0014 CEDARVIEW STREET BUILDING JACKET t
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,
�?Ps MHsT-BE f#L-E� APPROVED By T44E
,W P XTD-R ,PR b1R TD A PERMIT BEING GRANTED
CITY OF SALEM
No. �$ ZOV y y?� VN� �\ Date
�.r k
.� 4 -
ne
Is Property Located in Location of
the Historic District? Yes_No_ Building H ewwo— V eey
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply)�eroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
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
Address & Phone ILI CeCAC \1jpW 0 1 `��� 5 �ad,75—
Architect's Name Pjla�2 1 �u
Address & Phone aV U Pf& M- Qp A A)�Z 6I LLO646
Mechanics Name
Address & Phone ( 1
What is the purpose of building?
Material of building? If a dwelling, for how many families?
Will building conform tolaw? Asbestos?
Estimated cost 3 /5-0- ' City License# N PA State Licensee p
Home Improvement V
l q��aa C l� Lic. 1 l 193 I/►, `
Signature
of Applicant
I21 K SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
MAIL PERMIT TO: �qyQ ` �All thew
i
No. $r2
APPLICATION FOR
PERMIT TO
LOCATION
PERMIT GRANTED
�O 3 19
APPROr
�iIT�
r
INSPECTOR OF BUILDINGS
Porn nonwaabk 0/ ///aeaachtc CH6
cc�� na
y 2 d/.J.Par"Al .L.&J— tetu.e/ n6
nn 600 ywae�i,yton Slydal
James J.Camooes 8Jo I , /!/adaacht A 021 /i
Corrrtusssorser
q Workers' Compensation Insurance Affidavit
1, 17 ell 204
,aea.eee,.r.ie.Q
with.a principal place of business at:
�C/y Arf 1C' / Vo. b rC /� /
. . ,caryrsaar.raa)
do hereby certify under the pains and penalties of perjury, that:
�✓ I am a em 1 n em to Oyer rovidin worker compensation coverage for m o ees working on
P Y P 8 D B Y P Y li
this job.
E
(7o �97i
Insurance ComSCpany Policy Number
I am a sole proprietor and have no one working for me in any capacity.
() 1 am a sole proprietor, general contractor or homeowner (circle one) and have hired the
contractors listed below who have the following workers' compensation policies:
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
Contractor Insurance Company/Policy Number
O 1 am a homeowner performing all the work myself.
I undawnd vet a copy of this wgesnent will be forwarded to the Office of Imesuta Vitt of the DIA for corerate verification and that laiure to severe
co.erate as feoured under Section 25A of MCL 152 can lead to the inocutien of criminai oenanies corsotint of a fisx of no toi 1.500.00&Woof one
scan'inwison rent as.cod as cw oenasda it gh lone of a STOP WO RK ORDER and a A"of S I00.00 a an stainst me.
Signed this , r (�� day of -,Tow
Licensee/Permittee Building Department
Licensing Board
Seleamens Office
Health Department
TO VERIFY COVERAGE INFORMATION CALL: 617-727-4900 X403, 404, 405, 409, 375
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
M svua 12C` A*&% M Suer o SAtth K%UAC14 eF I lS 01970
'ra6 :97L745.9595 0 F.ut:971-740.9846
Workers' Compensation Insurance Affidavit: Builders/Contactors/EleariciatWPIumbers
Annlleaat Information Please Print Legibly
dame tuuaita•..rchynintiwvinJtv,alvoll: .J fJS�t1 � e�e�
Address:
City/statwzip:
Are you as employer!Cheek the appropriate boF
1.Q 1 am a employer with 4. Q I am a bCluxal contractor and 1 . [ of project rr coon dJ•
� cm6loycou(full aullor Part-time). have hired the avb•cumractors 6. ❑ New construction
2.IT'S 1 art a sole proprietor or partner. listed on the attached ahcee t 7. Remodeling
ship and have no employees Thus wbeonaacums have tl. Q Demolition
working for me in any capacity. workers' comp.inumnon
(No worbcn'camp. insurance S. Q We are a corporation and its
9. Q 8urldr�:uldlttaa
required) office rs have exercised their 10.0 Electrical repairs or addirfons
).Q 1 am a homeowner doing all wont right of exemption per MOL 11.Q Plumbing repairs or additions
myself.(No workers*comp. C. 152.¢1(4),and we have no 12.0 Roof repaid
insurance required.] r :mpioycca(No workers' 13.Q Other
comp. insurance requimLJ
•A,p:pphocaal dW ehcehe boa al mast also as w On wilm 4,:low,' ins their wwhata'ownpaaatba podgy ioa+reWim
' 11. wnws who au0ak tail atedavu isekattna ary ore ioi n an ww t and mas him madde eaauooae maw autmttk a maw affidavit ittdicolna soh.
