18 BELLEVIEW AVE - BUILDING INSPECTION )� 0 ,0 �
iy
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
j Massachusetts State Building Code,780 CMR SALEM
- Revised Mar 201/
Building Permit Application To Construct,Repair,Reno v e Or Demolish a
One-or Two-Family Dwellin
This Section For Official se Only
Building Permit Number: k6atc ApWfieqi
Building Official(Print Name) Signa Date
SECTION 1:SITE INFOIWATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 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 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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
t
2. ne of ord:
Name(P ' t) ���- City,Sta ZI Opt;
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s)A!I�I Addition ❑
Demolition V!� Accessory Bldg.❑ Number of Units Othe ❑ S cify:
BriefDescriptiQQnof Proposed
�W+ork': C E' G X/
w/I�17dll) APFW r Jm 'Alm sil j.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ 2 66a 64i 1. Building Permit Fee: $ Indicate how fee is determined:
�t ❑Standard City/Town Application Fee
2.Electrical $ 6�V ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $Suppression) Total All Fees:$
6.Total Project Cost: $ 06— Check No. Check Amount: Cash Amount:
�f ❑Paid in Full ❑Outstanding Balance Due:
3s ��
-7
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction
�S�isorLicense(CSL) 3 �(Z
{'(�')1 5 L e e No e�� C' irption,pgte
Name of CSL Hold /r 1 4 Cyr 7
p / ''/_e 0ev �L List CSL Type(see Blow)
No and Street / A^ // Type Description
�il! � A D>'///y ./1/Q�� U Unrestricted(Buildings u to 35,000 cu.ft.
/Y�y N ' - I C/! / R Restricted 1&2 Family Dwelling
City/Town,State,'ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/ ' wry./ SF Solid Fuel Burning Appliances
it- '�J I Insulation
Telephone Email address D Demolition
5.2 ftegistered H to improvement Contractor(HIC) // Atw 7 .�/422L
Z (S HIIC�,`Registration Number Expiration Date
HICAamp 4 ,�r.I3I�I�.egistra 4�4v1, v
/!/ el �i•7r 7 �/,l"`r! /6 90A/ Email address
gz.J
City/Town,State,ZIP Telephone
_6 T
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 ........A No...........❑
SECTION 7a:OWNER AUTHORIZATION TO E COMPLETED WHEN
OWNER'S AGENT OR CONTRACTO�R,,//APPLI FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 4X� f 3
to act on my behalf,in a atte relative 6 work authorized by this ing permit application.
�
Print Owner's Name(Electrod c Si etu ) 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
cc coed in this ap lica'on is true and accurate to the best of my knowledge and understanding.
l w415 7 2611
'nt Owner's or Au[ho d 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
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass. oe v/damps
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"maybe substituted for"Total Project Cost"
CITY OF SALEM
-;'; ;,/' (PUBLIC PROPRERTY
'' DEPARTMEN
T
.i\n:. nfl Y:InIV\91
t I N'Yt
11'. �Vmm�.�.au.�ilvf�T • 3.tu•u, M.Icvat.rn a I "
Workers' Cumpensalion Insurunce Ufldavitt Buliders/Cuntracturs/Ele trieluns/Plumbers
\ ) Jlicant In unnullo
PI a.q r(nt it 'hl
ViI117C Illuuna,yt)rganrraliofvinJnnluull: S ��^ ���
�Jdrexs: h nQP
CIly,.Srarc Zifr 41ea /yl q I'hunr
I /�ryc�t uu all employer:'Check lho upprnprlute boas;II•Cy_I flnl a empluyvr wish /6 4. 1,11M for Project frequlrod):
entpluyccs(full anlYur Part-time),• 0 hava hired the.nh�c seat lu rst ani
h• ❑New cullstructiun
'•❑ I am a sale prnprichw for peones- listed on the anachcd.nceet 7 �• ❑RelnoJelin�
.hip and have no cmpluycc's These sub-contractors have
wmrking lair one in any capacity, workers'comp• insurance. g' 0 Demolition
I No workers'cutup. insurance 5. 0 We are a ea q• ❑ OuiWing udditiun
3.❑
required.) pontinn and its
otrcen have exerciscfl Iheir 10'0 Electrical repsirs of additions
I tun a hofrurowner Joint'all work right of exemption per NIGL 11.0 Plumbing n:puirs or additions
InysvlL IN•o workers'comp, c. 132,¢1(4),and tvc how no
insurance required.)/ .mpluyecs. (No workers' 12.0 Ruul•repuirs
cntxlp. insurance required.J 13.0 Other
•\�y.q'potcwa'hd Yheeha aaa wl dual ana till uul the wYlwo Iwlow dwwury'hvu wwhui cunrPanyalyw pufiey tnrialrWiaa�
'Il�fr.,n'r'wra why rWrnNl box amdevit in es,o na thug ue Juana all\Yuri and that him wluM curwritow,mwl.Ylwfu a new alnea•ir inJluwina uwh,
f,.ntrwhwY Ihw.AYYY this hoa'ntrl anahad.In aJJitivlwl..11uM,lo-win,tow nanw of the lub.-a wrar:hwa and thew wuhen'car".pulfty tnlbnn3hua.
