34 BRIGGS ST - BUILDING INSPECTION The Commonwcallh of Massachuscas
Board of Building Regulations and Standards Town of
\, � Massachusetts State Building Code, 780 CMR, 7"edition oom B Dept
S �\ Building Permit Application To Construct, Repair. Renovate Or Demolish a �
Th
�6l One-or Tiro-fumdr Duelling
Lion For Official Use Only
Building Permit Number: Date Applied: -
Signature:
Budding Commissioner/Ins hector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 roper. ddrea 1.2 Assessors Map& Parcel Numbers
U ddPl� l�S
1.1 a Is Ihis an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions
Zoning District Proposed Use Lot Ana(sit R) Frontage(fl)
1.5 Building Setbacks(B)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,{Sa) 1.7 Flood Zone Information: 1.8 Sewage Dbposal System:
Public O Private 0 Zone: _ Outside Flood Zone? Municipal 0 On site disposal system 0
Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
2 Owner'of Retord• r ��
fS +r'�
Name IPrint) Address for Service:
Signature Telephone
SECTION J:DESCRIPTION OF PROPOSED WORK'(cheek oil that apply)
5g2TIMATEDCON
ting Building 0 Owner-Occupied O Repairs(s) Alteration(s) O Addition O
essory Bldg.0 Number of Units_ Other 0 Specify:
ed Work': Y
t2
SECTION♦: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllcltd Use Only
Labor and Materials
1. Building f Z o rr.sa I. Building Permit Fee: f Indicate how fee is determined:
0 Standard City/Town Application Fee
2 Electrical f i
O Total Project Cost (Item 6)x multiplier x
J Plumbing f 20 2. Other Fees: f 1�h
a. Mechanical (HVAC) f List: v CCz
J/
I Mechanical (Fire f
Su ression Total All Fees. f
Check No. _Check Amount: Cash Amount:_
h Total Project Cost: f �lTa� O Paid in Full ❑Outstanding Balance Due:
A �IF�,�
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) 7 �<-S lO
DALE -TMe tq L,,cn w Numbi;r Espuation Date
Npoa of('Sly Helder List CSL Type(a1 hclow)
�Za L Bgy-!:�j w T. I Description
Address
S M/ O1�i 75� U I Unrestricted u to JS,000 Cu. Ft.
5rgria11, ,r� R Restricted Ih2 Family Dwelling
M Masonry Only
RC Residential Roofing Covering
Telephone w'S Residential Window and Siding
'7'7 (_ 15-8. 1 SF I Residential Solid fuel Summit Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name se HIC Registrant Name Registration Number
Address
Expiration Due
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this afGdsvil will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yea..........O 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.
Signature of Owner Date
/+:t�I� SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1, l G t I OAK.0 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
6 i}fJ
Print N
QO � 091
Signature of Own or Aulildrized Agent Date
(Signed under the pains and penalties ofperjury)
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 gg have access to the arbitration
program or guaranty fund under M.G.L. c. 1 d2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below
Total floors area(Sq. FL) (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
Tvpe of heating system Number of decksi porches
Typcefcoolmgsystem Enclosed Open
1 "Total Pro)ecl Square Footage"may he.uhsistuted for Total Project Cost"
CITY OF S.1I.EM, NLliSSACHL•SETTS
BCUM(ING DEPARTIL
120 WASHINGTON STREET, Ya FLOOR
TEL (978) 745-959S
FAX(978) 74069846
KI.BERLEY DRISCOLL
MAYORMOMAS ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/St:MDLNG CONLMSSIONER
Workers' Compensation Insurance AlTidavit: Builders/Contractors/Electrlcians/Plumben
4artilicant Information Please Print Legibly
Nalne IBusittvv Orgr aizario t lndtvt 1ua1I:
(/�l 6,)fa
Address: l02 �� V 2-, In
City/Statc/Zip- S (- All ( L?bn) (`^'k 019121'hone
Are you an employer'Cheek the appropriate box: Type of project(required):
I.® I am a employer with 41— 4. ❑ 1 am a general contractor and 1 6. Ncw construction
employees(full and/or pan-time).• have hired the subcontractors
2.❑ I am a sole proprietor or partner- listed an the attached sheep : 7- Remodeling
.ship and have no employees These sub-contraeton have S. ❑ Demolition
working for me in any capacity, workers'comp.insurance. 9. ❑Building addition
[No workers*comp. insurance 5. ❑ We are a corporation and its I O.�Electrical repairs or additions
required.] omcen have exercised their
3.❑ 1 am a homeowner doing all work right of exemption Per MGL 11.❑Plumbing repairs or additions
myself[Na workers'comp. c. 152.§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.(No workers' 13.0 Other
comp.insurance required.)
•Any applicant that cheese tica II must alwr fin ac we the stioe below showing their work m ne'c penryiun po licy infurttwk n,
'i L,ttwtwts m who submit this affldwh indicting ihey an,doing dl work and thin him amide conrrncears must auhmit a maw aMdavit iretisaitq suck
:("Masten that cheek this lea mud attached an 3"liwd sheet showing Use tumr of the subs unebn ees their wwkera'comp.polity infamallal.
l um an employer that h providing workers'compenamloa Insurance for my emp/tayeex Below/s the polley and/4 site
informutlon. /,
Insurance Company Name: ArAW 1 nCL ezi.hc L
Policy M or Self-ins. Life. N: Expiration Date:
Job Sire Address: 37 City/State/Zip: NA 0 (]
Anacb a copy of the workers'compensation poglry declaratba pago(showing the policy number and expiration dato)r
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of■
nine up to S 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 S250.00 a day against the violator. lk advised that a copy of this statement may be forwarded to the Office of
Investigations of ilic DIA for insurance coverage ventication.
/do hereby certijy wtdir rkr pain r penalties ojperjury that the informadon provided above is
true and carreca
`loll t it ' Date! V t 1 u
Phone A:
iOfriel use oa/y. Do riot write in this area, to be cunopleted by city or town gfi-ial
I
city at ruwn: __ ecrmitf1.Iccnse#___
Issuing Authority (circle une): —
I. Ruird of Ilealih 2. Building Department J. City/rows Clerk J. Electrical Inspector 5. Plumbing Inspector
6.01 her
'-wilact Person: - _ --, -- inane so:
i;
yam\ CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I11tlt 1/�
I 1_0 W.\il II\G 1'ilIN)CItELT !•$.\I P\1, M.\tii.\l.I It ih.1'i
T'rl;978.745`h95 • F:\X:978-740-9846
Construction Debris Disposal Affidavit
(required 1'or all demolition and renovation work)
I
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
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 he disposed of in a properly licensed waste disposal 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 raci yT
(address of facility)
I
signature of permit applicant
7 /0
date