address is not available) No.and Street City/Town Zip Code Name of Building(if applicable) 1 SECTION 2:PROPOSED WORK Edition of MA State Code used_ If New Construction check here❑or check all that apply in the two rows below Existing Building Repair V1 Alteration ❑ 1 Addition❑ TDemolition ❑ (Please fill out and submit Appendix I) Change of Use ❑ 1 Change Of Occupancy ❑ Other ❑ Specify: Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ NO Is an Independent Structural Eagineerfn Peer Review required? Yes ❑ No [B' Brief Description of Proposed Work: '/9 :ve. E - f twr:h i r�o fti�. fs r7✓e trrsi lj o e i SECTION 31 COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR CHANGE IN USE OR OCCUPANCY Check here Ilan Existing Building Investigation and Evaluation is enclosers(See 780 CMR 34) ❑ Existing Use Gruup(s): IProposed Use Grou p(s): SECTION 4:BUILDING HEIGHT AND AREA Existing Proposed No.of Flours/Stories(include basement levels)&Area Per Flour,(eq. ft.) Total Area(sq.ft.)and Total Height(ft.) SECTION 5:USE GROUP(Check as applicable) A: Assembly A-1❑ A-2❑ Nightclub ❑ A 3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑ F: Factor acto F-I❑ F2 Cl Ft: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4❑ H-5 Cl 1: Institutional I-t❑ 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3 Cl R4❑ S: Storage S-1 ❑ 5-2❑ U: Utility❑ Special Use❑and please describe below: Special Use: SECTION 6:CONSTRUCTION TYPE(Check as a licable) - - - 1A ❑ IB ❑ IIA 13 116 Cl IIIA ❑ IIIB ❑ IV ❑ VA 11 VB ❑ SECTION 7.SITE INFORMATION(refer to 780 CNIR 111.0 for details on each item) Trench Permit: Debris Removal: Water Supply: Hood Zone Information: Sewage Disposal: A trench will not be Licensed Disposal Site L1 Public Check if outside Flood Zone indicate municipal �,.,� 44 required pe or trench Or specify: Private❑ or indentify Zone: of oh site system❑ permit is enclosed❑ p WpL, Ti:;S�/Gno:n Railroad rightof-way, hazards to Air Navigation: 41;�\I I t����.C'mnl syi n Not Applicable Gy Is Structure wit m airptirt apf�roach area? is their re t r Co pichd7 or Consent to Build enclosed❑ { Yc � or*[ Yes i\1 SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY ,t Edition of Code: Use Group(s): Type of Construction: Occup,p+t Load Fier-I i?h Dues the building contain an Sprinkler System?: _�_Specia'l Stipulations: r i` \ f11L j0tis : SECRON9 PROPEMOWNatAUTHORQATION ' Note and Addles of Property Owner �R„rCC si4&c-i t1a P.O. lion $ C'1� _ 4 ��wl rn� Narne(Print) No.and sheet - �r/T. zip Property Owner CmW hdotmatimc t 0(4Nld raw �O 78% 4 3S g iv Tide Telephone No.(hus) dcyhone No. (rein elmail adds ifapplicaW the properly Oavrner hereby mtlmriaes Name sheet Addles Chy/Town state Tap to act m the pmperly owrees behat(in all matte relative to wait aulhariaBf by this - SECTION ilk CONSTRUCTION CONTROL Whale fill out Appendix / - (EFbmWfV9isIWdW3&=,n.ROferadnsm mnotaodaemmvOarC�dWmrbedrtneeW ad - to 111.1 Reltisbered Professional Responsible f"Consdaction Canto/ Name(Re&bao) Telephone Na e-maii addles Registration Number Street Addles - CBy/Tovara state ZW Discipline &0zaMa Date . 102 General Contractor Campmy Name Name of Pinson Responsible for Construction lionise No. and Type ifApplimble St Addy CBy/Tovru state Tip T No. T IVn emm7aSTr� SECTION 11:yy(Mkm7C IPQjSr1T10N 1MUR.10YI--.AMDAATi QL.GLr$.. A Wadoed C.mrpmwbm hasaranQ Affidavit tm the MA D%mrtusmtaf Industrial Amdents be omopleted and su6mitad with this application. Failure to provide this affidavit will nesaft in the-1—b of th�e�varr�ofthe braiding permit. Ha Affilavitw6®tted with the ? V.VXU SECTION I?`C DNSTRU CTTON COSTS AND pFBMTT FEE Them Estimated Costs:(labor Total Construction Cost from Item 6)=S and Materials) ( L Building s' Ot7 `. Burbling Permit Fee=Total Construction Cost a_(btmt here 2 Electrical - s - appropsiate municipal factor)=s 3.Plmbmg S op p d.Modmiiral (HVAC) s K%ht hfmimum fee=S (-.tact mvorag lily) S.Mafimtral S Eoclnse dmck payable to 6-Total Cost s -('�pO —' (contact muoicipafity)and write check number here SECTION I&SIGNATURE OF BUILDING PERMIT AEFLICANT By entering my name below.I herby attest umder the pains and penalties of perjury that all of the information cuataamd in this applicatim is true and amnre to the bestof my kmwledgead uadeatamlmg. KeN �iNACs/NG 17/(1EC1!)M1 � 3 �f si 9m;I ��t MJf- e3 ,ZO Street Addreg Crty/TOwo stare Tp . Municipal Inspector to fill rot this section upon application approval: Name line "PLOW 01:1STISE fgdNk%W APPROVED ev IM JMSPJ:C =PRIGA TTl A PERMIT WING GRANTED CITY OF SALEM No. 1 V Dab I/ , \ Ward Z, \ , zor"Dlsbfat i"atioa of Me WMab Did"?„ Ya—No_ %Uditg ✓r o-5 57- Is Propwly LocmW in Me Carow%sl n Ana? Yaa No Permit to: ING BUILD PERMIT APPLICATION FOR: (Circle whichever apply) f� _.._, Install Siding, ��Wtr De(k. Shed, Pool, her: (�J -_ PLEASE PILL OUT LEGIBLY 8 COMPLETELY TO AVOID DELAYS IN PROCESSMq TO THE INSPECTOR OF BUILDINGS: ' The undemigneed hereby applies for a permit to build aocorckig-to the following spedflations: Owner's Namep Address d, Phone 13 E c re v- 5-�e e C�7Y) 7 y Architect's Name l P� O� /Cr M o✓ Address A Phone Rio %T AG-� Cs05 ) 3a 6- y36" Mechanics Name Address ✓1< Phone ( ) Whal Is Me purpose of b~ f mwww of fa~ n a dwalwq,for how mmy fwn§=? _ We b At" to low?�/P t Aabasros? �f/O F.rinraMd coat Za�r� ' qfy Ucarw r sbb Lkans r ignature of Appl' SIGNED UNDER THE PENALTY' OF PERJURY DESCRIPTION OF WORK TO BE D/OhE / _�2N1(�✓2- �tii0 02�1Gi�-�- � (�.S � � i�i/t � S' MAIL PERMIT TO: Oa {c/ Cti/J`4 No. ` CO APPLICATION FOR PERMf TO v LOCATION A PERMIT GRANTS 19 APPROVPD OR ILDINGS