3 BECKFORD ST - BPA-12-502 RESIDING t 1
Sa I'Ite Commonwealth of Massachusetts
t, Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 Chi SALEM
'L•'•• Building Permit Application To Construct, Repair. Renov lte Or D niolish a Rdri.red Ilur•_'11l!
One-or rtvo-Frmih Dwelthiip
This Section For Micial Use Onl
Building Permit Number. aatte/e Ap�p'lilee'd:
Bwlding 011icial(Print Mune) Signatur I Date
SECTION SECTION I: SITE INFORMATION
L I Property Address: 1.2 Assessors Map& Parcel Numbers
3 ��c/rfd,(rp S'T
I.is Is this an accepted slre . yes no Ffap Numher Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Gering District Irroposcd Uc Lol Area(sq Il) Frontage(Il)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7 Flood Zone Information: La Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check fifes❑ Municipal❑ On site disposal system ❑
SECTION1: PROPERTYOWNERSHIPt
2.1 Ownert of cord:
ZY°Print �3ALPR E r r :Mt4o InA 0 I c/ 2a
N;une(Pool)) C u).Slate,LIP
No.and Street 3 eef sf 9'79 7*/
Telephone F.maiI Address
SECTION J: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) IY Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Spccil'y:
Brief Description of Proposed Works: /� [J •LC'
5 J N T WEsr S/]
SECTION a: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs:
I Labor and \laterials) Official Use Only
I. Building S I. Building Permit Fee:S Indicate how fee is deteril ed:
2. Electrical g ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier
1. 11umbing S —
'_. Other Fees: S
J. Mcchanical III\':\CI S Lisl:
;. .Mechanical (Fire _ ------__.-_--_.--- --
SuppressioM S fowl All Fees: S --- ---- -- _-
o. Total Project Cost: S "= Check No. __('heck Aniounl: - _----- Cash Amount: _ -
o ❑Paid in Full 0 Outstanding Balance Doc:
{ s
SECTION 5: C'ONS'fRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
' cs_q/ 6e3-
/Ofl7iP/!X-- License Nwnbcr Pcpiralion Date
Name of C'.SI. I lolder
M�1 Lisl('St. Pe(see below) f�L�Q.CS�(YP/,
�fJ_QDX _1-1LLr_ �c9�---'_.4t!— 'I'lpe Description
No. and street
/y� i 1 hnrestrieted Iliuildin-s li to 35,000 cu. It.)
��AA&4r ;R� — _—_... . R Restricted 1@2 Tamil Dlwllin
l'itci loan.state.LIP M Mason
RC Rlwlin Coverin
.. WS Window and Sidin
SF Solid Fuel Ilurning Appliances
fIY"D /�nn7 OSGOOOS28^� fP/��' I Insulation
'I'ele hone Ifntail address D Demolition
5.2 Registered Home Improvement Contractor(HIC) B,l a a-D
es6x ) —R, /8z' A6 S' f 0e;e�'< IIIC It-gistratiun Numtwr licpirutiun Dutc
I IIC'Con un N;unc or 111C'Registrant Nwnc tD�r
.mt CJ-16W 11A JV1)g0 r DO') Email address
City/Town.State.ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.it. 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 . ..... ❑ No........... O
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 P4 f—,Yl6" &5Gl90A
to act on my behalf,in all matters relative to)vork authorized hy this building permit application.
Print Owner's Name(Electronic Signature) ate
SECTION 7b:OWNE n 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 ap ication is true and accurate to the best of my knowledge and understanding.
