21 BRADFORD ST - BUILDING JACKET fL*NS*1WT,9EfKA94A9 APPROVED By 744E
JWZCM PRIOR TD A PERMIT REWG GRANTED
\_ CITY OF_SALEM
No. v� \ Dab
Al''
\ r1`>i fie Wam
Location\\�X(,� Zoning Distw
da Hlatoric DIdW?„ Yet N% of 1`
Is P,psrtY Locabd in v
ft C rdwvadon Ann? Yes 1 o
Permit to:
BUILDING PERMIT APPLICATION FOR:
(Circle whichever apply) Roof Reroof, Install Siding, Construct Dock, Shed, Pool,
epaidRepla e, er.
PLEASE FILL OUT LEGIBLY&COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS: '
The undersigned hereby applies for a permit to build acconAig.to the.following
specifications:
Owner's Name
Address & Phone
Architect's Nam
Address & Phone
Mechanics Name
Address & Phone
What is the pnupose nit brdlding?
Mairdal at buNdng? M a dweW for how mo ny fwmmn?
Wa buk*q cordon,to law? Asbestos?
Eswn@W coat \� CRY Wow a State Llcwna N
ture 6f Applicant
SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
h
MAIL PERMIT TO:
APPLICATION FOR
PEFOW TO
LOCA71ON
PERMIT GRANTED
f 7leq 19
APpROVFD
G�
INSPECTOA OF BUILDINGS
t
� The Commonwealth of Massachusetts
(11 Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
- _ This Section For Official Use Only -
Building Permit Number: - Date Applied:
Buil ing offic' (Print ame) Signa Date.
SECTION 1:SITE INFORMATION -
1.1 Property Atki ss: 1.2 Assessors Map&Parcel Numbers
2l 11J,,t S�• 16
1.Is Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
_ !/000 �o m 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 R!r,— Private❑ Zone: _ Outside Flood Zone? Municipal X On site disposal system ❑
Check if yesd�
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Rec d:
Meses�oan tae(fiCS / �6le(rr�- d
Name(Print) (') City,State,ZIP T
,SJ Q(L(`al J1. �Tpr/o—It i2N/C��e IXfr>:�n.ntt<
No.and Street Telephone Email Address
'SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) 91 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work 2: (OdA T f n
ezli,As S e r. 44 d 6• r S t c on! &.434e
t 5.
SECTION 4:ESTIMATED.CONSTRUCTION COSTS
-
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ S A a' 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ -Y
a• -❑Standard City/Town Application Fee
D — ❑Total Project Costs(Item 6)z 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: $ f� apJ — 11 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES ..
5.1 Construction Supervisor License(CSL) 9 Q/_7
r-s-o VA License Number Expimton a[e
Name of CSL Holder
List CSL Type(see below)
?rJ uA,., 15
No.and Street I Type Description
1 J� A O 1 G 0 U Unrestricted(Buildings u to 35,000 cu.ft.
_I R Restricted 1&2 Family Dwelling
City own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tel hone Email address D Demolition
5.2 Registered Home Improve ent Contractor(HIC) ,
uJ I
1A,0 •A `7K.1 G(tt7 1tjc HIC Registration Number Expiration Date
HIC Co any Name or HIC X[rant Name
No.and StreetEmail address
g1461 J�Aa . rAoa. `1$1-U3 -OW
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 ..........❑ 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 five Irk authorized by this building permit application.
fC i
Print-Owner's Name(EI ctronic S 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 ins application is .accurate to the best of my knowledge and understanding.
�3
P Own 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
www.mass.•og v/oca Information on the Construction Supervisor License can be found at www.mass.@ov/dps
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.) )'L{ 3 ql Habitable room count
Number of fireplaces O Number of bedrooms 13
Number of bathrooms Number ofhalf/baths 11)
Type of heating system t9il Number of decks/porches - I to �IltillT�
Type of cooling system Enclosed "Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
Filenumber: t30777-23
----
l UNREGISTERED LAND
AKOrn ANTHONY G KECK&ASSOCIATES De Ok 32557 q
Lender: e
E49n Book 1990 a e 600 t s. t 6
Owner: wILLIAM SAXONIS - REGISTERED LAND
R .Book Sheet Imr(s)r
ate: 7/t 8/20t 3
Assessor's a 17 Ce Tit!¢
BIk: Lot 3t Census
T Traract
MORTGAGE INSPECTION PLAN spate: !1 =zD'---1
21 BRADFORD STREET, SALEM, MA
LOT 8 LOT 9
50.00,
CAR. .N
LOT 16
4000 S.F.
0
o � o
0 5 o
LOT 17 °O LOT 15
e
W
Y
PORCH
50.00'
BRADFORD STREET
CERTIFICATION
I CERTIFY TO THE ABOVE ATTORNEY,B N'K#Nv THEW TITLE INSURANCE COMPANY THAT THE MAIN BUILDING,FOUNDATION OR
DWELLING WAS AN COMPLIANCE WITH THE LOCAL ZONING BYLAWS IN EFFECT WHEN CONSTRUCTED(WITH RESPECT TO
STRUCTURAL SETBACK REQUIREMENTS ONLY)OR IS EXEMPT FROM VIOLATION ENFORCEMENT ACTION UNDER MASS,GENERAL
LAW TITLE VH,CHAPTER ADA,SECTION 7.
