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The Commonwealth of Massachusetts
° Board of Building Regulations and Standards CITY OF
SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: ate Applied:
r "tR l.r
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
�-
1.In Is this an accepted street?ye Map Number Parcel Nmnber
1.3 Zoning Information: 1.4 Property Dimensions: t
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) Q n
1.5 Building Setbacks(ft) Jt) R1
Front Yard Side Yards Rem Yard D frt
An
O
Required Provided Required Provided Required Pmvid
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 yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
1 Ownert of Record: YII y C�%7
I'n4l f (L',P'h t�(fi2��Us3/e,� A(Gn1 M
Dame(Print) City,State,ZIP -
No.and Snee Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition
Gl
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed WorlcZ:� C1LG„I .1'�w �N �e:'23Y1 i[r'jr X (fo
G`rttQ nt -t �rGIC fully
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 6 r 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
?I 57LO ❑Total Project Cost"(Item 6)x multiplier x
3.Plumbing $ 00 2. Other Fees:
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Su ression Total All Fees:$
/ Check No._Check Amount: Cash Amount:
6.Total Project Cost: $ Y 1 tv ❑Paid in Full ❑Outstanding Balance Due:
� I
�7 3tf-Q T" 0% Z'4
1
SECTION 5: CONSTRUCTION SERVICES
r:Nle
onstruction Supervisor License(CSL) CS—���7 3 3iz�/
co
II ,, License
R,✓1 ��C-Wt�1 c:/� a Number Expvanon Date
f CSL HolderList CSL Type(see below)
QQ//��//Stree�t�� Ty Description
• ICJ ,6 j ,Aa A �7c'1r-t Unrestricted Buildin s u to 35,000 cu.ft.
lJ 411� �I CJ J R Restricted 1&2 Famil Dwellin
City/Iown,State,ZIP M Moo
RC Roofn Coverin r
WS Window and Sidin
�iy Cny j i�f�/ G�yl SF Solid Fuel Burning Appliances
IICC N7 ary j`(,�14a0f I Insulation
Telephone Email ad esrd'r s D Demolition
5.2 Registered Home Improvement Contractor(HIC) Z��g
�^
�whlct �1
� et HIC Registration Number Expiration Date
r. HIC Company ame o HIC deg' trant Name
�z Iul �Yt tic 10�a5 C Zlt 2 rl/lGC
FC No. 67
dSveet / gy`, 4`j"/
Email address
CityUown,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
1 , this affidavit will result in the denial of the Issuanc the building permit.
Ir
�v 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.
/ •Name
El (c ( 4 —,.may
ar (t I�I
Print Owner's Name(Electronic Signature '� Date
SECTION 76:OWNERI 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.
Print Owner's or Authorized 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.gov/oca Information on the Construction Supervisor License can be found at www.niass.gov/dos
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'
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y I
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MORTGAGE INSPECTION >, �°� ��
PLAN IN WN A# m
N0.29iY1 y
SALEM, MASS. " 9 p
REID LAND SURVEYORS
o�su
365 CHATHAM ST., LYNN, MASS. TO UNION TRUST GE CORP., PAUL M.
& HELEN K. LAZDOWSKI AND THE TITLE IN-
SURANCE COMPANY INSURING THE PREMISES.
I CERTIFY THAT THE DWELLING IS LOCATED
AS SHOWN AND CONFORMED TO THE ZONING
SET BACK REQUIREMENTS OF THE CITY OF
SALEM WHEN CONSTRUCTED, OR IS
EXEMPT FROM VIOLATION ENFORCEMENT
UNDER M.G.L. TITLE VII CH. 40A 'SEC. 7.
4.71 L. C.
75.32'
LOT 619 �
N/F p0 ! v I19
- N/F
ANE'LIS 0; RILLOVICK
0) r" 1 1/2 STORY Lo
CD
VINYL SIDED
#23
19't
'v
' N
90.00,
23 APPLEBY RD,
'I, HEREBY, CERTIFY TO THE BEST OF MY KNOWLEDGE NOTE: THIS PLAN WAS PREPARED FROM P
THAT THE PREMISES SHOW ON THIS PLAN ARE NOT LOCAT- TAPE SURVEY AND IS INTENDED FOR
ED WITHIN A SPECIAL FLOOD HAZARD AREA AS DELINEATED MORTGAGE PURPOSES ONLY. OFFSETS SHOD
ON THE MAP OF COMMUNITY #250102-B PREPARED BY THE
FEDERAL EMERGENCY MANAGEMENT AGENCY OR ITS ON OR SCALED FROM THIS PLAN, ARE
SUCCESSORS DATED 8/5/85, PANEL 5 , ZONE C - APPROXIMATE ONLY AND SHOULD NOT BE
I FURTHER CERTIFY THAT THIS INSPECTION WAS PER- USED TO DETERMINE PROPERTY LINES.