OSGnO,9
Printllwemrs or Aulhorircd Agent's Nwnc(Electr is..SignaluruI Date
NOTES:
I. An Owner whu 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 M.G.L. c. la?A.Other important information on the HIC Program can be frond at
WM n1.i1.. �n "I I Information on the Construction Supervisor License can be found at
2. W'hen substantial work is planned,prov ide the information below:
Tidal fluor area(sq. ft.) 1 including garage, finished basentellL'attics,decks or porch)
Gross living area l sq. 11.1 _ _--____- - _ Habitable room count
,timber of freplaces.--___ _ _.-- _.-- _ --- Number of bedrooms _....-
\uniherolbathruoms -- \'umbcruflydfhatiu -- - -
I)pe of herring SlStenl Number of decks, Porches
1'\Pe0f0o0lm6i}S1e11 . .. ._ . -- P.nclosed , - _-. --.Open _ - -
1. '?oral Project Square Footage'mat be Substituted for"loml Project Cost"
1
r PA CITY OF SALEM
,
PUBLIC PROPRERTY
'`' DEPARTMENT
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l
Workers' Cumpensmdon Inurunc0 %lilduYit: (IuilderyContracturyElc triclanyPfumbers
� 1 Illcan In nrmudo
1 In a 'hi
\kill){:Illu.uKalif)ramlrrni�+rvinJrr,11ua11: �}Lwr�/
City,Stare.Zip-
I hone// 9g 7�o 1D-�
.{rrv,1 ua all I .nydoyerh Cheek the:glproprltele boy:I LJ I:una.mpluyurrith 0. I')Mll(prlyeet(rvyulred);
etllplU)'a'eN(IUR Jlld/Y/pJr4Ullle). O huva hind the:nh•cr mrrclunt
h• ❑Now cunxlruciiun
�•❑ 1 din a sole prnpriwor or partner. Iisled on the anachcd shoot. I >• ❑Remodeling
ship and have no vinpluyvas These sub•contracton have
Lurking rite Ina in any capacfly, workers'cmnp, insurance. a ❑Demolition
IN"workers'sump. insurance S. ❑ We at*v colpention and its q' ❑oudding JJditiun
nquirctl.) .1rcen have vitemivil their 10.❑Electricd repairs or additions
).❑ 1 ant a hulfteuwn.r cluing all cork right of v.tcmpfion par hIQL IL[]Plumbing repairs of Jddiliafy
Inywlr,(Na Lnrkers'comp, C. 152.¢1(4).aml wt hnve no
inrurancu required.)t employe.*, (No Ives itts' 12'[3 RRoul'npuin
M1111% insunncw rcyuind,J 13.u7 u,her/IES/L7i✓
•1'q.,ppLcu/Ill,,CEeeY1 YVY el 'UM '1W lilt wa,
r I I1nry.rrrrlN•+Ae tuurflil mill r111rhvll indlurin r M w,J i Later dwrrne lNS him
Ali is ow„rrly(.,te policy nrtur,nwiy,A
e M► .4 dtv" Ill wrtA he an A p Ywtide cuternllep nwl.utvnk a hr Jllldsvil indiaaeina v,k
r,nlffwOMa IAY,M'ee IAI tKN 11111Nt Jna.Afe nx adJ,NtrW.Mel.Auriue IM noxK erlti lu►.Nnlr uuaa arse thfe%A Avp'Cony,1011Ky,ntbm,aA w
/I/I/dfn YeIrIYIl1 un em//Lploy,,that It prvvldkif 1varArn'r10101prufnt/on brsurnnrrJAW fray ffnpluprre Bdotr is in0pu114),end job sits
Inlurancu C'untpany.Name, /� L_L�/��
Policy is of SulGins. Lic.M WC�O 3a.Q�� — • _
tt!! Expiraffors Date: q g !�'-
1vb situ Addevsx: Y/�C7.�FnQA c
\ttaaA is coo
py or the lvorken' vumpunianoe pull.) jv%:Ij p.jjil n I)age(show)NI thetpollcy n�car d of a dula).
p'—
PJllun to accure cweruye as required under.Svctiun IS, al' 172 eau lead to ate im
titre lyt r,t it 00 a d J dlur Ipiluue•year nnprislnununt, ax Loll ax civil pcnahlu in this turm era STOP 1VORK ORDER snd a fine
position ot'criminJl penalties of a
ni up ra i'j0 )0 a Jay ryuinst the N"'"'If lie adviscu thul i ropy urlhi.% ,Ijlemvltl nay 6o IurwarJuJ a the 011ie.ul'
Ia1,nu�Jn'nu vl ,llv 11L1 ;or rnmr.a'ce oA%;rayv A alli.JlllIn.
/,/u/r.•rrAy I.rfi/�nnJ.v rhr plrinr,fnJlfarnl//ef u/prr//try litter//lr in urrnutlae
prvvided above is I've Yrfd rorru[t
rr„ . , pale
u
t1//Iris/I11I aq/y, l)J.rnl writ,in fhJl Jrru, /u Ae rump/t•led b ril
y y of/arvte a//Iriu1
( ifY or 1'nrvT. ,
ILuiny .\ulhnril --- PrnnioLleenlee
y (cirAa�nla;
I 1 r(Ih•.Jh
U1h1fivir 1 !. Ilinhhn� Ila p.lrtn,cnl 1, I.il).'f�tL ll C'Ivfk t. LIcrtric•d In%pe,fur i. Plontbina Inlpecler
b. rr
I1' n11 ,el I't rwn:
l
information
and Instructions
eve on in he service of another un,ler.ory cuntrnct Of hire.
�Lui.Ichu.ctts ticneral LJWf chapter I i2 acy i wres all euytloyen to provide wurken' wmpen.+atwn tar heir emp vyces.
I•unuaoI to III*.Ialuia, in neplura+Ii JetneJ ad" cry et+
P• .