-fua.xvos that slogan this box tart anxhed as additkml AM,Rowing Ike naasa of ale sub conpapon atW,hw w„dtata'rasp.policy ratan ache.
/uor an enup/oyer that/r provldlnr workers'co/apensadan btsarencr jar/try eanp/eyers Bi/ow!r We poNay and/orb r1/e
in/arleadaati.
ice.
In urance Company Name: e� ep?s N.n,tn�-nc-Z
Policy 4 or Self-ina. Lic. 0: _ .. Expiration Date: rat ;
Job Site Address: Cityr StaLwzlp: d AZtL,4^ f
attack a copy of the workers'compensation policy declaration page(showing rho policy number and expiration date)6
Failure w wcure coverage as required under Section 25A of.1GL c. 152 can lead to the imposition of criminal penalties Ora
fine up to S 1.500.00 and/or one-year imprixunmcnt,ar well As civil penaltius in the form of a STOP WORK ORDER and a fine
a(up to S250.00 a day against eke violator. Ile advised that a copy urthis statement may be t'urwarded to the Ot)ice of
Ln:angaautts of dic DIA ror❑1lurance cOvCra.L• %Crtfcattun.
I do hereby certify r Ide�Only and u/rler ujper/ary that r/re iujorwation provided above is Irmo and correct
7` — r
ii•:rrti,r• Date`
-74
U/Jlcr&/ore an/p. Aa not writs/w/hh area,to be rawplervd by chy or town ofjli I d
City or 'roan: Permibl kcese Y
Nsuing Autburify (circle one): —
I. hoard of llcalth 2. Building 1)cpartntcot ). City/fono Clerk 4. Electrical laspcctor 5. Plumbing Inspector
6. Other
Gnuact Persou: _ _ Phone p:
EiTrOF3-J.=1
PUBLIC PROPERTY
DEPARTMEINT
Kl.%Qw u iv DROCo u
MAYDt 130 Wwwnrcrtw bMFET
SM&K YASSAarLSlllS 01970
W1,
T L 972.745-9S" •FAx 97L740-9tN
APPLICATION FOR THE REPAIR. RENOVATION CONSTRUCTION
DEMOLITION, OR CHANGE OF USE OR OCCUPANCY FOR ANY EMSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: vy A-,VVC, Building:
Property Address:
Properly Is located in a; Conaervatlon Area YIN Historic District YIN
3.0 OWNERSHIP INFORMATION
4.1 Owner of Land
Name: Oft A , 1- L r4 + r A R.4f
Address:
�`1 �t �ji1L.-vim c✓
Telephone: 7 Si 7
3.0 COMPLETE THIS SECTION FOR WORK IN FYIQTIN13 BUILDINGS ONLY
Addition Existing
Renovation �'" Number of Stories Renovated
Change in Use NeYV
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building New
Brief Description of Proposed Work: /C,,2 un
7'�i/L' /—'J's�•�. 1�+:3 /fv./cam� ` + .
—-- Mail Permit to:
What is the current use of the Building?
Material of Building? kz qua "f It dwelling. how many units?__
Will the Building Conform to Law? i�f :5 Asbestos?
Architect's Name
Address and Phone
Mechanic's Name
Address and Phone h -6 =� ��� S�
Constriction Supervisors License# Y,r� HIC Registration# «7 `�3
Estimated Cost of Projed S � permit Fee Calculation
Permit Fee i !y�' Estimated Cost X$7/$1000 Residential
Estlmated Cost X$i lt$1000 Commercial -
An Additional $5.00 is added as an
Administrative charge.
Make sure that all fields are properly and legibly written to avoid delays In processing.