/film use caopfoyn thus Ir pruridinx workers'rutnpenmdon Go etrrmce/or Iffy dmp/oyers, Be/ury/s/he pulpy und/u1 ails
imlonnu/Gna �,/� cP
swallow
In,uranccC'unlpany.Vame: Risk S/� A-mom
Policy is mr Sulr•ins. Lie.to: N
r� /J .EApiraflon Dare:
Job Situ Addresv: /il A'��Op7et,,) - a
C'uy,SmteiZlp:.lttury a copy u%
% ale u re win toildc lmn pulley declaration pug'(showing rht policy numbur and expiration date).
Pallun to Yccuro eowrsgt u required under Section?3A u1'.NGL c. 132 eau lead ro rh'imposition of eriminal penalties of a
rP li uof m S I1n0i J y idailun Ililil Bnprismnmcnt, ur \Yell as civil Iwnalllus in Iha Ibren of a STOP WORK ORDER and s rent
of up ro i'SO.rM n Juy.tgwnal the vtalahv, I Ie viecd(hut a copy urlho Yluicm0tt may be Iuruarded Iu the Onicu vf
Ins:eh yau'nts ul'Iliu DIA for nhur it!"Coot r,I of ailiw;un.
/du/r.•r,-by rcrliy Rode the/u' anJprn t utprr/nry/her floe a in nnallow l pruriJed u uvt is ae and rorrcrt
Ir)//leiuf rut an/y. /)o not trrird in this urea. lu ee runty/rtrd et'city up fotvrl=Pfumbin4
I rift or I'gwm:
I\\uing .Whitney (circle env); Pannit/Lieenae I
1. IL'urJ -or lIV41111 2. Ihuldul� J I yl.lrtulYnt 1. CifJ.'fonm Clerk 4.i G. I)rticr -
l'.nt.lct IOnull: -_
i
Information and Instructions
\LI)SJG 11uiCUs ce
Chaptef 1 J1 rlgalfcs all C,,,pjO)c s t In the SpryttO o prov'A Of another k111 ter/filly:unmet of hu
tJcnCral LJ Wx e s.
rtw,u.u+l to tins�wlula, an rmplus're is J0111C as"...every {ri
c%press or unplicd. oral or written." oration or other legal cntiry,or my two or more
urtnership,associanuo.Cory ..r or the
No crepluyrr is defined as"an inntvidual,p employingan+ loyees. Howcvcfrho
.t the t:,requmg engageJ ,n a lomf enterprise,and including the legal representatives of a deceased amp uY ' •
that
I CCGlver Or lfu�I°e ut .ul nldivlduAl. plutnenh,p,asscewu3r or Other A legal reside P
to s Woos to do Inaintenunce,wnwuction oro�nt Ir�C mcd tout in employer.
owner of a dwellings house having not snore rhea tAree apartment and who resides therein,of the occupant of
Jwc sling house of another who emp, Y. pe
or on the grounds or building-appurtenant thereto sheltaiot gxea,msa.of such employ
�3C 6 also states that"even'state or local llcenslo aaeney shall withhold the issuance or
%IGL chapter 132, t)- ( )
renewal of a Ilccase or Permit to operate•basin as&or to construct buildings la the comro°ew°ullis or any
s3C1�1 states"Neither the commonwealth not any of its political subdivisiatnshsll
renewVplieal
who has not produced acceptable evidence of cumpgaoce wlththe Insurance coverage required.
