19 BRADFORD ST - BUILDING JACKET fL1tmlft 6T1ff . ..two APPROVED BY Tm
IMWW IOB PWR W A PFAW WIND GRANTED
CITY OF_SALEM
Dab
Wwd
Zmq owes
Is PIOWY Loabd In Loaseim of ' n
NO H Add Dbpld4 Yrs ha aaliiiaa �2c /l ti ��
Is Pla"tv Looftd in
.� ft CanaaaaonAfm? YM N0�
PennR b: OtALD013 POW APPLIMM FOR:
(Ckcie whld,avar a") R-x&Rowd, In ft Congoat osac, shed, Poo(,
PLEASE FILL Our Loamy a toQPLETEI.Y TO Avow DELAYS im PROCES m
TO THE INSPECTOR OF BUILDINGS:
The undarsipnad Nusby applies for a permit to build a000rtft.to the.beowkq
speoiRoaUom: -
Owners Name 6ivu/v ^AlAA N�c�f (.(t
Ad*m a Phone 1q 13 y t AA� -J ji— (WF-) 1l 4 -7c y y
Mchiomes Nome
Ad&m a Phone
Mechanics Name
Address A Phone ( 1
who is Nr papoaa cr kaw k4w/\.e_ 1
t dww d taddnp? Nall 11 Mr hm m"bmara4 /
MAN kfift om In b bW Adalaloa? �`�
tbllmalad and J My uo aft Ub r �—
am lwmv�t
Lie. i
/ ipnawn
S1f�D UND®1 THE PENALTY'
OF PERNJRY
DESdIEsf10N OF WORK TO BE DONE
MAIL PERMIT TO: l q ffi
. . .
;r .
:�
�,. .
^_ `.(
%.�} a' -
c
r
� � �� � $
�� . � . S ��
,�
I'he C'o III III oil%V%ltlIII of MussachuscIts
Board of Building Regulations and Standards CITY OF
SALEM
t Massachusetts State Building Code, 7SB C'NIR
Building Permit Application To C'onslruct. Repair, Renovate Or Demolish a
One-orTun•Pinmill Dentin,\"
Phis Section For OtP ' I Use Only
tuilding Permit Number: O te(�Applied:
_
IluilJing 011icial(Print Marc) Signature Dale
SECTION 1: SITE INFORNIATION
P/7—mi—nSDistrict
ddress: 1.2 Assessors Nlap St Parcel Numbers
acre ted street? es no Map Number Purcel Number
formation: I.4 Property Dimensions:
I'rnpmscJ tlse Lat Area(sq 11) Fmnlage(11)
1.5 Building Setbacks(R)
Frunt Yard Side Yards Rear Yard
Required I'ruviJud Required Provided Required I'rovitled
1.6 Water Supply:(M.G.i.c.40,§Sq) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Ihtbile❑ Private O Zone: _ Outside Flood Zone? Municipal O On site disposal s)stem JOCheck if yes0SECTION2. PROPERTY OWNERSHIP'
1.1 Owner'ofRecord:
ait-crn rnA m970
j C'ity.State.ZIP
N;ww l l'rint 19 �R.P\LLJao '55L 78/-307 -31/2 ��Y�YVko0GMaCoM
No. and Sleet re(ephone Email Address
SECTION): DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building O Owner-Occupied Cl Repairs(s) O 1 Alteration(s) O I Addition O
Demolition O Accessory 0idg.❑ Number of Units_ I Other O .Spceily:
Brief Description of Proposed Work : LI K - E
<T`2 142 L
t G T/rem to I n �a5-�� A/'0 �l/1 S rA /i
r1rrG./ /-lS/�,r_lIIl��l,t rt �('L GS" e
SECTION J: ESTB ATED CONSTRUCTION COSTS
Item ing Estimated Costs: Official Use Only
il.ahur and .\I:nerialsl
I. Build S ) Al 010 r 00 1. Building Permit Fee: S Indicate how tee is determined:
S ❑Standard City?uen Application Fee
:. 1:'Icctrical
C3 Total Project C'ust'(Item 6)x muhiplier
t I'hunhing S 2. Other Fees: S
J. \IcOmnical ill\ %0 S List:-- -----
1up resiwnl total .\11 Fces: S_..-----
C11"k No. Chcck :\nwunl: Ca. h \iwtunl:
I, rulal Project Cum: i l/ -(V p ❑ Peid in Full C2 Oulstand Ill g Hul.ulcc Due:
SECTIONS: f'0NSI-R11(-rI0N .NFRViC'FS
5.1 C'msstructimt Supen isor License IC'tiL)
I icensc io
ir:uian I):11a l'NI. cription1. wd Street
ricted t0uddin'i ti to 11,U111)a1. 11__ _ il DllcllolCinifall n,Ntotc.LII' �I%S w,Ink5idinSF ucl 1)urning Appliances
1 Insululion
fcic hone Finail address L D Demolition
5.2 Registered Home Improvement Contractor(HIC)
IIIC l4g6tralion Nunitler F\Iiirution Date
IIIC C'ompau) Name or I IIC Itcgislrunl Nentc
No. and Street Emuil address
City/Town, Stnte ZIP relc 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 .......... Cl No...........O
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 Utater's Na:ne(Elcctrunic Signutum) Data
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
;EBlyentering iffy name below, I hereby attest under the pains and penalties of perjury that all of the inrormaliun
this application i true and accurate to the best of my knowledge and understanding.6s orIGlcctronic.Nigmlturc)NOTES:
er who oblains a building permit to do his.her own work,oran owner who hires an unregistered contractor
istered in the Hume Improvement Contractor I HIC) Program),will na have access to the arbitration
or guaranly fund under\I.G.L. c. 11_'A. Other important information on the HIC Program can be found at
.r•, „ .-,.I Inronnation on the Cunstruction Supervisor License can be found al 1,,,,, Imo.; >:'t �Ilt,
2. \\'hen substantial work is planned, pro\ide the information below!
