B-19-924 - 0009 BURNSIDE STREET - Building Permit a� 7 � �� � �
The Commonwealth of Massachusetts
sg` ti Board of Building Regulations and Standards ;, FOR
®' Massachusetts State Building Code,780 CMR » .= MUNICIPALITY
USE
Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011
One-or Two-Family Dwelling
This Section.For Official Use Only
Building Permit Number: _ Date pp lied:
`�,•`' .. ' ''r
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Pr erty Addr ss: , 1 „r�P 1.2 Assessors Map&Parcel Numbers
1.1a-Is this an accepted street?yes no Map Number ,� .� Parcel Number s
1' 1.3 Zoning Information: 1.4 Property Dimensions: `, r
Zoning District .Proposed Use Lot.Area(sq_ft) Frontage(ft) W
1.5 Building Setbacks(ft) i
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Whiter Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public 1..3 Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP.''
2.R.nt)
et' f Record: _ ^ v f
r :Ll .y' Y r`t e�
4
N City,State,ZIP
No.and Street Telephone 1 Eih1ttWddress f�
SECTION 3:DESCRIPTION OF PROPOSED WORK2.(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief L►e cri 'on of Proposed W rkZ: 11 Ogg
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 11A��Oi 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ / O Total Project Costa(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: $
' 9#0,01 ❑Paid in Full ❑Outstanding Balance Due:
N,p
M pp
SECTION 5: CONSTRUCTION SERVICES
5.1 nstruction upervisor ense(CSL)
License Number Exj4iratiod ate
Name of CSL Hold
��� List CSL Type(see below) V �,
—�� �( Type. Description
No.and�treet
r U Unrestricted(Buildings u to 35,000 cu.ft.
�d R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP , M Masonry
RC Roofing Covering
Q WS Window and Siding
t1y tg- SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Im roveme t Co ractor(HIC) - !J '
•77 �
IC Registration Number 4x ion
Date
I ompany N e or IC R istrant Name
-0.� A � i&^ hi-Iv
to Ike /�vi
No. 14. U � tr,s/f`,� Emil address f
Ci /Town tate,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 .........�jg No...........❑
SECTION 7a OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENYOR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorizeV� c3
to act on my behalf,in a matters relative to,work authorized by this building ermit application.
Winf wner's Name(Electronic Signature) l5ate
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name belo ,I hereby attest under the pains and penalties of perjury that all of the inform tion
contained in phis ap li o tru urate to the best of my knowledge and understanding.
Print Owne ' or orized Agent's Name(Electronic Signature) 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. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss
2. When substantial work is planned,provide the information below:V..
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"
CITY OF SALEM
MASSAC HUSETTS
I" BUIMING DEPARTAENT
12.0 WASHINGTONSTRMET,3RDFLOOR
7hL.(978)745-9595 ,
KRvIBERLEYDRISOOLL FAX(978)740-9846
MAYOR 71iO1 M STAERRE
DIRECTOR OF PUBLIC PROPERTY/BLU DM GDAMSSIONER
Construction Debris Dis osal A •ffidavi•
p t
(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:
(n6ime of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signatur of plicant
(tod s d e)
I
M;
CITY OF Siuxa I, INLkSSACHUSETTS
• BUILDING DEPARTNELNT
` 120 WASHINGTON STREET, r FLOOR
TEL (978)745-9595
FAX(978)740-9846
KI,\tBFiti FY t)RISCOLL
MAYOR T HOMU ST.PlERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Busim-WOrsanization/Individual): t
Address: -�- d�� J�t,
City/State/Zip: ' Z d- Phone !#: Q?P"7�O—_Yr�,6
Are you an employer?Check t�e appropriate box: Type of project(required):
I.W I am a employer with 4. ❑ 1 am a general contractor and 1 6. Q New construction
employees(full and/or part-tithe).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.2 ?• 'g-Remodeling
ship and have no employed These sub-contractors have 8. Q Demolition
wo king for me in any capacity. workers'comp.insurance. 9. Q Building addition
[No workers'comp.insurance 5. ❑ We are a corporation and its IO.Q Electrical repairs or additions
required-] officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL l I. Plumbing repairs or additions
myself.(No workers'comp. C. 152,§1(4),and we have no 12.Q Roof repairs
insurance required.)t employees. [No workers' 13.Q Other,
comp. insurance required.)
•Any applia�d that Checks liox 01 must also till rut the section below showing their workers'wmpensvion policy information.
t t Wwowners who submit this affidavit indicating they as doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors6that check Ibis box must attached an additional sheet showing the name of the sub-contractors and their workers'comp,policy information.
Ian:an employer that Ls providing workers'compensation insurance for my employee& Below is the policy and fob site
information.
lnsunrnce Company Name: Lt p
Policy#or Self-ins.Lie.#: — 26 -sal Expiration Datw
Job Site Address: 411 Z.,- >!"J ' City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number an expiration date).
Failure to s cure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to.�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 S250.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Office of
Inves6gaiiunx of the DIA or insurance coverage verification.
l do hereby certify ui, r the a and penalties of perjury that the information provided above's true nd correct
1.60;t tr Date.
Phone#: .�r'2�- ?Of ys7�
Official use only. Do not write in this area,to be completed by city or town ofrciaL
City or Town: Permitfl.icense# _
Issuing,A u I hority(circle one):
I. BoarO of llealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Otherr
Contacg Person: Phone#: