0023 ANDREW STREET - BUILDING JACKET tndaf®
74520 400/oP4
Cite of 4balem, A1a!5garbu!5ett!5
Public Propertp 3hpartment
�p Ouilbing nepartment
One Salem Oreen
(978) 745-9595(Ext. 3SO
Leo E. Tremblay
Director of Public Property
Inspector of Building
Zoning Enforcement Officer
December 24, 1997
To Whom it May Concern
RE: 23 Andrews Street, Salem
According to the records on file in this office, it has been
determined that 23 Andrews Street is a lawful, nonconforming,
grandfathered three (3) family dwelling.
This is to determine use only and in no way is meant to
confirm or deny whether said property is in compliance with all
building, plumbing, gas, electric, fire or health codes.
Sincerely, _
Leo E. Trembaly�
Zoning Enforcement Officer
LET: scm
NoU61 3 Ward
APPLICATION FOR
PERMIT TO ROOF
REROOF OR INSTALL SIDING
Location ZS (^�rQ 4�
PERMIT GRANTED
19
App ved
/1Q ilding/ p for
� VV
�A\
Ul
Plans must be filed and approved by the Inspector before a permit will be granted.
No. 3b1 -93 City of Salem Ward._
IS PROPERTY LOCATED IN THE ;
HISTORIC DISTRICT? Yes No a
., ! 9
IF SIDING, HAS ELECTRICAL °+cciwwxcdd �Z,I ��3/
PERMIT BEEN OBTAINED? Yes No Home Phone #
APPLICATION Bus. Phone #
PERMIT TO ROOF REROOF R INSTALL SIDING
Salem,Mass.,
TO THE INSPECTOR OF BUILDINGS:
The undersigned herebv applies a permit to build according to the following specifications:
fo
Owner's name and address _ V8&—/C1T
Architect's name
ty 71—
Mechanic's name and address
Location of building,No. 2.3 411-,Z�e41/ .5-7—eeZ'7-
What is the purpose of building? 3 f/�/LY _
Material of building? �ff/9a.7J Asbestos?
If a dwelling,for how many families". _ SSE
Will the building confonn topjhe requirements of the law? V-
Estimated cost f�/�OO.DO Contrs
ctors Lic. o.
Signature of applicant Z�
REMARKS 51GNED UNDER THE
PEN LTY OF PERJURY.
noxa y
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a
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{` CITY OF SALEM HEALTH DEPARTMENT
BOARD OF HEALTH
9 North Street
ROBERT E. BLENKHORN Salem, Massachusetts 01970
HEALTH AGENT
508-741-1800
June 9, 1993
CAlbeEisen
rt
8 Putnam Street
Beverly,MA 01915
('5——Mr EEisen;
In accordance with Chapter 111,Sections 127A and 127B of the Massachusetts General laws,105 CMR 400.00:Stale Sanitary Code,Chapter L General
Administrative Procedures and 105 CMR 410.000:Stale Sanitary Code,Chapter II:Minimum Standards of Fitness for Human Habitation,an inspection was
made of your property at 23Andrew Street Salem,Massachusetts by William T.Burke,III,R.S.Senor Sanitarian,Salem Health Department on
May 28,1993.
The following violations of the Slate Sanitary Code were noted,as checked off:
X CMR 410:600 Storage of Rubbish and Garbage
X— CMR 410:601 Collection of Garbage and Rubbish
X — CMR 410:602 Maintenance of Areas Free From Garbage and Rubbish(A through D)
Reg.#7 s.3.10 Board of Health Regulation
Description of Violations: Accumulation of trash in driveway. The property must be cleaned and maintained pending
further administrative action.
410.600: Storage of Rubbish and Garbage
(A) Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight-fitting covers.Said receptacles and covers shall be
of metal or other durable,rodent-proof material.Rubbish shall be stored in receptacles of metal or other durable,rodent-proof material.
Garbage and rubbish shall be put out for collection no earlier than the day of collection.
