48 CLARK ST - BUILDING INSPECTION (3) 14 The Commonwealth of Massachusetts CITY OF
� Board of Building Regulations and Standards SALEM
t / Massachusetts State Building Code, 780 CMR Revised thir 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
M Building Permit Number: Date pplied:
1
Building Official(Print Name). Signature Date
SECTION 1.SITE INFORMATION,
1.1 Property Address: s
y 1.2 Assessors Map&Parcel Numbers
1.I a Is this an accepted street9 yes no Map Number Parcel Number
1.3 'Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(R)
Front Yard Side Yams 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? Municip al❑ Po y On site disposal system ❑
— Check if es❑
SECTION 1: PROPERTY OWNERSHIP,'
2.1 Owner'of Record: Q 1 7D
Csarvt <Sq If Vh V0 R
NN me(Print) City,State,ZIP
q � C M -g93 5s2(
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied O 1 Repairs(s) d I Alteration(s) ❑ Addition ❑
Demolition 0 Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Prop ed 2 r
vl 1. +CIL It
k C2 Vti eti ✓t a
G 2 c c
SECTION 4: ESTIMATED CONSTRUCTION COSTS
itctn Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ / 9 - I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard CitylTown Application Fee
2. Electrical $ Cl Total Project Cosh(Item 6)x multiplier x
3. Plumbing S P Qther Fees: S
4. Mechanical (HVAC) $ List:
5. \mechanical (Fire S Total All Fces:S
Suppression)
_ Check No._Check Amount: Cash Amount:_
G.Total Project Cast: .S 9 9J ❑Paid in Full ❑Outstanding Balance Due:
TA P" I uED to/ n /I S
SECTIONS: CONSTRUCTION SERVICES
5.111jmtstructiolnSup rvisur License(CSL) vQCf R� a
'\ `�)C Z 0(I License Number Expiration Date
Name of CSL Holder
List CSL'fype(see below)
No. and Street '.'l `J TYpe. Description
c ('� U Unrestricted(Buildings tip to 35,000 cu. 11.
U�il I-� � `� 7 D M estricted 1&2 Family Dwellin
Cityfrown,State,"LIP Maso
Roofing Covering
Window and Siding
olid Fuel Burning Appliances
aVM In
Tcie hone Email address emolition
5.2 Registered pomp.n rovemenft\Contractor(HIC) 1' �2(0 8 93
t�>�1 e ✓ !E' HIC Registration Number Expiration Date
fit Cm m r HIC� Re tram Nmpe v�n
Nu.Ur F1S11Q,iJ$ Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M G.L:F.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 Ishuance of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7u:OWNER AUTHORIZATION:TO BE.COMPLETED WHEN!
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING.PERMIT
I,as Owner of the subject property,hereby authorize �� 6�
t9 act on my behalf,in all matters relative to work authorized by this building perm application.
S[-:-E 00V, +,-0C-i--
Print Owner's Narne(Electronic Signature) Dale
SECTION 7b:OWNEW ORAUTHOR►ZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
contai fed in this applic tion is true and accu ate to the best of my knowledge and understanding.
M AMC Fl ial �il��K�� G y-
Print Owner's or Authorized 1 ent' ante(Electr m Stgnautre) Date
NOTES:
I. An Owner who obtains a building permit to do Iris/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 i1M.G.L.c. I42A.Other important information on the HIC Program can be found at
www mass eov:'ort Information on the Construction Supervisor License can be found at www.mass.��ov�'dns
2. When substantial work is planned,provide the information below:
'total tloor area(sq. ft.) 'x .(including garage,finished basement/attics,decks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rype of cooling system Enclosed Open
i. "Total Project Square Footage"may be substituted 1'or"fatal Project Cost"
PLEASE RwiTHIS
it
Branch Name!Boston North Atiouth Dme;A II I Su1J iuroadhN and Installed by:
ic Services.Inc.
doh/a ne ne De- At-Home ScrviCes
Broach Number:31 and 33
908 Hoilon Turnpike,Unit 1.Shrewsbury,MA 0134.5
1,95 'roll Free 877-1)(13-3768
FMffW ID 9 75-2698460ME U0 0 C 02439:RI Cmi.fjo 16427
Cr Uc 0 HIC.0565522.MA Hn tic larprovernona Contractor Reg 4 l2hK93
Installation Address:. UA
c!) `Zip city state Zip
purchaser(a);
Work Phone:
Home Phone:
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III dress)
(Ifififfentrif,froto[mi 110600
Address(to romw4rd)oit t communion
slate, -zip
E-tooll Add
-Cmmumcati
r.
