16 1-2 CHASE ST - BUILDING PERMIT APP R
\ The Commonwealth of Massachusetts
y; }� Board of Building Regulations and Standards CI'I'1 OF
tr'i, Massachusetts State Building Code, 730 C NIR SALE,
Building Permit Application To Construct. Repair, Renovate Or Def olish
One-ur Tuvr-huwrh Dn ellhuq
This Section For Official Use Only
Building Permit Number. Date Applied:
Building 011icial(Print Nun!) 1 Siµrmlurc Dulc
SECTION I:SITE INFORMATION
I.I Property Address: 1.2 Assessors Map& Parcel Numbers
1.la Is this an accepted street?yes no Map Number 1'arccl Number
I.3 Zoning Information: I.d Property Dimensions:
Zoning District Propu,cJ lJx Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(B)
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: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposals)
Check fifes❑ P stem ❑
SECTION3: PROPERTY OWNERSHIP'
2.1 Ownerl of Record•
y<� vard0 �a 6 9u/ram sn �c ) AtA-
Mono(Print) City,date,LIP
/6 '/z CtiGJ� s; rff- s9�- SJy2
No.and Sircet telephone Finail Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ Alteration(s) ❑ Addition O
Demolition ❑ Accessory Bldg.❑ Number of Units` Other ❑ .Specify:
Brief Description of Proposed Work-:
SECTION J: ESTIMATED CONSTRUCTION COSTS
item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building $ I. Building Permit Fee: f Indicate how fee is determined:
2. Flectrical S ❑Standard City/Tosvn Application Fee
❑Total Project Cost'(Item 6)x multiplier _ —_x
j 1. Plumbing S 2. Other Fees: S
a. Mechanical 111%,W) 5 Lisc
>. \Icchanical IFirc — ----- ------- -- --
tiu ressionl T0tal .\11FCes: S__
Check No. _('heck Amount: Cash \mount: _
a. Total Project Cull: S ❑ P;lid in Full 0 Outstanding Balance Due:
SECTIONS: ('ONS"I'RIICTIONSF.RVICES
S.I/C�bnstructimr Supervisor License(C'SI•) /o 7 7_q3 Yj7-�,T, .
Nanlc of l'SI. I lulder
/vim Iist('SI. I)pe(we
heloel"__"?'G
Na. :u1J Street )PC Description
It 141resoideJtlhlilJin Sli to 15d100 cu. 11.1
I Pam it Ihtellin
l'ityi fort n.RLac,LIP NI I Masonry
RC Rotllin C'overin
...—._ W'S 0.'inJuw;md Siding
SF Solid Fuel Burning Appliances
17 1yl- 3 y y! 1 Insulation
fcle hums Entail address U Demolition
5.2 Registered Home Improvement Contractor(HIC) 11161-1
S
�[A'� (N if,� I IIC Registration Numller lisp rant n Uate
I IIC Company Name or I IIC ltegistrunt Name
3 O ��P+✓rs✓e_
Nu.and Succt n U M� Emuil address
City/Town,State,ZIP rcie hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52. 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 ....4...4. ❑ No....4......❑
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 o/n�my behalf,in all matters relative to work authorized by this building permit application.
4
Print owner's Nnne(Electroni .'ignalure) oute
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below.I hereby attest under the pains and penalties of perjury that all of the information
contain plication ' true and accurate to the best of my knowledge and understanding.
1L J r
Print 0%%ner'e RAathon/cd,%gi:nt's Name(lilectronic.Cigma11rc) Dale
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 Hume Improvement Contractor(HIC) Program),will LL)i have access to the arbitration
program or guaranty fund under\I.G.L.c. 1 J2A.Other important information on the HIC Program can be found at
tuft% In.l,' n ;v.l Information on the Construction Supervisor License can be found at tt>ttt nm,;S % ,111,