FORMED IN ACCORDANCE WITH THE 'TECHNICAL STAND- SCALE: 1" = 30' DATE: DECEMBER 29, 15
ARDS FOR MORTGAGE LOAN INSPECTIONS' AS ADOPTED
BY THE MASSACHUSETTS ASSOCIATION OF LAND SURVEYORS BOOK: PAGE: CERT.# 67033
AND CIVIL ENGINEERS.
THIS CERTIFICATION DOES NOT INCLUDE SHRUBS, WALLS, CONTROL 4:P97-1135 C
FENCES OR DRIVEWAYS AS THEY DO NOT ALWAYS INDICATE
PROPERTY LINES. SLS
3
1
8/
�1
24V
3]V" �
No p
313/4- B111/4-- In 1/2 .
-2JF-
Bath a
Kitchen iiDlnine
1 6 i
i
n M 3/4- 4tB30
Wm
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13edroom#1
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w
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The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards ,
Massachusetts State Building Code, 780 CMR, 7"edition Building Dept
Building Permit Application To Construct, Repair, Renovate Or Demolish a t1
One- or Tiro-Faintly Duelling
is Sect n For Official Use Only
Building pcnEnitNumber, Dale Applied:
Signature:
Building Commissioned i pector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map At Parcel Numbers
I.I a 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 II) Frontage(R)
1.5 Building Setbacks(R)
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 SewageDisposal System:
/ Zone: _ Outside Flood Zone? Municipal l7 On site disposal system ❑
Public❑" Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
L Q
Na (Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction]C3 Existing Building Owner-Occupied Repairs(s) ❑ Alleration(s) Addition ❑Demolition Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work=: T5rAA ,Al1� lc i+Cha.-- C'1 b �e•� ( ��'—�
Cw r7FCT •1-o�S� �GuN R-e.c¢s�f t ul�t ��t an�F y`Ac '/rue
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Ofllcial Use Only
Item Labor and Materials
I. Building S jp /�Zi� -- I. Building Permit Fee: E Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S zO r ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 5 (, 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Su ression
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S /6/ (//}1, 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 2— )3 3
IIA< �— License Number Expnauon Datc
Ngmc of CSL-Hfllder
List CSL Type(sec below)
'A dress
Descri tion
✓/ ( / Unrestricted u to 35,000 Cu. Ft.)
�— R Restricted 1&1 FamilyDwelling
Signa re ���/ M Mason Only
12 D" cl C/ / RC Residential Reciting Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residemial Demolition
5.2 Regered Home Improv [[tent Contractor(HIC)
12-
Z�7�is
I Nc�wA4 l(� h1�
HIC Company Name or HIC�Registr Name �f 5 l� Registration Num er
Add N �f�C�t�g�Q 17,r�r�//a/
Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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..........l' No...........❑
SECTION 7s: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.
Signature of Owner Date
SECTION 7b:OWNER[ OR AUTHORIZED AGENT DECLARATION
I• ,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.
Print Name
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 I IO.R6 and I IO.RS, 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'
CITY OF SALEM
a
PUBLIC PROPRERTY
_-� DEPARTMENT
e'11- Ie1,l,-I1
12: W n,w.\It Ha.i S I s LL 1 • SAI t sa,M.I cc.II III it I n x 197:
Icl. ' 78.713-.3'6 Is 1:%x 9711.74G M46
Workers' Compensation Insurance \flidasit: Builders/Contractun/ElectricianslPlumben
Itpplicant Information Please Print LeCibly
' Vdlnl tdlhnM:,YI)rp]mr.uinrulndn�duull: 41..rYL \/�L�-�.� �1 C1f'r�i�-Gf� C-wt/"1/'�G��� .�-il�C
I
C..I Iy,State.y 117' Phone .!: �) y)7-- Y"5 i
.\
rc s u all employer'! Check the appropriate box: Type orproject(required):
W4
I. I ;un a employer with [1 1 am a gi:neral couuactor and 1 6. Q New construction
cnglloyres(lull anlL'ur pan-tine).• have hire!the suh-contracturs
2.❑ 1 3-m a sole proprietor or Panner-
listed on rhe anichcd sheet. i 7• 0-4etnodeling
,hip and have no enpluyevs Theca sub-contracton have S. Q Demolition
working for me in any capacity. %corkers' comp. insurance. 9. Q Building addition
I No workers' comp. insurance 5. Q We are it corporation and its
I acquired.]
officers have excused their 10-C] Electrical repairs or additions
3. Q 1 ant a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myscif. (No workers'comp. c. 152, ¢1(3),and we have no 12.Q Ruuf repairs
insurance required.) r employees. (No workers' 13.Q Other
comp. insurance required.)
•\u, ..,gabcuul that checks box of must alba lilt WI rhe wcuun Iwluw ihuwina their wurkus'cunlpenwiwl Iwlwy it)I,
' t lomuuwnen
who mbmil this at7l,lavit indi Anvil Is,)we donne u11 work mol then hire outsads cmaxtum must.uhmir a new al'Edavil indiuhny.uch.