(B) Plastic bags shall be aced to store garbage or mixed rubbish and garbage only if used as a liner in watertight receptacles with tight-filing
covers as required in 105 CMR 410.600(A)provided that the plastic bags may be put out for collection except in those places where such p
practice is prohibited by local rule or ordinance,or except in those cases where the Department of Public Health determines that such practice
constitutes a health problem For purposes of the preceding sentence,in making its determination,the Department shall consider.among other
other evidence of strewn garbage,torn garbage bags,or evidence of rodents.
(C) The owner of any dwelling that contains three or more dwelling units,the owner of any rooming house,and the occupant of any other
dwelling place shall be responsible for providing as many receptacles for the storage of garbage and rubbish as are sufficient to contain the
accumulation before final collection or ultimate disposal,and shall so locate them to be convenient to the tenant that no objectionable odors
enter any dwelling.
(D) The occupants of each dwelling,dwelling unit,and rooming unit shall be responsible for the proper placement of her or his garbage and
rubbish in the receptacles required in 105 CMR 410.600(C)or at the point of collection by the owner.
410.601: Collection of Garbage and Rubbish
The owner of any dwelling that contains three or more dwelling units,the owner of any rooming house,and the occupant of any other dwelling
place shall be responsible for the final colelection or ultimate disposal or incineration of garbage and rubbish by means of:
(A) The regular municipal collection system;or
(B) Any other collection system approved by the Board of Health;or
(C) When otherwise lawful,a garbage grinder which grinds garbage into the kitchen sink drain finely enough to ensure its free passage,and is
otherwise maintained so as not to create a safety or health hazard;or
(D) When otherwise lawful,a garbage or rubbish incinerator located within the dwelling which is properly installed and which is maintained so as
not to create a safety or health hazard;or
(E) Any other method of disposal which does not endanger any person and which is approved in writing by the Board of Health
(see 105 CMR 410.840)
t SALEM HEALTH DEPARTMENT
1\ 9 North Street
Salem, MA 01970
ir4r�n��
410.602: Maintenance of Areas Free From Garbage and Rubbish
(A) Land: The owner of any parcel of land,vacant or otherwise,shall be responsible for maintaining.such parcel of land in a clean and sanitary
condition and free from garbage,rubbish,or other refuse.The owner of such parcel of land shall correct any condition caused by or on such
parcel or its appurtenance which affects the health or safety and well-being of the occupants of any dwelling or of the general public.
(B) Dwelling Units: The occupant of any dwelling unit shall be responsible for maintaining in a clean and sanitary condition and free of garbage,
rubbish,other filth or causes of sickness that pan of the dwelling which s/he exclusively occupies or controls.
(C) Dwellings Conta n ne Fewer Than Thee Dwelling Units: In a dwelling that contains fewer than three dwelling units.the occupant.shall be
responsible for maintaining in a clean and sanitary condition free of garbage,rubbish,other filth or causes,of sickness the stairs or stairways
leading to her or his dwelling unit and the landing adjacent to her or his dwelling unit if the stairs,stairways,or landing are not used by another
occupant.
(D) Common Areas: In any dwelling,the owner shall be responsible for maintaining in a clean and sanitary condition free of garbage,rubbish,
r
other filth or cusses of sickness that part of the dwelling which is used in common by the occupants and which is not occupied or controlled by
the occupant exclusively.
(i)The owner of any dwelling abutting a private passageway or right-of-way owned or used in common with other dwellings or which the
M1 owner or occupants under her or his control have the right to use or are in fact using shall be responsible for maintaining in a clean and
sanitary condition free from garbage,mbbish,other filth or cause of sickness that part of the passageway or right-of-way which abuts her or
his property and which s/he or the occupants under her a his control have the right to use,are in fact using,or which s/he owns.
odHRhRu [ h Id d Ordinary Commercial Waste.Garden d I W t � These shallBparld
edge of the sidewalk appurtenant to the premises of the owner not later than 7:00 a.m.on the day of collection and not before 6:00
p.m.on the day preceding the day of collection,and shall be removed from the sidewalk on the same day as emptied.No commercial establishment shall
place a cause to be placed more than four barrels or other containers of ordinary commercial wastes or any extraordinary commercial or industrial wastes or
tree waste upon any sidewalk or way for disposal.