2. When substantial work is planned, provide the informntion below:
Total Iloor area Isy. n.) _ I including garage, finished basement attics,Jccks or porch)
Gross living area(sy. it.) _ __. . Habitable roost count
\tanbcr of fireplaces.._".. Number of bedrooms
\unlherofhathrounu \'wnberufhalfhaths j
I)pc of heating iy stem _ . ." Number of Jceks, porches
I' pe of Qooli11_L' "\ilelo _ 1,I1elowd Open
1. "fod.d Project Square Postage"nlay he substituted liar"ftual Projm Cost"
CITY OF SALEM
�' PUBLIC UBLIC PROPRERTY
is
111 n 11'.. DEPARTMENT
\111,M
11. \VA It n/,v ilaCft'•iA1PM, M.N+.u.lu v r r+Jly/�
Workers' Cumpensadon Insurance 11(lduv
l 1 )I(1:un 'it: Uuildere/Contracture/Ele trlclans/Plumbers
In nnnatio
^ 1 e
n PI • .� 'hl
V,IInc I I11,n,wvei l7(aantl4how Ind,nd�ulul'):, ASS /C
ry+no an rulployer'!Cheek 1ppropeldta boa:
j. I •1m a emPluyvr with 4. Q I am a general cuuuaelor and 1 h)M nrprl+)eel(rvqulred):
Lnys
luycca(lull md/ur pert-time).• have hirvJ Ihv.ruh-cumncup rl' ❑New cunxtrucliue
2.C3
a'old prnprivtlw or partner- lisrvd on theanachedhvetI 7' ❑Remodeling
nd have no v rpluyt:" Then sub.contracton haw
ind tin ne n any capacity, workers'camp, nswenea. ' ❑Mmalirion
urkvn'vamp, inruranCdQ Wa are a eniparelion and ill q' ❑ouddine addiliwt
hoo ,a)9cen have ewlcim6d their IA.❑Electrical repairs or additons
homvulatvr s, all workrightor vremprion put VIOL 11.0 I lumbin ry ire ura.(Ko w,nrken' c. 132,111(4),and vet hnvo norti ddirinnece required.)I cnptuyvcir. INC workers' I2•❑Ruul'mpuirs
comp insurancwrcyuimd,) I3.C3 dr
•�'O ;plDfae IhW chude Ooa tl muN.live MI uA the Wtlh•a 4tuw aww"Is Ww u'weWe'runl/1,11WIuI1Iwlirt u,hutlwliyp
why 1uu,nil Ibis 40T,lewir i,Wtulin I
f.Mmwnws lDN lMva this Dee net, auahed,,n�aMr►/u auind Wl wu,r,N lMw hkv uwridt ewYrlle
11n11•D,wr J1u,oin tAt nenN W tM tua.enr tan mwl MN"il a rww/lndrvil indiad'ra.,II.
Nfara.tlld thew%metre•cor"A p111wy,nrbr111sllua
IIIlY/1 ur WI enl/1/oyf///IY/Jt/1/YI'J✓/ne IrY/A/q'rYle�//rMidair htfererre/jY//ey/rn///YJ,e/R B/IYIv Jl(AI plllll�,Ynr/�u�,+ll�
/I/IY/JIII�
tmurunce Company.Vnmr. ���✓T j !
I'ulicy Al'ur SuIr-ins. Lit. ---
lab Silo dddress; CluS to f7 - EApiraoon Darer
C'uyButmZlp: 7�
41lufu a copy or Illd rvarkare'eu e j ujid rlYn pulley duvlurarlun pugs hhdwlna the Polley number and vsplrarlue dory;
I+,I11urY to secure cue erugd as requlredvudvr.SCcliun-?!�\ vl'.�IGL c. I32 eau lead to rhd imposition of criminal penalties ore
sin.•up r,+Sl Ja0•gn anlLur uua•year hnprisohncnr, 41 twll am civil
[KIIJI
he
i up m i?i0 M a Jay Idaiosr Ihd vLrl.n,v I le adn.lcd that a copy orthnl,ul�nvnr nay by urw( P NVORK ardcd lu the UROErR I, a Rnd
IIn:.,11.4u,Ilu ul';hu DIA :or nl.u(oVV,: ,viru ye.r C1 riivahun.
/,lu/r,•rrhy 1,rlij►.Iwder r/re point Iln✓prnu/sire ujp/r/riry rhYr sirs in unnal/ow
/' yrvriJe✓u0uvd is rrut nerl rtwvtR
119 —7'(j, 3 . )ale. .
r//Nciul Ins uu/y, l)o I,nr Irrift in this urev, /u At ruulylrb✓by ri/y u/rolre II/�Ji iuL
f ilrur I'nrrn: _
hluin --� N�rnir/Llcrnllt s
N \ulhnrily (rirvld noel:
I Ih,.u'd ,d llv+llh 1. Ihuhhny n�p.Irllnvul LCil�. l'unu Clelk !. l'lerlricdl in+rcrrur i,
1 b. 1)II
er I Prunlbiny In,peelor
1 • 1111�1 I•1 r 1J 11:
I'hune 1•
I
Information and Instruct ions'nhtr their etnplayeei:
on its scrve of another uudef any cunen
l,icnenl Laws chopper dvpry p• . et of hire.
