B-19-723 - 0015 ALBION STREET - Building Permit l
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• The Commonwealth of Massachusetts -
Board of Building Re FOR
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� g gulations and Standards ���� ��� �` Massachusetts State Building Code, 780 CMR 4L
USE
N Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two Family Dwelling
1
This.Section For Official Use Only
Building Permit Number Date Applied:
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Bwilding Official(Print Name) Signature Date
SECTION l:SITE INFORMATIO
1.1 Property Address: 1.2 Assessors Map&Parcel Nuigbers
1.la Is this an accepted street?yes 1/ no Map Number Parcel Number
1.3 stoning Information: 1A Property Dimensions:
39�3
Zonuug District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
R*ired Provided Required Provided Required Provided
1.6 VYater Supply:(M.G.L c.40,154) 1.7 Flood Zone Infoimation: 1.8 Sewage Disposal System:
Public: Private❑ Zone: _ Outside Flood Zone?
Check if yesD Municipal IN On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP' j
2.1 Owner'of Record:
-,70 A Q o l rt
Name(Print) City,State,ZIP^
l ✓ A 13100 �� a �&)-3,/6-0-410 SF�v,1�P►:� ��I� �Ivlr�►a.C. r�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition
Demolition ❑ I Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work2: WE w Act .-i v N ee �/ ) -7+ q a
'1L i1c2✓ S'eCv Lec•c� w�It 6e L)5et k5 Q. 6gn14?(AaA 1 Ate -rNe
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building--. $ V S 1. Building Permit Fee:$ Indicate how fee is determined:
2.Elecitrical $ ❑Standard City/Town Application Fee
❑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.Toti�l Project Cost: Is Soo ❑Paid in Full ❑Outstanding Balance Due:
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SECTION 5: CONSTRUCTION SERVICES
5X Construction`Supervisor License(CSL)
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street Type Description
U Unrestricted(Buildings to 35,000 CU.R
R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP ro ^^ M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERS OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
(1 . . ?yIIIA to l
Print Owner's or Authorized Agent's Name(Electronic Signature) Dat
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.¢ov/oca Information on the Construction Supervisor License can be found at www.mass. ov/d s
2. When substantial work is planned,provide the information below:
Total floor 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"
r
CITY OF SALEA MASSAC RUSE M
r� BUILDING DEPARTA ENT
120 WASHINGTON STREET,Yz FLOOR
TEL(978)745-9595
KIMBERLEY DRISODLL FAX(978)740-9846
MAYOR THOMAS STIP ERRE
DIRECTOR OF PUBLIUROPERTY/BUILDING OOMUSSIONER
r .HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
DATE: 'l j
JPB LOCATION 'v, HA
HOME OWNER ADDRESS: 1 � ,' LPN _�44
PRESENT MAILING ADDRESS: 1.�� �C�1'f�k� 57 �5A `P H, f�J�
Thp current exemption of."Homeowners"was extended to include owner-occupied dwellings of two(2)units or less and to
allciw such homeowners to engage an individual for hire that does not possess a license,provided that the owner acts as
supervisor.
Definition of Homeowner.
Perhon(s)who own a parcel of land on which he/she resides or intends to reside,on which there is,or is intended to be,a
one-or two-family dwelling,attached or detached structures accessory to such use and/or farm structures. A person who
constructs more than one home in a two-year period shall not be considered a homeowner. Such"homeowner"shall submit
to the Building Official,on a form acceptable to the Building Official,that he/she be responsible for all such work performed
under the Building Permit.
The iundersigned"homeowner"assumes the responsibility for compliance with the State Building Code and other applicable
by-laws and regulations.
The undersigned"homeowner"certifies that he/she understand the City of Salem Building Department minimum inspection
procedures and requirements and that he/she will comply with such procedures and requirements.
HOMEOWNER'S SIGNATUREQyT►1jV 1 Gt�1/� t/•
APPRhVAL OF BUILDING INSPECTOR
QTY of S
}G-j�
ALEM, MASSACHUSE'IT5
BUILDING DEPARTW ENT
120 WASHINGTON STREET,31D FLOOR
TtL.(978)745-9595
KIlv1BERLEYDRisco , FAX(978)740-9846
MAYOR THOIM M STJP ERRS
DIRECTOR OF PUBLICPROPERTY/BUILDING ODINWSSIONER
Construction Debris Disposal Affidavit
p
(required for all demolition & renovation work
In accordance with the sixth edition of the State Building Code, 780 CMR,Section 111.5 Debris,
and the provisions of MGL c40,554; Building Permit#
is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licenses
;waste deposit facility as defined by MGL c 111,5150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility) s
Signature of applicant
(today's date)
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PLAYROOM _ BATHROOM ❑
HAB#1
BOILER FAM. ROOM 01
KITCHEN
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HOT WATER
7 LIVINGROOM FHAB#2
OIL TANK
BASEMENT 1-ST. FLOOR 2ND FLOOR
EXISTING EXISTING EXISTING
T4 ST AG
BATH
1-11 T � ❑
PLAY ROOM BATHROOM ❑
HAB#1
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BOIL ER KITCHEN FAM. ROOM
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HOT WATER
LIVINGROOM [HAB#2
OIL TANK
BASEMENT 1ST. FLOOR 2ND FLOOR
NEW NEW NEW
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Your Confirmation number is 2019071010164707
,Date of Confirmation:7/10/2019
'NOTE:When paying by ACH(Checking)it will take two business days for the payment to be debited from your bank account.Your
account number is not verified until this payment is presented to your bank.They have the right to return this payment if unable to
process this transaction against your account.
Your request for payment(s)of$58.50 has been received and is subject to approval by your financial institution. No email was entered
so a confirmation was not sent.
Accsount Information Payment Information
Name: JOAQUIN GUILLEN Payment Type: Credit Card
Note: QUICK PAY TRANSACTION Payer Name: JOAQUINGUiLLEN
Card Number: **************2895
s
Trarisaction Information
Transaction Quantity Amount Fee Payment Type
City of Salem-Inspectional Services 1 $56.00 $2.50 Credit Card
Building Permit
First Name:Joaquin
Last Name:Guillen
DBA/Company Name,if applicable:
Name cif permitted/inspected property:
15 Albion Street
Address of permitted/inspected
property:15 Albion Street
Phone#:781-346-2710
Contact Email Address:
JfGuillen1618@hotmail.com
Total:$!i8.50