Addifionully, MGL chupler l3 i-
wmract for the erfornwnce ul' ublio work unfit acce noble evidence Of compliance w ith the insurance
D i
our into any ' P le,ented to the contracting authorit _.
requirements of this chupur have been p'
Ayyllcsna to our situation and. if
ensation aly davit completely.by checking the boats that apply Y
D hone numlrer(s)along{with fheu calliflcau(s)of
Please rill out the workers' comp as)and p with no eta loywas other than the
necexsary.supply sub-eontractot(s)name(.$), adlhtsxl
workers'compensation insuranco. If an LLC or LLP does have
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)
Carry
members or purtnan, are not
b Be aded vised that this atlldavit lnay be submitted to the Department of Industrial
employees,a policy is requite
unit or license is being requested,not the M-Iss tment of
\ccidents for contlrmatiun of insurance c I cation foAlso be r the W sure to$lur anti Jute the uftlJavlA The allillevit should
he returned to the city or town that the application
regarding the low or if you ate required aanies should enter their
lndustriul ,%ecidmis. Should you have any q
co,npensatgon policy,pica"call he Department st the number listed below. Self-ins comp
self-insurance license number on the a ro rime line.
_try
or Town OMclels
you tf till out in the even(the 011ice of Investigations has to contact you re
gorlints the applicant
Please he sure that the Affidavit is complete :tad printed legibly. The Depafartant he provided u space h the bottom
cant
Of the affidavit for y
Imcutions in any given year, need only sub,tilt one atl)dovit indicatin`current
Phase bb suro to till in the pr;rtnif/liceuse number which will be used❑s a reference numlwr.�In addition,an tip
Chat ,oust submit multiple pennidliceluas app ' iu provided to the
policy information 1 if necessary)and under-Job Site Address"the upplicmu should write liely be p o (he ter
towns•" coPY tf the u171duvit that has been officially stamped or marked by Cho city or town Inayust Pout
applicant as proof that a valid at is ten file f'or tLturs pe1nnits or liUMS45. A new nnit not related to any bustinessavit'or comenlarc al venture
year. W here a home owner or citizen is obtaining a license or p
I i.e. a dug Iicen..je or permit to burn leaves cte.)-laid is NOT required to complete this affidpvit.w uesuons,
he Invcuiyatiu
1 )tlkc of ns uuld Ilse to dwok you in advance fut your cooperation and should yuu ha,e.uly y
please du nut hesitate to give us a call. x
Od
fhe U.panlnent's adJte+s, telephone 'The
Cn mmonwealth of Mamchusit"s
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 02111
•I'e1. 9 617-727.4900 ext 406 or 1-877-MASSAFE
Fax M 617-727-7749
d us www.maw.gov/dia
e a
Nr y
CITY OF S.UY. N1, AtSSACHUSETTS
BCIIDLNG DEPARTNMNT
110
WASHLNGTON STREBT, Ye FLOOR
TM (978) 74S-9595
FAX(978) 740-9846
Kl.-,®ERLEY DRMOLL
MAYOR THo.WS ST.Ptjttt8
DIRECTOR OF PCBLIC PROPERTY/HCI DLNG CONNISSIONER
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 it 1.5
Debris, and the provisions of MGL a 40, S'54;
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
l 11, S 150A.
The
debris will be transported by:
lI N L2 /',
(name of hauler)
The debris will be disposed of in :
&mm
(name of facility)
(address of facility)
,���
signatur permit plicant
date
do blLwll�,Lp '
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