row flour area I iy. f1.1 - ____„_I including garage, linished basement ottics. Decks ur porch 1
tlrosili\wgareatiy. 11.1 _-.. . _ fIjbitable room count ..
Nunthcr of lircplaccs .. _. ._ --- Number of h\'drooltli - . .
Nunlhcr of hathnwnls . . _ Nlunbcr ul'hall haths
i
pc of healing i)ilanl Nunlhcr of decks, parches
I\Ile ol'caoling i�itoll I`ncla,cJ . .Opan
t 11ye"nlay I v 1
"I�tl.11 �'fl,�Cel Nllllare r,h. , �' \Ilhillllllh IUf I In.II FrujKl2m,l
CITY OF S.V-&Nf, AukSS.ICFfUSETTS
OLLUMNIG 0EP.1R ON-r
110 W kSH04GTON STRM, 1i6 FZ001t
TIRL k973) 7439395
FAX(978) 740.9&W
1U113F_RF Ky DRL CLL
MAY01! Tko.%W ST.PMXAS
0fx=T0I<0►PL3L.fC PRaPERTY/at:MDLYC,CONNISSlONEA
Construction Debris Disposal Af ldavit
(required for all demolition and renovation work)
fn accordance with the sixth edition of the State Building Code, 780 CMR Section 11 I.1
Debris, and the provisions of MCL o 40, S 54;
Building Permit a is issued with the condition that the debris resulting from
(his work shall be disposed of in a properly licensed wrote disposal facility as defined by NIGL c
I 11, S I JOA.
The debris will be transported by:
(nuns ofhoular)
The debris will be disposed of in
(nama of famliry)
(luareu orfud+ty)
+ynamce permit ipphc.nt
>/2J-,/i,Z
r .
CITY OF S.U-F.Nf
PUBLIC PROPERTY
DEPARTMENT
waWit✓nyi�=
`L"'d t b�.ra•t✓w�a must• sK,•a Vwv�oRr:rrs otre
Mi.9-11.741.911ss •r..a r.tir+o.osw
HOMEOWNER LICE,NSS EXE.I4MON
Ptetw Met
Date �-
lob Lacadost lot 9 fZ n f y R D ST
Home Owner Address 19 C3 e A n i)a.n ST
Home Owasr Telephone 7Q i o
euM Mailing Address l 9 /gzA �Jr Pr �tz rn 'TT- - a 44c eh 01 76
The current exempdon of"Homeowners"was extended to include owrneroccupied
dwellinip of two Units or teas and to allow such homeowners to eagage so individual for
hire who does not possess a keens@ provided that the owner acts as superviatw.
DEFINMON OF HOMEOWNER
Person(s) *be owns a parcel of land as which halshe resides or intends to reside. an
which there it, or is intended to bs, a one or two ll nily dwelling, attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall trot be considered a homeowner. Stich
-homeowner"shall submit to the Building Oilcial, on a form acceptable to the Building
Official, that heshe be responsible for all such warp performed under the Building
Pamir.
The undersiSned "homeowner"assume@ raporsibility for compliance with the State
Building Code and other applicable by-laws and retuladons.
The undersiSned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and requirements.
HOytEOWNERS SIGNATLRE a y
APPROVAL OF 3U(LDIYG OiSPECTOR �o
See other side far sate code