BAKERS ISLAND - BUILDING INSPECTION (43) The Commonwealth of Massachusetts
W
Department of Public Safety
klassachuseitsStaw Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling '
(This Section For Official Use Only)
Budding Permit Number. Date Applied: Building Official:
SECTION 1:LOCATION(Please indicate Block 0 and Lot A for locations for which a sheet address is not available)
&Lkers 1-3Lcx ,s- , s,-te — C>k120 8o-kef3 LcaE1.tIn«.s�
No.and Street City/Town Zip Code Name of Budding(if applicable)
SECTION 2:PROPOSED WORK_
Edition of MA StatetCode used 4— If New Construction cheek here❑or check all that apply in the Iwo rows below
Existing Building 11Y I Repair fd I Alteration ❑ 1 Addition Denmlition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ 1 Change of Occupancy ❑A . t I Other ❑. Specify: r
Are building plans and/or construction documents being supplied as part of Ibis permit application? Yes ❑ No
Is an IndependentStructural Engineering Peer Review required? Yes ❑ No B'
Brief Desuipt``ion of Proposed Work: aL e.o
YG p0.ein'1'srsm tankmer+ Inou / • (GGt 2 e• yi.. po -+� ��.ss�kr�0/e_0 14
� s
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADL&TIONAR '
CHANCE IN USE OR OCCUPANCY c-)
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): - Proposed Use Group(s)- �1 :2,
SECTION 4:BUILDING HEIGHT AND AREA
Existing Pr sed coo
No.of Floors/Stories(include basement levels)&Area Per Floor.(.sq. ft.) <_
Total Area(sq.ft.)and Total Height(ft.) ,I 5O'�, 5Q r.)..) m
SECTION 5:USE GROUP(Check as a Iicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B. Business ❑ E: Educational ❑
F. Facto F-1❑ F2❑ H: High Hazard H-1❑. H-2❑ H-3 ❑ H4 0 H-5❑
I: Institutional I-1 ❑. 1-2❑ 1-3❑ 14❑ M: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R-0❑
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and lease describe below:
S ecial Use: ,{.y. _. oe.c$t
SECTION 6:CONSTRUCTION TYPE(Check as applicable)IA ❑ Ill ❑ IIr\ ❑ If6 ❑ IIIA ❑ IIIB ❑ IV Cl VA ❑ VB ❑
SECTION 7.SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supply: Flood Zone Informationci Sewage Disposal: Trench Permit: Debris Removal:
Public❑ Check if outside Flood ZmW Indicate municipal,_3 A trench ill not be Licensed Disposal Site❑
Private or indentify Zone: or on site system'ss requiredfl[]or trench or specify:
permit is enclosed❑ n ! F
Railroad rightof-w,{y: - Hazards to Air Navigation: �tm I Iktorir I ,n....
Not Applicable Is Structure within airport a oach area? Is their mvi w completed?.. ;
or Consent io Build enclosed❑ ❑Yes or No Yes No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY W A.
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Dnes the building contain an Sprinkler System?: Special Stipulations:
c%f?,L-L.alp (4 p v �V�S
3 � 7? C� )
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property�Orwneer : 2y1 Essgc Sl- 3uike et I „
Essex K ri ,clt-,q5wt1 t: 10 Safe.*. m.A %-1) 0
Name(Print) No.and Street City/Town Zip
Property Owner Contact Information:
Anna t44rees , Cr.,0 978 _7Yo_ oLf L(K 617 680 323o ann,Y (,tatSYrAC ,erAcle a
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 owners behalf, in all matters relative to work authorized by this building permit appIication.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less thin 35,000 cu.ft.of enclosed space and or not under Construction Control then cheek here I and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control
Name Reg tmnt) Tee hone No. c maj addre s istration Numbe
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor - -
Company Name
YYle "n-n 1�ell�
Name of Person Responsible fur Construction License No. and Type if Applicable
12 Cn� L-C!d4A "V-,. (!7. �,�.SM-✓ I�4 a t9 30
Street Address City/Town - State Zip
G17. 8z3 1 T6v gSrr c Yhat..a(ly mlfeo . c.ov—
Tele hone No. business Telephone No. cell e-mail address
SECTION 11:VVORKI-MY COMIPENSAI"ION INSURANCT AFFIUAVri' M.G.L.c.252§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of Industrial Accidents must be completed and
submitted with thisapplication. 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 O No 0
SECTION 12:CONSTRUCTION COSTS AND PERMIT FEE'
Estimated Costs:(Labor
Item and Materials) Total Construction Cost(from Item 6)=$ 22., SaJ
I. Budding re m,6 5 1, 2 Soo Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
4. Mlechanical (HVAC) $ Note:Mininnm fee=$ (contact municipality)
5. Mechanical Other $ Enclose check a able to
PY
6.Total Cost 5 22, �'� (contact munici ality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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.