Thy Home Depnj�,,,.
a 'Niqemails finnoi
ect II&f 11"tion;
Undersimed(ftCmdbmjM d_owaery St.theaboine4milatI& ad
PT
cc%. Inc.("rhe Home
.,It aawl IA, dv�wl 11kd I Installat ion�)()''
relcicnce.al(ing with am Ipplwdinle -p,c all of which are milh,this
"Contract"); ��ULIC SLIPI�lclacat and Payment Summary attached hercit),ud any Change Orden
LV' !
UK0(NIn9 Prod
_I7§idmg-.en!dows Insulation
[]Guam/ Olintry,Doors,
Roofing Siding Windows Inand
W
qqq W,
Wong Siding sahaasr
Windd s
4 Z CIGuaters I Covers E]EN,yDuz,,r
Roofing. Siding. Windows laulati
G tares,
�butmm25%Deposit or
Contract Amount due upon evendon
ofthiscontrict.
Date thron one'third Ofthe CMUW Amount.'
Maine Pumitsisen maynatriepasit' Total Contract Amount
4_
CUStOrou agrees. hal-'.m nerism:,�y upowcompletmof the:,wok4oreach Produc Customer wiUexmtoa Completion Certifior-,
by
�an mifividual,Spec'Sheet)and pay any halaracedue. As applicable,each Custaraff mil
�*'IVe:�Comrructaipmtq bejointl �Srd,scvvrdlly,obligated and liable bercumd
TIw Home Depot reserves�e right to issue a Change Order or[Cominioce this Contract or arty individual,Products)inc
laded hffcin.at
--,its discretion it The Home Depot or jIs=-u1bori',d service provider determines that it cannot,perform,its obligations due to a suncooral
*.problcnn with the heire.-env6ormental,hazards Wch,as mold,asheSICS(ir lead Point,othcr.safetyconcms,pn'cingerruirsch-becan, o
7t -.?,wqk-(equir%t0 complete the)ch,was not included in tfic Carina.
,rfrynwgtSummry,�-ThesPnymp6tsumm-ary# losnbocf included as part of this Cast '4
MCI. Sets forth the total•
C mract.amount and payments requirestfar the deposits and final payments by Product(w applicable).
NOTICE TO CUSTOMER
You are entitled to a completely filleiffir copy of the Contract at the time you sign.
Do not sign a Completion CertiB I C;-
ate(note-
there is one CompletionCcrtifwute for each listed Product as;defined by individual Spec Sheets)before worlopri.that
is complete Product
-9 In thievent of ternifirtation ofthis Contract;Customer agrees to pay The Home Depot the costs ofinaterl 'lailter,
c
�:mmourds set forth in this Agreement orrafloftd trader applicable law. THE HUM DEPOT MAY W1
andl Services provided by The,Horme Depot or Authorized Service Provider thronri the date or termination,pusanyot r
�,OWED TO THE HOME' DEPOT'FROM THE DEPOSIT PAYMENT OR , LDAM AMOUNTS ZQ*
OTHER PAYMENTS I, WITHOUT
LIMITING THE HOME DEPOT's OTHER REMEDIES FOR RECOVERY OF SUCH AMOUNTS.
-,Acceptance and Authorization: Customer agrees and understands that this Agreement is the entire agreement between Customer I
and The Home Depot with regard to the Products ad Installation Services and supersedes all prim discussions and agreements,eith&M6,
*"at or:written,relating to Said Products and Installation.This Agreement cannot be assigned or affin except by winting signed
It by Customer and The Home Depot.Customer acknowledges and agrees that Customer as r u it,voluntaril acce
terms of and has receivedo copy of this'Agremacia. y pts the
Accepted by ad •LLAnt—
7
bustoo e'r S P;guhwe Date'', Sa Co u s Si at Dar
Telephone No.,
Customer's Signature Date
Sales Consultant License Na-
CANCELLATION: CUSTOMER MAY CANCEL THIS (W.Wicatilt)
AGREEMENT WITHOUT PENALTY OR OBLIGATION
BY DELIVERING WRITTEN NOTICE TO THE HOME
DEPOT BY MIDNIGHT ON THE THIRD BUSINESS
DAY AFTER SIGNING THIS AGREEMENT. THE
STATE SUPPLEMENT'4�; ATTACHED - HERETO
CONTAINS i`A 'FORM TO To US
J SPECU?ICA y CA ULY PRESCRUIV6115,B
CUSTOMER'S STATE. 4u
NOTIC&-ADDITIONAL TERNIS AND CONDITION'ARE 3rATrD ON THE REVIEWSK SIDE ANU ARE VAR](IF THIS CONTRACT
;k White-BrairchFila' Yellow-
custiarner