You are hereby Ordered to make a good faith effort to correct these violations within 24(twenty four)hours of receipt of this notice.
Failure on your part to comply within the specified time will result in a complaint being sought against you in Salem District Court.
Should you be aggrieved by this order,you have the right to request a hearing before the Board of Health. A request for said hearing must be received in
writing in the office of the Board of Health within 7 Days of receipt of this order. At said hearing,you will be given an opportunity to be heard and to
present witness and documentary evidence as to why this order should be modified or withdrawn. You may be represented by an attorney. Please also be
informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders,and other documentary information in
the possession of this Board,and that any adverse party has the right to be present at the hearing.
One a more of the above violations constitutes a condition which tray endanger or materially impair the health or safety and well-being of the occupant(s)
a the general public.
If you have any questions,kindly contact this office at(508)741-1800.
For the Board of Health Reply to:
Robert E.Blenkhorn,C.H.O. William T.Burke,Ill,R.S.
Health Agent Senior Sanitarian
cc: Councillor Kevin Harvey
Building Inspector
Certified Mail P 348 635231
toxorL�
s`
a
���'TCOIMINE�� y
CITY OF SALEM HEALTH DEPARTMENT C �� » ��� )88
BOARD OF HEALTH M
Salem, Massachusetts 01970 9� Eqp
� 19�,�+�
ROBERT E. BLENKHORN 9 NOT2TY! STREET
HEALTH AGENT
(617) 741.1800 June 1 , 1989
Mr. Albert Eisen
58 Putnam Street
Beverly, Ma. 01915
RE: 23 Andrew Street
Dear Mr. Eisen:
The Health Department has received complaints from neighbors about possible
conditions of over crowding at 23 Andrew Street.
Please be advised of the following sections of the State Sanitary Code II-
Minimum Standards of Fitness for Human Habitation.
410.400: Minimum Square Footage
(A) Every dwelling unit shall contain at least 150 square
feet of floor space for its first occupant, and at least
100 square feet of floor space for each additional occupant,
the floor space to be calculated on the basis of total hab-
itable room area.
(B) In a dwelling unit, every room occupied for sleeping
purposes by one occupant shall contain at least 70 square
feet of floor space; every room occupied for sleeeping
purposes by more than one occupant shall contain at least
50 square feet of floor space for each occupant.
(C) In a rooming unit, every room occupied for sleeping
purposes by one occupant shall contain at least 80 square
feet of floor space; every room occupied for sleeping
purposes by more than one occupant shall contain at least
60 square feet for each occupant.
410.401 : Ceiling Height
A) No room shall be considered habitable if more than
three-quarters of its floor area has a floor -to-ceiling
height of less than 7 feet.
uw 4,ot` SALEM HEALTH DEPARTMENT
y 9 North Street
Salem, MA 01970
' 4kMeR!�
Mr. Albert Einsen
June 1 , 1989
Page 2
(B) In computing total floor area for the purposes of
determining maximum permissible occupancy, that part of
the floor area where the ceiling height is less than 5
feet shall not be considered.
410.402: Grade Level
No room or area in a dwelling may be used for habitation
if more than one-half of its floor-to-ceiling height is
below the averaage grade of the adjoining ground and is
subject to chronic dampness.
The Health Department requests your cooperation in making sure that these
minimum standards are met.
If you have any questions or require assistance, feel free to contact this
office at (508) 741-1800. We are also referring this matter to the Inspector
of Buildings/Zoning Officer for his assistance.
Very truly yours,
FOR THE BOARD OF HEALTH, Reply to:
0` f tgjL.
Robert E. Blenkhorn,C.H.O. Sharon Cameron,
Health Agent Sanitarian
REB/JM
cc : William H. Munroe, Inspector of Buildings/Zoning Officer.
CITY OF SALEM
MASSACHUSETTS 01970
From The Office or November 14. 85
ASSESSORS 19
TO WHOM IT MAY CONCERN:
Re: 23—Andrew reet-
According to the records in the Assessors'
Office* the above property has been assessed
as a three (3) family since 1973.