FLOOD DETER1YfIN,:I TI01V -. .
H 5 0 CO4 8F ASZONEEX DAD 77By SCALE,THE DWELLING SHOWN I--3-12 DBY THE NATION`AL.�FLOOD INSURANCEOPROGOP .'D e M COPY �f\9\tea\5.��\lOW ,MMUNU.X
Olde Stone Prot PZare Service, LLc
P.O. Baz 1166
LcxkeviZZe, MA 02349-
TcZ: (8001 993-3302
Fox: (800) 993-3304
PLEASE NOTE: This inspection is not the result of an instrument survey.The structures as shown are approximate only. An instrument survey
would be required for an accurate determination of building locations,ermmoChmenta,property
may reflect different informat on than shown here. The land as shown Is based on client ishled information onlyine dimensions fences or a sessorsand lotomanfipur
&lion anti
occupation and maybe subject to further out-sales,takings,easements and rights of way: No responsibility is extended to the landowner or
surveyor, or occupant. This is merely a mortgage inspection and is not be be recorded.
CITY OF SALE.\[, itiWSACHUSETTS
BUILDL\G DEPARTM&NT
p 120 WASHLYGTON STREET, 311D FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
Kj,NffiFRt FY DRISCOII
T
MAYOR HO:�fAS ST.Pi£RRIi
DIRECTOR OF PUBLIC PROPERTY/13LIMNG COSLtiRSSIONER
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 c 40, 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 disposal facility as defined by MGL c
111, S I50A.
The debris wilt be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility) -
i
signature of permit applicant
ao!�
date
dcbrisal(dx
�!°" CITY OF S:1 zms 1NLkSS�ICHUSETTS
N BULM G DEP1M.LENT
.fi t. 120\VASHLNGTON SmET,3"'FLOOR
mod'0TEL 978 745-9595
FAX(978) 740-984(j
KI.%fBF RLEEY DRISCOLI
MAYOR DIRECTOR
StPIF.RRS
DIRECTOR OF PUBLIC PROPERTY/BUMDLNG COJLMISSIONER
\Yorkers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbert
Annlicant information Please Print Legibly
Naire(Business.Orgsnizatiorvindividual):pp SE1OS1.l�\A `�Mt\UC�� T NL.
Address: CN �(CkA l A )�L
City/State/zip L t.1(1 1 t- 0�"So — Phone 1f: A
Arc y u an employer?Check the appropriate box: Type of project(required):
1. I am a cm �
to cr with e 4. ❑ I am a general contractor d 1 conracor an
P Y 6. ❑N w construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached shcat.t �• emodeling
ship and have no employees. These sub-contractors havo g. 0 Demolition
working.for me in any capacity. workers'comp.insurance. 9. Building addition
[No workers'comp.insurance 5.'❑ We are a corporation,and its. IO El Electrical repairs or additions
officers have exercised their
3. 1 am a homeowner doing all work right of exemption per MGL 114:1 Plumbing repairs or additions
myself.[No workers'comp. c..152,§I(4j,and we have no 12.[]Roof repairs
insurance required.)t employees.[No workers"
comp.insurance required.). lJ.❑Other
Any appikaid thatchucksbaxe I mustalso fallout theu im below showing their aarkeis'mmpenwtuo policy infunnutdom
I hweuwm"who submit this adidavit indiwing they am doing all work aed then hire outside controeton must submit a new alridnvil indicating such
:Cantractuts shot cheek this box must anaehed an addiflunel sheul showing tho mama of tho mbeuntnctan and thole workers'comp.policy Information.
1 am an employerthat ds provfding workers'compensation taturance for my employees Below/s the pofley and fob site
hifor iatlnn.
Insurance Company Name:
Policy 4 orScif-i is.Lic.At: Expiration Date:- p� }�
lob Site Address: a'\ &"X,, ", 71' City/State/zip: SAN,P iACA
,knaeb a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Suction 25A ot•Mc. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S230.00 a day against the violator. Be advised that a copy of this statement may bo forwarded to the Office of
Investigutiwss ul'dre DIA for insurance coverage veritication
/da hereby rrrl/fy v wrd pee ojprrfary that the information provided above it true and correct.
S �r n,nurr: lJaro / 3
Phoned:
OJJtcfal use a ly. Do not write in this area,to be completed by city or town n/JtrluL
City or'rown: Permit/f.1cense _
f.ssuing.\uthority(circle one):
h Boord of llcalth 2. Buildinb Department J.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing limpeefor
6.Outer .
iContact Person: - ---- -- _.. Phone It:
1