58 APPLETON ST - BUILDING JACKET f t + the Commonwealth of Massachusetts
yl i� hoard of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CNIR SALLM
ti•�•' Rrrisc•d 1hu•_'rl//
Building Permit Application 'ro Construct, Repair. Renovate Or Denny sh
One- or Tuv-Family Umdlliti
This Section For Official Use Onl It
Building Permit Number: Date Ap lied:
ao
Building Official(Print N,une) S ,talur I
ate
SECTION 1:SITE INFORMATION
,C 1.1 Property Address: 1.2 Assessors Niap& Parcel ers
(� I.)a Is this an accepted street?yes no Map Numher Parcel Number
U1.3 Zoning Information: 1.4 Property Dimensions:
np Zoning District Proposed Use Lot Area(sy It) Frontage(It)
1.5 Building Setbacks(R)
( dI Front Yard Side Yards Rear YarJ
Required Provided Required Provided Required Provided
J 1.6 Water Supply:(M.G.t.u.a0.§Sal 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposals)s ❑Check if es0 P P )stem
SECTION2: PROPERTY OWNERSHIP'
2.1 wnerl of Record:
Natne(Print) City.State.Z.IP
Nu. eet rele hone ��� "t` V�
P Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Gvi Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_L I Other ❑ Specify:
Brief Description of Proposed Work-: l�I--i - �4)mom . N Z.(•si k� Tt-4�-,J C✓, I�
� )'.S�
SECTION a: ESTIMATED CONSTRUCTION COSTS
Itcm Estimated Costs:
(Labor and .Materials) Official Use Only.
I. Building S Ci - (3 I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S S UO ❑Standard City/Town Application Fee
5
❑Total Project Cost'(hem 6)s multiplier — — ,¢
7. Plumbing g 2 —
UJ _. Other Fees: S
4. .\lod1anica1 illl':\CI S S UJO List:---- —
5. „\lechanica) Wire S .—_-- _-- -- _-- ---
Su rc,sion l Tond .\II Fees: S
Total Project Cush S ('heck No. ---('heck :\nwunh - --- Cash :\nnnu t: _
OUv ❑Paid in Full 11 Outstanding Bahmce Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 C'onstruction Super isor License(C'SLI
License Nwnber --- -__ P\pirutiou Date
N;uue of CSI. I)older
List CSL 1)PC Isec below)
Nu. .old Strat
--------- ----- ----- '1)PC Description(I I Inrcsvicted I IhtilJings Up to 35,0110 cu. It.l
R Itesvicted 1 r2 Famil Dwellin
Cit)i I oen,Statc.LIP — ----- NI Nlaioo
RC Roolin Coverin
WS Window and Siding
SF Solid Fucl Burning Appliances
1 Insulation
fcic hone Email address D Demolition 1
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registr t on Number lispiraliun Oulu
I IIC C'ompan) Name or I IIC Itegistrunl Name
No.and Svact Email address
City/Town. State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all oft information
/ontained in this application is true and ac rate to the best of my knowledge and understand' g. l
1'r of Owner's or AwhorizcJ Agent's Nun C(h.lcclromc.'ignaturu) Date
NU
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 Hume Improvement Contractor(HIC) Program),will no have access to the arbitration
program or guaranty fund under I.G.L.c. 1 42A.Other important information on the HIC Program can be found at
www ni.n. 1;0% 'C.l Information on the Construction Supervisor License can be found at �oN dp,.
2 When substantial work is planned,provide the information below;
Total fluor area(sq. ft.) _ ___--_1 including garage, finished bascnlentmtics,decks or porch)
Gross living area(sq. 11.1 Habi(able room count
-------- - -
\untberof fireplaces, _-. _ _ ..._ Number of bedrooms
Number otbathrooms \umber of hall'b;uhs -
I)peolhcatings)stcm - Number ol'decks, porches _
1)1'cofcoolingsystem - Fliclosed _ - - --Open _
}, "folal I'n,jcct Syu:ve PoolagC"m;q I,e substivacd 1Lr"Folal Project Cost'
CITY OF SM.EI I
PUBLIC PROPERTY
DEPARTOMENT
u.o.au+r ewsmu
w1OG 1]o wAwmc70N 2MsW•&*As^waAoa asrn 019V
T1L f'L7117SN•1t.4A 9'5.746764
HOMEOWNER LICLNS6 EXEMPTION
pbw hint
Date t sS t
Job location 2 1
m Hos owner Addy ress L I M h
Home Owner Telephone ::J-Y k
Present Mailing Address �—A C9z. -A-iev :V-V 7 �.�9
The current exemption of"Homeowners"was extended to include ownsr-0ccupied
dweitings of two Units or fees and to allow such homeowners to engage in individual for
hire who.does not possess a licenser provided that the owner acts as supervises
DEFINMON OF HOMEOWNER
Persons)who owns a parcel of land on which hWA@ resides or intends to reside, on
which them is, or is intended to ber a one or two family dweilieg, attached or detached.
structures accessory to such use and/or (arm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
-homeowner"shag 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 undersigned "homeowne''assu me@ responsibility for compliance with the State
Building Code and other applicable by4sws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that hNshe
.vill comply with said procedures and requirements.
HOMEOWNERS SIGNATURE
APPROVAL OF BUILDING NSPECT R
Sce other side for state code
CITY OF S.1LE%f, Akss:tcjjE:SETI"S
9LMDLNG DEP.1RT IUNT
120 WASHNGTON STREgT, J'O FLOOR
11+L (978) 745-9595
KINtHERLBY DUXOLL FLX(978) 740-994
.MAYOR TkO.�w ST.PtP.Rtts
DIRECTOR Of PLBUC PR0PERTY/9LaM YG CoNaltsstONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with Debris, and the provisio the sixth edition of the State Building Code, 780 CMR section l l 1.5
ns of MGL c 40, S 34;
Building Permit p 1 is issued with the condition that the debris resulting from
1 11, S ISOA.work shall be disposed of in a properly licemed waste disposal racility as defined by MGL c
I
The debris will be transported by:
CC
(name of hauler)
The debris will be disposed of in :
3v ti(,{Z CunTr;,v�
'y (name o-
APOLC
(Jddrar or r3cillly)
I'd .hurt orpermlt hunt
1 � .Fv 0
The Commonwealth of Massachusetts INSPECTIONAL S RVICES
Board of Buildins Revtdations and Standards CITY OF
Massachusetts State Buildin Code, 780 CNI farLM
` � SUIS DEC I0 xlr ,llnr?orl
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling VtxCf17M- P , 61 e-t13
This Section For Official Use Only-TS? 2^ A
00 Building Permit Number: Date A ted:
Building Official(Print[Name) Signature Dale
SECTION 1: SITE INFORMATION
1./1 Prro(o�pe�yr�ty Addres : L2 Assessors Map& Parcel Numbers
rl
Lia Is this an accepted street?yes no_ iklap Number Parcel Number
(�
1.3 Zoning Information: lA Property Dimensions:
Tonin.,District Proposed Use Lot Area(sq Et) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
L6 Water Supply: (NLG.L c.40, §54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes[] ib(unicipal C3On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.��w erlof Record:
I to 74': Y'i S+e_r_ 6l�oc d12 t�'0 l�f 70
Name(Print) City,State.ZIP
r6 g (e-fon � tfl3 r7S-tF9b'lo
No. and Stre t Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Descc iption of Proposed Work': ys S 'F-a� I -)-z,U-e vvAWL Gio') Err O-Ykal +
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Ntaterials)
L Building $ j L Building Permit Fee: $ Indicate how fee is determined:
1. Electrical $ ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. Nlechanical (HVAC) $ List:
5. Nlechanical (Fire $
Suppression) Total All Fees: $
q Check No. Check Amount: Cash Amount:_
6. Total Project Cast: $ f I lg,�) ❑ paid in Full ❑ Outstanding
Balance Due:
L=-
c��"
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License (CSL)
r.G�ri S z2✓2�l License Number Expiration Date
Name of CSL Holder '
s IVO 51 List CSL Type(see below) U
No. and Street Type Description
_ M O e(—76 U Unrestricted(Buildings u to 35,000 cu. ft.)
City/Town,n, Sta et , ZIP R Restricted 1&2 Family Dwelling
M Masonry
RC RoofmR Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
A,} �t �i �S /nG - LDI X00 q
HIC Company Name or FITC Registrant Name HIC Registration Number Expiratwn Da[c
/L5 IV o ✓t[ L Sir
No. nd Street
Ll
LL W� O (qrJ U Email address
Ci /Town, State,ZIPS l 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 .......... 2/ 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 C I1 L r , —Z0,--2-,t
to act on my behalf, in all matters relative to work authorized by this building pe it application.
(o ,,`-}yazA- DEC 0 9 2015
Print Owner's Name(Electronic Signature) Uate
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
Bye ring my name below, I hereby attest under the pains and penalties of perjury that all of the information
cont ' d this arITT\
lication is true and accurate to the best of my knowledge and understanding.
DEC 0 9 2015
Print Owner's or Authorized gent'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.00v/oca Information on the Construction Supervisor License can be found at www.mass�ov/dpss/des
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"
1-7 sl
The Commonwealth of Massachusetts
Board of Building Regulations and Standards REC IVE S
Massachusetts State Building Code, 780 CMR INSPECTION L S
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Dej *%IJ? a _A
One-or Two-Family Dwelling 1��144 �J[[�r
This Section For Official Use Only
Building Permit Number: Date App 'e'dd: n
7 ///
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Proper.",Agdress: S 1.2 Assessors Map&Parcel Numbers
1.1a 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❑ Private❑ Zone: _ Outside Flood Zone?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSIIIP'
2.1 Ownelr'of Re ordZ( yf /�j� 11
HeICA i lM;„MS SC1,[Qvt� ,ub� V L-! L V
Name(Print) City,State,ZIP
No.and Str�r - Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ J Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Specify: jn60ofiof
Bri=BriefDescription o ,posed Vor
r_ J op
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials Official Use Only
1. Building $ (� 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑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. Total Project Cost: $ y ❑Paid in Full ❑Outstanding Balance Due:
Nor-Ih 'Sf Sc ip
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) mda )v�J [/)
�"itl jm s - License Number Expiration Date
Name of CSL Holder p^ - Type
(see
I � W(�1,(OZ7 IYJ List CSL T a seebelow)
No.and Street /� Type Description
� Y tAA'_1�'1 µ la I J U Unrestricted(Buildings u to 35,000 cu.ft.
R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and SidingSF I
G 17-3 3; -a7o6 W DTJp10M FD R it Solid Fuel Burning Appliances
G I'OU{�� .,, G 9�4 I Insulation
Telephone Email address D Demolition
5.2 Registered ImQprQo(vement Contractor(HIC) / I g'7 D a 3 ��
`�f�)) go+ ,/ HIC RPegistration Number Exptranon Date
HIC Compa ytame or HIC Re trant Name s
LCO
No.and Stree roar address
Veuy �,A 61a15 �e1 33) 4 706
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 .......... 13 No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,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:OWNEW 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:
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 can be found at
wD".mass. ov/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:
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"