Very truly y rs,
CE
Peter M. Caron
Assessor
of 'Salem' 'fflanar4usffls
::. / s 7 uhlu ru Px# a ttr#men#
s��'Ego"? �lI1�TIi$ �PiI2IY#I.LQLT#
William H. Munroe
One Salem Green
745-0213
i
November 14, 1985
TO WHOM IT MAY CONCERN : •
RE: r2'3— NDREC8T_.1
According to the records in this office , the above
reference property , 23 Andrew St . , is a three family _dwel-
ling and may continue to be used as such .
Sincerely , 000
vk.a_`_�
William H . Munroe
Zoning Enforcement Officer
WHM : bms
4olma r^'
CITY OF SALEM HEALTH DEPARTMENT
BOARD OF HEALTH
9 North Street
ROBERT E. BLENKHORN Salem, Massachusetts 01970
HEALTH AGENT
508-741-1800
April 8, 1993
Albert Eisen
58 Putnam Street
Beverly,MA 01915
Dear Mr.Eisen:
In accordance with Chapter 111,Sections 127A and 127B of the Massachusetts General laws,105 CMR 400.00:State Sanitary Cade,Chapter I:General
Administrative Procedures.and-105-CMR 410.000:State Sanitary Code,Chapter IL Minimum Standards of Fitness for Human Habitation,an inspection was
made of your property at 23 Andrew Street Salem,Massachusetts,by William T.Burke,R.S.,Senior Sanitarian of the Salem
Health Department.
The following violations of the State Sanitary Code were noted,as checked off:
X CMR 410:600 Storage of Rubbish and Garbage
X CMR 410:601 Collection of Garbage and Rubbish
• CMR 410:602 Maintenance of Areas Free From Garbage and Rubbish(A through D)
• Reg.#7 s.3.10 Board of Health Regulation
Description of Violations: Property must be cleaned and maintained in accordance with the regulations.
410.600: Storage of Rubbish and Garbage
(A) Garbage or mixed garbage and rubbish shall be stored in watertight receptacles with tight-fitting covers.Said receptacles and covers shall be
of metal or other durable,rodent-proof material.Rubbish shall be stored in receptacles of metal or other durable,rodent-proof material.Garbage
and rubbish shall be put out for collection no earlier than the day of collection.
(B) Plastic bags shall be used to store garbage or mixed rubbish and garbage only if used as a liner in watertight receptacles with tight-filing
covers as required in 105 CMR 410.600(A)provided that the plastic bags may be put out for collection except in those places where such practice
is prohibited by local rule or ordinance,or except in those cases where the Department of Public Health determines that such practice constitutes a
health problem.For purposes of the preceding sentence,in making its determination,the Department shall consider,among other other things,
evidence of strewn garbage,tom garbage bags,or evidence of rodents.
(C) The owner of any dwelling that contains three or more dwelling units,the owner of any rooming house,and the occupant of any other
dwelling place shall he responsible for providing as many receptacles for the storage of garbage and rubbish as are sufficient to contain the
accumulation before final collection or ultimate disposal,and shall so locate them to be convenient to the tenant that no objectionable odors enter
any dwelling.
(D) The occupants of each dwelling,dwelling unit,and rooming unit shall be responsible for the proper placement of her or his garbage and
rubbish in the receptacles required in 105 CMR 410.600(C)or at the point of collection by the owner.
410.601:Collection of Garbage and Rubbish
The owner of any dwelling that contains three or more dwelling units,the owner of any rooming house,and the occupant of any other dwelling
place shall be responsible for the final colelection or ultimate disposal or incineration of garbage and rubbish by means of:
(A) The regular municipal collection system;or
(B) Any other collection system approved by the Board of Health;or
(C) When otherwise lawful,a garbage grinder which grinds garbage into the kitchen sink drain finely enough to ensue its free passage,and is
otherwise maintained so as not to create a safety or health hazard;or
(D) When otherwise lawful,a garbage or rubbish incinerator located within the dwelling which is properly installed and which is maintained so as
not to create a safety or health hazard;or
(E) Any other method of disposal which does not endanger any person and which is approved in writing by the Board of Health
(see 105 CMR 410.840)
SALEM HEALTH DEPARTMENT
e 43 � 9 North Street
Salem, MA 01970
M�
410.602:Maintenance of Areas Free From Garbage and Rubbish
(A) and: The owner of any parcel of land,vacant or otherwise,shall be responsible for maintaining such parcel of land in a clean and sanitary
condition and free from garbage,rubbish,or other refuse.The owner of such parcel of land shall correct any condition caused by a on such parcel
or its appurtenance which affects the health or safety and well-being of the occupants of any dwelling or of the general public.