The undersigned does hereby apply for a Building;Date
it to uild to the above stated
specifications. Signed under penalty of perjury
`I
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3 �
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,
The Commonwealth of Massachusetts RECEIVED
Board of Building Regulations and 66tidaFds 10 H A L SERVICES CITY OF
Massachusetts State Building Code,780 Clv SALEM
6— 1t�: Revised Mar 2011
C� Building Permit Application To Construct,Repair,R�t�✓ moo is'ga2
v One-or Two-Family Dwelling
This Section For Official Use Only.. - -
/1 Building Permit Number: Date pip ied:
^ Building Official(Print Name) Signature - Date
kNJ1 SECTION 1:SITE INFORMATION
L- 1.1 P�p/erty ddress: 1.2.Assessors Map&Parcel Numbers
/1 � I'a�2
1.to Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Lt3�Prlvate❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal Z3-C�n-site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recor7t
l°!/y/ iPjil
Name(Print) City,State,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Worle: e
l�o ST7t v�tzi>!�/ h•an�csi�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building 5-L - '• Building Permit Fee:$ - Indicate how fee is determined:
7�-� i7 Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $ - -
4.Mechanical (HVAC) $ List: -
5.Mechanical (Fire $
Suppression) Total All Fees:$
�/ Check No. Check Amount: Cash Amount:
6.Total Project Cost: $S/. 3 ' ]Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) ltJt'9)3/
License Number Expiration Date fP
Name of CSL Holder
cyan List CSL Type(see below)
/�t' Type. Description
No.and Street -
J_L�D U Unrestricted(Buildings u to 35,000 cu.ft.
/7 Restricted 1&2 Family Dwelling
Cityffo tale,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
17 SF Solid Fuel Burning Appliances
1/ I Insulation
Telephone ' Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) 7/G/,W
HIC Registration Number Expiration Date
HIC Company N e or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP 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 G,<w'L
too'act on my behalf,in all matters relative to work authorized by this building permit application.
lrlr?At� m ��Qti /�Jla� &Iy� /D /S-Ii
Print Owner's Name(Electronic' nature) 11) Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contain in ' applicatio is true and accurate to the best of my knowledge and understanding.
Print Owner's r Authorized A ' Name(Electronic Signature) Z Date
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 can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dps
2. When substantial work is planned,provide the information below:
Total floor 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 Cost"
`r
t
/Iro The Commonwealth of Massachuscus Town of
Board of Building Regulations and Standards
Massachuscus State Building Code, 780 CMR, T"edition Budding Dept
Budding Permit Application To Construct, Repair, Renovate Or Demolish a
\�\ One- or T -Fmnrll-Duelling /
This SFcu n For Official Use Qfnly
` J Building Permit Num r: �_ 1/ li
Signature: " rn,
Building Commissioner/ spectorof Builm td —
Date
SECTION : Sin INFORMATION
1.1 P arty 4ddress: 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street:'yes no Map Number Parcel Number
I.J Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq(1) Frontage(R)
1.5 Building Setbacks(D)
Front Yard Side Yards Rev Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L e.a0,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Munici al O On site disposal s stem O
Public O Private O Check if esI3 P Y
SECTION 2: PROPERTY OWNERSHIP'
[�;f�CG R.
Name(Print) Address far Service:
97,7 7y.6--;ZA ys-
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied Repairs(s) X I Alterations) O Addition O
Demolition O Accessory Bldg. O Number of Units_ Other O Specify:
Brief Dexri (ion f P5ro7 W rk': `
SECTION•: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OAlclal Use Only
Labor and Materials
I. Building f g I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical f O Total Project Cost'(Item 6) x multiplier a
) Plumbing f 2. Other Fees: f
a. Mechancal IHVAC) f List: CZ)
s Mechanical (Fire f Total All Fees: f
Su ression
J Check No. _Check Amount Cash Amount-._ I
h Total Project Cost I S 9 �y p Paid in Full O Outstanding Balance Due:
P aOcld
r
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
LweNumber Est; l me ion ate
N.ype or CSL- NylrJ7er L„t CSL Type fwv lwlowl O
• .a �v l' c5! ��icLlJlic�
Address 7 �I T' De
sch twn
U Unrestricted(up to 35.000 Cu. Ft.)
R Restricted I&2 Family Dwelling
S�aMlYre c�. ! M Masonry Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance fnstallatton
D Residential Demolition
S.2 Reghtered Home Improvement Contractor(HIC)
/I/Mr J�'rfl fJ /
AHIC Company am or"Vel, �t f�(ame L Registration Number
ddle 7 �3
Expiration Date
Signature Telephone
SECTION 6:WORICERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS2.f 23C(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.
Sighed Affidavit Attached? Yes..........114, No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize RAJ�O/ Q to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si nature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
1 /(/L 0 .l'�v , a,@wmer 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.
b 6�
Print Name
/o iS o/C
Signature ner or,Autho ized Age Due
(Signed under the pains and nalties fperjury)
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�have access to the arbitration
program or guaranty fund under M.G.L. c. 1 J2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I IO.R3,respectively.
2. When substantial work is planned,provide the information below:
Total Goon 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 Laths
Tvpe of heating system Number of decks/ porches
Type of cooling system Enclosed Open
1 Total Project Square Footage"may he suhsiituted for 'Total Project Cost'
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