�Lu;uchusetts I i2 ieyuues all employers io provtJe vurkers wmpen++ a
1'unuaat to III*oaluld, an ierplgrdd is JVIIIICJ as". v,+ n h tc
;.Prods or unphcJ.Oral ar Witten." of an two or more
to employer iv drained as ,an nJrviJual.purtnanhip,asatxtauua, corporation or ohpr legal cnnry, Y
oIngasm rise. A d 11WIuuda or other let{al cnoty,emplaymti employees. However the
t the t;,requiny coined 3 m a Inds ideal. at. and utctuJiutl he legal ropreseulalives of a JeceuseJ employer,ter the
90111p,
Issocia
Lccetver or uutae ul'.m indivtJual, p
rwns to Jo "Oldnaned,cunaruelidn or repair work on wch Jwalhn l house
owner of a dwelling house havint{not mare than hm aparanenu and who resides hermn,or ht xcupanl of
JWelltng house of anoher who employsI7e
or on the ,rounds ter building appurtenant thereto shall not because of each employment be JaemeJ to be an etnpluyer."
nsla outcry shad withhold the Iafaanee or
tt or local Ilse s th for ally
\tGL chapter IS2. �23C(6) also stops ateas abusi1`0117 ses required."
cis III dance with the Insurance asubdivisicns.+hall 1
renewal of r license ter penult to operas■AuslnW or is eoutruet bulldlntls In he commuawd
Applies who has fiat produced acceptable
albs as"Neither ht ommonweallh not any ol'iu political
\JJiltunally. MUL cltuptpr I S-, i-
,:near into any contract tot the parfomeunce ufpublie work until acceptable evidence ofeontpliurtce with the uuuranct
rcquir+menu of his 0141111111113 ve been preaanteJ ro ht cantractina authority."
.lipplicanu 1 to your situation and,if
ettsation affidavit completely,by checking the boxes that apP Y
ns and hone numbers)slang with their certificates)of
Miss till out the workers' comp with if employees uthrr Than the
necessary,supply sub"Contracto ip n ics (s),aJJt Li 1' D
workers' compensation imuranco. Iran LLC or LLP Jolla have
inswvnee, Limited Liability Companies(LLC)or Limited Liability Partnerships(LL
members or purtnprf,are not required to carry be subminad to the Depurnnettt of industrial
empiny,Is,a policy is required. 13e advised that this isle be t maylL davit should
of
\ecldpnu for confirmation of instsra+teo eovcretle, A he sure r scan and tAenot the Mptlavit show
snit or license f You
beingrequested,ruired to obtain a workers'
hd rearmed to dv city or town that the application for regarding the low ter if you an required
Industrial,\ccidenu. should) have any 4
ir
compensuliun policy, plea call the I7epuranent st the number listed below. Sdf•instared campanias should enter the
sclf•insurance license number on he appropriate line.
('try or Towts officials aent has provided 11 Ud at he boI
Please hC turd that taffidavit II is
si Coran the event the O Tree lof Investigati Oons has to contact you regarding the applicant.
of die afrlduvit fur you to
I'l:aw be suro to till in hd purmitllicanse nusnbor which will be used m a reference bineba n in addition,is Applicantcurrent
or
tI write";III
hat muss submit multipb penniu'licemte applications in Jay given Year, need Duly submit and.I &:ujjuit indicating (city o
the bd roviJcd to the
Policy intormutiun1 if nVCdIa i�hail has ban ofneiully sumpud at marrkedtbyihe city of town,naytba p o .(city
A w of I Imiis or licensds. A now atlldavit nwst be pitied nut each
tuwnl. PY Affidavit is ten rile for Nlure pe
valid a business or eammereial venture
't at a led to an
applicant y pro
of h t related Y
y dart \Yhdre a home owner or citimn is obtaining a license or permit no
It e. all du licdn.+e fir permit to burn leaves cle,) said peramt is NOT required to complete his affidavit. uuhons,
I he i>iike IIIluvestigaliuns would like w dwnk you it, aJvunce fur your cooperation anJ+huu1J you hard,utY 4
pka,e du out hdsttatd to grvd us a call.
c adJ
{•truncnt's fa+.t. ICICPhunt
Ad rAx number
the U aThe Cornmonweolth of Mmsachuseltts
Department of Industrial Accidents
Office of Isveadjadans
600 Waswaton Street
Baston, MA 02111
rei. q 617.727-4900 ext 406 of 1.817•MASSAFE
Fax N 617.727.7749
www,rnus.jov1dill
CITY OF SALEM, .tiLkSS:ICHUSETI'S
1 OLt1DLNG DEPAfl UNNT
120 WASHLYGTON STREB'r, JW)ZCCE
ILL (978) 745-9593
Kl\®ERI EY DAMOLL FAX(978) 740.9&9
MAYOIt 1I10-%W ST.PMMA
1)1"CrOE OP PLSLJC P1t
OPEATY/8t:MDL%G CO-%0USSIONEIt
Construction Debris Dis osal
- p AYtldavlt
(required for all demolition and renovation work)
►n accordance with the sixth edition of the State Building Code, 780 CMR section I 11,S
Debris, and the provisions of MGL c 40, S 34;
Building Per ak is issued with the condition that the debris resulting from
INs work l be disposed of in a
11 I 1 I, S I SOA.shal properly licensed waste disposal facility as defined by A lGL c
The debris will be transported by:
(Warne of haular)
The debris will be disposed of in : n /
.(name r facdiry) �—
izCf� ST
(J11dR1! Of f]tllllly)
1 'n�ofpermltJpp6�
,life
',hn vl/ Lp