(B) Dwelling Units: The occupant of any dwelling unit shall be responsible for maintaining in a clean and sanitary condition and free of garbage,
rubbish,other filth or causes of sickness that part of the dwelling which s/he exclusively occupies or controls.
(C) Dwellings Containing Fewer Than Thce Dwelling nits: In a dwelling that contains fewer than three dwelling units,the occupant shall be
responsible for maintaining in a clean and sanitary condition free of garbage,rubbish,other filth or causes of sickness the stairs or stairways
leading to her or his dwelling unit and the landing adjacent to her or his dwelling unit if the stairs,stairways,or landing are not used by another
occupant.
(D) Common Areas: In any dwelling,the owner shall be responsible for maintaining in a clean and sanitary condition free of garbage,rubbish,
other filth or cusses of sickness that pan of the dwelling which is used in common by the occupants and which is not occupied or controlled by one
occupant exclusively.
(i)The owner of any dwelling abutting a private passageway or right-of-way owned or used in common with other dwellings a which the
owner or occupants under her or his control have the right to use or are in fact using shall be responsible for maintaining in a clean and
sanitary condition free from garbage,rubbish,other filth or cause of sickness that pan of the passageway or right-of-way which abuts her or
his property and which s/he or the occupants under her or his control have the right to use,are in fact using,or which s/he owns.
Board of Health Regulation k7 Section 3.1 : Containers or Bundles of Household and Ordinary Commercial Waste Garden and Lawn Waste These shall
be placed at the outer edge of the sidewalk appurtenant to the premises of the owner not later than 7:00 a.m.on the day of collection and not before 6:00
p.m.on the day preceding the day of collection,and shall be removed from the sidewalk on the same day as emptied.No commercial establishment shall
place or cause to be placed more than four barrels or other containers of ordinary commercial wastes or any extraordinary commercial or industrial wastes or
tree waste upon any sidewalk or way for disposal.
You are hereby Ordered to make a good faith effort to correct these violations within 24(twenty four)hours of receipt of this notice.
Failure on your part to comply within the specified time will result in a complaint being sought against you in Salem District Court.
Should you be aggrieved by this order,you have the right to request a hearing before the Board of Health. A request for said hearing must be received in
writing in the office of the Board of Health within 7 Days of receipt of this order. At said hearing,you will be give an opportunity to be heard and to
present witness and documentary evidence as to why this order should be modified or withdrawn. You may be represented by an attorney. Please also be
informed that you have the right to inspect and obtain copies of all relevant inspection or investigation reports,orders,and other documentary information in
the possession of this Board,and that any adverse party has the right to be present at the hearing.
One or more of the above violations constitutes a condition which may endanger or materially impair the health or safety and well-being of the ocepant(s)
or the general public.
If you have any questions,kindly contact this office at(508)741-1800.
For the Board of Health Reply to:
be�Blenkhom,C.H._O William T.Burke,R.S.
Health Agent Senior Sanitarian
enc: Councillor Kevin Harvey
Building Inspector
Certified Mail P 348 634 728
�a
Citp of 6atem, Amoarbuzettg
DATE FILED JJne Type: ew
Expiration DateTLS-3 2 '00 I] Renewal, no change
Number 96-135 Q Renewal with change
In conformity with the provisions of Chapter one hundred and ten, Section five of the Massachusetts General
Laws, as amended, the undersigned hereby declare(s) that a business is conducted under the title of:
N1v2 / //'s ( e„/F"e- alaw�A/AA/CC
ai—&-3—U4 U 5 A/t' /V A s s n 9 7y
type of business c ✓e rL L M A /F N A Ncc
by the following named person(s): (Include corporate name and title if corporate officer)
Full Name Residence
Znatures
-���`= -;;-3 r------------------- -----------------------------------------------------
I
----------------------------------------------------- -----------------------------------------------------
on 19— the above named persons) personally appeared before me and made an
oath th the foregoing statement is true.