1u t+r-19
Artyve_ k4 .,ryes C E:-10 97$_7Y° oYKY tot)
Please print and sign name Title Telephone No. Date
22l V-sscp Sl- _ 30(4. PMA O 1-7 7 6
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval•
Name Date
The Commonwealth of Massachusetts
Department oflndustrialAccidents
I Congress Street, Suite 100
Boston,MA 02114-2017
www.massgov/dia
FV rkers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE PH.ED WITH THE PERMITTING AUTHORITY.
Applicant Information - Please Print Leeibly
Name(Business/Organization/Individual): 33e,)C Ndvh-mn a.�
Ct-.rrtr,a-: 22t -saarr SH, Scs.,'tt.Ail Sa.lt,rrrr r'rtA ol9'7a
Address: tap et= fir*is t 1 , acs t S : t cs FeaEe rn t 3trte4, See:4e tZ 3a ie., vrao, o tq 7 p
City/State/Zip: Se(e. , e""A ot9')o Phone `rt75- 740 • at{c-(c(
Are you an employer?Check the appropriate box: FILD
oject(required):
LE]turn a employer with employees(fiill and/orpart-time).'
consWction
2.❑I am a.sole proprietor or partnership and have no employees working for me in '
my capacity.[No workers'comp.insurance requited.] odeling
3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.]t olition
ding addition
4.❑I am a homeowner and will be hiring contractors m conduct all work on my property. I will
ensure that all contractors either have workers'compensation insurance or are sole trical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑I am a general contraRor and I have hired the sub-contractors listed on the attached sheet.
These sub-contractors have employees and have workers'comp.iasmance.t 13.❑Roof repairs
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.[✓�Otber rp 4U r3
152,§I(4),and we have no employees.f No workers'comp.insurance required.]
*Any applicant that checks box o]must also fill out the section below showing their workers'compensation policy mtormuim.
f Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Connacmrs that check this box most attached an additional sheet showing the name of the subcontractors and state whether m not those entities have
employees. If the subcontractors have employees,they must provide their workers'.comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees.-Below is the policy and job-site
information. I -
InsuranceCompanyName:
Policy#or Self-ins.Lic.#: Expiration Date: 5116, ap l 6
Job Site Address: Bko-� . 4 5za City/State/Zip: 019')'0
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby c/ertuynde^��the pains and penalties ofpepury that the information provided above is true and correct:
Signature: 1� +--�� Date: 0a,
Phone 7-{O - c:)44 L'
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual;partnership,association or other 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 house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to he an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152,§25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),addresses)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners;are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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 Officials
Please be 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.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pennit/license applications in any given year,need only submit one affidavit indicating current
policy information(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 file for future permits or licenses. A new affidavit must be filled out each
year.Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dQg license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston,MA 02114-2017
Tel. #617-7274900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
CITY OF SALEA MASSACHUSE M
BUIIDING DEPARTb1ENT
120 WAsiwGTON STREET,3'D FLOOR
TEL(978)745-9595
RIlv18ERLEYDRISQ7LL FAX(978)740-9846
MAYOR 7 iO STYIERRE
DIRECTOR OF PUBLiCPROPERTY/BMD]NG ODNAgSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and 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, S 54; Building Permit is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
'F5se.?'- 6aA-C'-+ I
.
(name of hauler)
The debris will be disposed of in:
(name of facility)
2
(address of facility)
Signature of applicant
Date
R
of `
The Commonwealth of Massachusetts
Department of Industrial Accidents
Wykers'
1 Congress Street, Suite 100
Boston, MA 02114-2017
wwwmass.gov/dia
Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Leeibly
Name (Business/Orgaaization/Individual):
Address:
City/State/Zip: Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).- 7. ❑New construction
2.❑1 am a sole proprietor or partnership and have no employees working forme in 8. ❑ Remodeling
any capacity.[No workers'comp.insurance required.]
t 9. El Demolition
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]
10 ❑ Building addition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. twill
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
5.❑1 am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insurance.[
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c. 14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also rill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
[Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152, §25A is a criminal violation punishable by 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$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Sionature� - Date'
Phone#:
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r
Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership, association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other 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 house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152, §25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers' compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
_ insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned 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 Officials
Please be 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.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple pemut/license applications in any given year,need only submit one affidavit indicating current
policy information(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 file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e. a dog license or permit to bum leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02 1 14-20 1 7
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax#617-727-7749
Revised 02-23-15 www.mass.gov/dia
n
s
The Commonwealth of Massachusetts
Department of Public Safety
JIB Massachusetts State Building Code(780 CMR)
Building Permit Application for any Building other than a One-or Two-Family Dwelling
(rhis Section For Official Use Only)
Building Permit Number. Date Applied: - I Building Official:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
No.and Street City/Town Zip Code Name of Building(if applicable)—
SECTION 2.PROPOSED WORK
Edition of NW State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ 1 Alteration ❑ 1 Addition❑ 1 Demolition ❑ (Please fill out and submit Appendix I)
Change of Use ❑ 1 Change of Occupancy ❑ 1 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 Ilan Existing Building Investigation and Evaluation is enclosed(See 780 CMR 34) ❑
Existing Use Group(s): I Proposal Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
No.of Floors/Stories(include basement levels)&Area Per Fluor(sq.ft.)
Total Area(sq.ft.)and Total Height(ft.)
SECTION 5:USE GROUP(Check as applicable)
A: Assembly A-1❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A-5❑ B: Business ❑ E: Educational ❑
F. Facto F-t❑ F2❑ H: Hi h Hazard H-1❑. H-2❑ H-3 ❑ H-4❑ H-S❑
I: Institutional W ❑ 1-2❑ 1-3❑ 14❑ 1 Nf: Mercantile❑ R: Residential R-10 R-2❑ R-3❑ R 4❑
S: Storage S-1❑ - S-2❑ U: Utility❑ Special Use❑and Please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable) -
IA ❑ IB ❑ ILA ❑ IIB ❑ IIIA ❑ IIIB ❑ IV 1 VA ❑ VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Trench Permit., Debris Removal:
Water Supply: Flood Zone Information: Sewage Disposal: Licensed Disposal d Site❑
Public❑ Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be P s
required❑or trench or specify:
Private❑ or indentity Zone: or on site system❑ permit is enclosed❑
Railroad right-of-way: hazards to Air Navigation: MA I listorir C.nnmisiym IL_gica�,1'nvg.5:
Not Applicable❑ Is Structure within airport approach area? _— Is their review completed?
or Consent to Budd enclosed❑ 1 Yes❑ or No❑ 1 Yes❑ No ❑
SECTION 8:CONTENT OF CERTIFICATE OF OCCUPANCY
Edition of Code: Use Group(s): Type of Construction: Occupant Load per Floor:
Does the building contain an Sprinkler System?: Special Stipulations: --
SECTION9: PROPERTY OWNER AUTHORIZATION
Name and Address 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 application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If budding is less than 35,000 cu.ft.of enclosed space and or not tinder Construction Control thencheck here 0 andskip Section 10.1
10.1 Registered Professional Responsible for Construction Control.
Nance(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 Telephone No. cell e-mail address
SECTION 11:WORM-XS'COMPFNSA'I'(ON INSURA.NCP.AFFIDAVIT 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 0 No 0
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE'
Item Estimated Costs:(Labor
and Materials) Total Construction Cost(from Item 6)_$
1. Budding $ Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3.Plumbing $
d. Mechanical (HVAC) $ Note:Minimum fee=$ (contact municipality)
5.Mechanical Other - $ Enclose check payable to
6.Total Cost $ (contact mum i ality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
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.
Please print and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approval•
Name Date
-fa QTY OF SALEM, MASSACHUSE M
G� rj BUILDING DEPARTMENT
120 WASFBNGTONSTREET,3' R.00R
nL.(978)745-9595
FAX(978)740-9846
KINIBERLEYDRISOOLL
MAYOR 'I} omm STIP ERRS
DIRECTOR OF PUBLIC PROPERTY/B=jNG COIvMSSIOMR
Construction Debris Disposal Affidavit
(required for all demolition and 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, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
(address of facility)
Signature of applicant
Date
Unofficial Property Record Card Page 1 of 1
Unofficial Property Record Card - Salem, MA
General Property Data
Parcel ID 46-0124-0 Account Number
Prior ParcellD --
Property Owner BAKERS ISLAND LIGHT STATION Property Location BAKERS ISLAND
Property Use U.S.Govt.
Mailing Address 221 ESSEX STREET STE 41 Most Recent Sale Date 7/16/2014
Legal Reference 33410-213
City Salem Grantor UNITED STATES GOVERNMENT,
Mailing State MA Zip 01970 Sale Price 0
ParcelZoning RC Land Area 8.800 acres
Current Property Assessment
Card 1 Value Buildin9128,200 Xtra Features 4,400 Land Value 348,500 Total Value 481,100
ValueValue
Total Parcel Building 389 200 Xtra Features
Value Value Value 4,400 Land Value 348,500 Total Value 742,100
Building Description
Building Style Govt.Bldg. Foundation Type Brick/Stone Flooring Type Hardwood
#of Living Units 1 Frame Type Wood Basement Floor Earth
Year Built 1867 Roof Structure Gable Heating Type None
Building Grade Average(+) Roof Cover Asphalt Shgl Heating Fuel None
Building Condition Average Siding Clapboard Air Conditioning 0%
Finished Area(SF)1613.5 Interior Walls Drywall #of Bsmt Garages 0
Number Rooms 5 #of Bedrooms 2 #of Full Baths 2
#of3/4 Baths 0 #of Baths 0 #of Other Fixtures 0
Legal Description
Narrative Description of Property
This property contains 8.800 acres of land mainly classified as U.S.Govt.with a(n)Govt.Bldg.style building,built about 1867,having
Clapboard exterior and Asphalt Shgl roof cover,with 1 unit(s),5 room(s),2 bedroom(s),2 bath(s),0 half bath(s).
Property Images
IP
Disclaimer:This information is believed to be correct but is subject to change and is not warranteed.
http://salem.patriotproperties.com/RecordCard.asp 6/25/2015