-f,•rtrrxu.n the#shuck this box MINI allachud an additional,Ilatll,h,iwiuy llw o:nttc of the sub.onnacton and then wurkem'ttxnp.gdrey Mflnmannn
fail; un employer that is pro riding workers'compensation insurance fur my eurpluyee.r. Below is the policy and job sits,
irrfunnudwn.
Ir.,uraucc Company Vnme: ""� /� }�--- (� -- - ---------
I'ulicv 4 or Sclr-ins. Lic. n: //,,`��j°� �J�/O . .. ___ Enpiration Date�',�/ I
JOU Situ -\ddress:� i0jk a"'"c ./ll�i`_. C'ny;swlc/Zlp: 2�
.\ltach is copy of lite workers' compensation policy declaration page(showing the policy number and expiration date).
I:adwe to secure cuccruge as required uudcr Sectiun 25A ul'NIGL c. 152 can lead to ilia imposition of criminal penalties of a
ting up to 51.500.00 ind,'or une-year imprisonment,is well ix civil(xnalllcs in the furan of a STOP WORK ORDER and a fine
,,f up u1 )250.00 a Jay.Igioml ilia violator. lie advised that a copy of thu stalancnt may be Iurwarded to the Office u!
IN%„u•siuum ul-div DIA :or in,io o'cc ancr.tge %s iliciUon.
I Jo hereby t crtify under ails un prroultievtifilerjury that the infunnurlon provided"buska .I true unr/!correct
( `.t_, _ _ DAIS_-__Y/ 1/G
%)/Juin/sae mdy. Da nor write ha Mix arc•u, to be rmupletrd by airy,or town a//it IwZ I
( itv or fawn: Per mit/Liccnie q
1„uing.\ulha it (circle nuc):
I. Ilr,.lyd ns,lle.dllt 2. Ituddin;; Departutcul 1. Cifa.'l tion Clerk J. Electrical iuspertor i, Plumbing In,pceior
6. other _
C.nuacl Terson: .. .. Phone If:
Information and Instructions
�ta�i.tdtu:etts Ccrleral Laws chapter 152 WgU1rCD all elllplo)Crs to provide workers' compensation (or their elllployees.
PkIrIU utl to ton %nit Ute, an empluree a defined as " ewcry pctson in the service of another under any contract of hire,
e kpreos or implied. oral or wvntten."
.\n .-mpjvy,-r is defined as 'an individual, partnership, ,lsbocianou, corporation or other IcgaI entity, or any two or more
..r the h,regomg engaged m a joint enterprise, and including the Icgal representatives of a deceased en)plo)cr,or the
receiver or 1rubtce ul Ar mclivldual,palrllers111p.AssoctatWn or Udder legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the
dwelling wuse of another who employs persons to do maintenance,construction or repair work on such dwelling house
or ot) the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
NIGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
rene)vut urs license ur penuit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of cumpUance with the insurance coverage required."
.kidiuonally, \,IGL chapter 152, §25C(7),rates"Neither the commonwealth nor any of its political subdivisions;hall
enter into any contract for the performance of puhlic wurk until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please rill out the workers' compensation affidavit completely,by checking die boxes that apply to your situation and, if
necessary, supply sub-contructor(s)name(s), address(es)and phone nu111ber(s) along with their certificale(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP) with no employees usher than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP docs have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
\ceidents for confirmation of insurance coverage. Also be sure to sign and dale the affidavit. The affidavit should
be resumed to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Of(Iclals
Plcasc he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Pl.ase be sure to fill in the pennitilicense number which will be used as a reference number. In addition,an applicant
drat must submit multiple pennitAiceuse applications in any given year,need only submit one affidavit indicating current
policy int'olmation(if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on rile for!future permits or licenses. A new affidavit must be filled out each
veer. Where a borne owner or citizen is obtaining a license or permit not related to any business or commercial venture
I i.e. a dug license or permit to but leaves etc.)said person is NOT required to complete this affidavit.
I I)c t)t Ince of 11lvesrhatlonl would ilhe to thank )'oU in advl111ce for your cooperation and should You have luny qucNt Wlls,
please du not hesitate to give us a call.
rhe Deparoncnt's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
OIR1ce of Investigations
600 Washington Street
Boston, MA 02111
Tel. # 617.7274900 ext 406 or 1-877-MASSAFE
Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
�,.. .� DEPAR"I'�tENT
')-8 '4; ♦ I \'-'i�$ 'J_')�h
Construction Debris Disposal Affidavit
(ICkltlll'Cd for all demolition and renovation work)
In accordance \tith the sixth edition of the State Building Code, 780 C NIR section 1 1 1.5
Debris, and the provisions of MGL c 40, S 54:
Building Permit N is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
(name of hauler)
I he debris will be disposed of in
f- Ufa+�Sl�Q CfK�>n�
(name of I'aeility)
ladilress of lacllilVl ..
.I�nalwc �tf pennrt .ytphcant
Mate