----------------------------------------------------- -----------------------------------------------------
CITY CLERK Notary Public
(seal)
Date Commission Expires
Identification Presented
State Tax I.D. # S.S.
(if available)
In accordance with the provision of Chapter 337 of the Acts of 1985 and Chapter 110, Section 5, of Mass.
General Laws, business certificates shall be in effect for four(4) years from the date of issue and shall be
renewed each four years thereafter. A statement under oath must be filed with the town clerk upon
discontinuing, retiring, or withdrawing from such business or partnership.
Copies of such certificates shall be available at the address at which such business is conducted and shall be
famished on request during regular business hours to any person who has purchased goods or services from
such business.
Violations are subject to a fine of not more than three hundred dollars ($300.00) for each month during which
such violation continues.
�!3 - 1L4 -q's
1n� L he Commonwealth of Massachusetts '
44yU Department of Public Safety
Vy( Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(this Section For Official Use Only).
Building Permit Number: Date Applied: Building Official
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
Z3 /r�D�EGU
No.and Stre � ' City/Town Zip Code Name of Building(if applicable)
SECTION Z.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❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix 1)
Change of Use ❑ 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 Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:
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 CMR 34) ❑
Existing Use Group(s): Proposed.Use Group(s):
SECTION 4: BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&a Area Per Floor(sq. ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as a plicable)
A: Assembly A-I❑ A-2❑ Nightclub ❑ A-3 ❑ A4 Cl A-5❑ 1 B: Business ❑ E: Educational ❑
F: Facto F-1❑ F2❑ 1 IL• h Hard ❑ ❑ ❑H-1 H-2 H-3 H-4❑ H-s❑
1: Institutional I-1❑ I-2❑ 1-3❑ 14❑ M: Hi u
Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R4❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as applicable)
1A ❑ Ill ❑ IIA ❑ IIB ❑ IIIA ❑ HIB ❑ IV ❑ VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Information: Sewage Disposal:
Trench Permit: Debris Removal:
Public❑ Check if outside Flood Zone❑ Indicate immicipal❑ A trench will not be Licensed Disposal Site❑
Private❑ or indentify, required❑or trench or specify:Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: Hazards to Air Navigation: \IA_L,I,i tc ri Cnngli srr n It .um I r,}�.is:
Not Applicable❑ Is Structure within airport approach area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No❑ Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Dues the building contain an Sprinkler System?: Special Stipulations:
`bib GAI,L.� 'l t,mov�n
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name ul r\ddress of Property Owner
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information: — --
Title Telephone No. (business) Telephone No. (cell) e-mail address
If applicable,the property 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 by this building permit a2plication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2). '
If building is less than 35,000 cu.ft.of enclosed space and/or not under Construction Control then check here 13 and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Nano(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
Company Name
Name of Person Responsible for Construction License No. and Type if Applicable
Street Address City/Town State Zip
Telephone No. business Tele hone No. cell a-mail address
SECTION11:lV0RKVR5'(-0N1lTN.,M l0N NSURANC.ti AITIDAVI"I M.G.L.c.152.§25C6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents 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.
Is a signed Affidavit submitted with this application? Yes❑ No ❑
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1.Building $ Building Permit Fee=Total Construction Cost x (Insert here
2.Electrical $ appropriate municipal factor)_$
3. Plumbing $
4. Mechanical (HVAC) $ Note: Minimum fee=$ (contact municipality) -
5. Mechanical Other $ Enclose check payable to
- 6."total Cost $ „j��0,OZ+j (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below,1 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.
Please print and sign name "title Telephone No. Date
Street Address City/Town A State Zip
j
Municipal Inspector to fill out this section upon application approval: •,` 1 M'1'^' " ' "'
Name Date