+prey or InfI oral or wnudn." ore on ut other legal entity,or any two or more
urtnanhip..Issueutuoo,Cory lu er or the
\n crnpluydr i+defined L"an individual. p em lu In jm Ioyeee. HOwcvcr the
r the taroqu 't engaged n a Imnt cmd 1. pji and uwluJing the legal represautatives of a deceased entp Y
ecery t, or trustee vl.ut indivtJual,paamenhap,assueaaueo or other legal cnetY, D Y If ' D
to c eons to do maiotan of loch employment be deemed tucbdJ o employer
owner r s truste no hatter having not snore than three apartrmenu and who resides therms or the occupant of that
n huuid of another who emp Y potions I not because
.Iwv II g thereto sArl
.-rounds ur building appurtsn ant th
or on aha
v also states that"sudry Slate or 1alai"closing;lIn s is the oy shad immeawttultk for ally r
\IGL chapter 132, tj_3C(6) aired."
table tvldeace of curnpusece Wilk the insurance its gsubdivisions.+hall
rendtvdI of a Ilona ur permit to Operate a busied"or is eautrutt ° of nc political
;tpplleome who has not produ1 4 ace+p
\dditionally, �IGl- chupt+r 13-, �27C1�1.rated"Neither the cammentable a not my
enter into any contract tau the pertamwnwentedbo tAe contract o atil uth rityY.dance utcumpliwto w ith the insurance
rcquirdmcnls of his chuptdt have been p'
Applitann to our situation and,if
altsatian altldavit catnplataly,by eheckinj fife boxes that apply Y
s udtkess(e4 and phond numbeda)dlonll with heir cartincate(sl of
PtO:Ixr rill Out the workers' comp
necessary,supply sutrcontroctor(s)mama(. ), LLP with no employs have
than the
ndustrial
nsw tea. Limited Liability Companies(LLCworkdry'janiteompdnsdtioed Liability a imumnee.(If ao LLC ar LLP floes
members or partners,are not required to carry
employee°,a policy is required. Ill advised that thlsAlse belsor•to Igte deed daft Ae ul'llde id to the vlbtttlluOf ta111davu should
ucidents for cantlrtnatiun of inswwcc coveroge it nnit at IWill' a is being requested,not the p,partment of
ha rcaa nod to Ilv city or town that he applicationat IIIregarding the law or if you are required to obtain a workers'
Industriul Accidents. Should you have any questions
cotnpansdtiun pulley,pleose call the Oaptsnmdnt at the number listed below. S+If•insurcd eompaoiet should enter the
urinal license number on the a ro riuta line.
('Ity of-'rown officials
ic um the a Itcant
rI iha affidavit fury u to I'll affidavit
Over" the Oltlr.mplete and printed loi investigation has to cohe Department ntact you regardin provided u g t tSpp ttom
I'I:asO be surd to till in ilia pOrtniulicanst nwnbOf which will be usdd:Ix a reference number. In addition,an upplicam
ticu,ntat submit multipld Pon'ry)and ttader"Job ilia Address"ho applied of houlJ Wr only iteit unll ons in any given Yom, Iwv�ut Providcd to ths in e
or
ion if necessary)' asked b did city or town in
ay but p
policy iu\Co at 1 nt
wwnl.",\ copy of the urllJuvit that has been officially sumpuJ ur Y
ch
of ht a valid affidavit is on file far tutum polmitx or not related to any businesslOr corn"'d oA I vdnour awo
applicant r pre obtainin a lictrt"or Win" affidavit.
Y
�e. . \juj li a hoes owner or citizen is �id er+mt is VOt requited to complete this
t i O. a ,lul{licmtul or permit to burn leaves Ora D udsuons,
a)uicc ul
I he Inve.Iiyatiuns would last w thank you in advancO for your :oupdralian an you should haw,ury y
I+lea.d Jv out heitnrd to gtvc us a call.
fhc Ucp.uuncnt'i aJJra+.t, telephone aTh Cartirponwealth Of MUMchla""3
Deportment of Industrial Accidents
0fflta of IsvesdQadons
600 WISMnaton Street
803ton, MA 02111
ft:l. p 617-727.4900 ext 406 at I.&71•MASSAFE
Fax M 60-727.7749
i .iiS www.mass.�ov/did
Jpft
CITY OF SALEV, AUSACHUSETTS
BL'tLDLVG ❑EPART1tENT
120 WASHNGTON STMAT, }iO FLOOR
n L (978) 745.9595
KI.NMERLEY DUXOLL FVt(978) 740.9au
MAYOR THO.�W ST.FtPRRs
DIREGTot oP PC9UC PROPERTY/8LILDLYG Co-%01ISStoN ER
Construction Debris Disposal Atttdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section I I I.5
Debris, and the provisions of MCL c 40, S 54;
Building permit q is issued with the condition that the debris resulting from
111 work shall be disposed of in a properly licensed waste disposal racility as defined by NIGL c
I 1 I, S ISOA.
The debris will be transported by::
(n u to of hauler)
The debris will be disposed of in
_ . (name o-t.)
f'
(iddre„ or•rjcdity) 1
wL
+1dn+mre orp"mrt ippli ne �7 C