24 CLIFTON AVE - BUILDING INSPECTION (3) • , — ---- The C'Onmmoms'Call h Of MaSSaehlfSCltS
Board of Building Regulations and Standards CI"I'Y OF
Massachusetts State Building Code, 780 CNIR SALLXI
I I 'L,�.• ltrri.crd.t hu _'!1/l
Building Permit Application To Construct. Repair, Renovate O mulls a
One-or Tmri-Fandl. 'DIt't•1111{q
This Section For Official Use Orf
Building Permit Number: le: lie
Building 011icial(Print Name) S gnatu Date
SECTION 1:SITE IN RDIATI
rX
1.1 Property Address:,�7 �-�• 62:!I-
1.2 Assessors Map& Parcel Numbers
zj
1.la Is this an accepted street?yes l�no Map Numhcr Parcel Numtmr
1.3 Zoning Information: 1.4 Property Dimensions:
Gating District Pn,p..ed LJsc Lol Area(sy 11) Frontugc(11)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Reyuircd Provided Required Provided
1.6 Water Supply:( I.c.40,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check iFes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 �Op'nerl yII Recur /�
pl'6 9 C I/y, V' �P-i �J
Name(Print) City. l
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction ❑ 1 Existing Building❑ Owner-Occupied ❑ Repeirs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ .Speci it'
:
Brief Description of Proposed Work
SECTION a: ESTI,NIATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S , 1. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)s multiplier x
1, Plumbing S '_. Other Fees: S /' ----
1. .\Ixh:utirul Ifl\':\CI S List:
_.-- GL ��' C)o _
'. .\lechmtieal IFirc S —_--
- -
Su,tressionl Total:\11 Fees: S ------ -----...__ .
v. Total Project Cost: S ��--7 Check No. ---Check Amount: _ _ -- Cash :\nunutl:_ - - -
-+ ' / ❑fail in Full ❑Outstanding Bulartce Due:
SECTION 5: CONS"I'RUCTION SERVICES
5.1 Construction Supen-isor License(C'SI.) oo /
..--_--- Licenx Number �qnali rat Unte
Name of 0l. I laldcr
__� List C'SI,I)pe Lace hcluwl
No. .mJ���tttrrrrat
------�--- -- ---- 'I)pe Description
�� //n U t in user d 1 I Ilui mi )s ti to i5,0110 ru. Il.l
/v/ �i L R RrslriflcJ I r? Tamil Dtwllin
Cirri I'o��n.State.LIP AI Nlasonry
Rtwlin Curerin
Window and Siding
/-� SF Solid Fuel l)urning:\ppliances
Insulation
l'elc hone Finail address D Demolition
5.2 egis pred ILWit Improvement Contractor(HIC) G
IIIC Registration Number lispiratiun Uulc
lilt'c,ompany �ie��c'Registrant Name
Nu. ;u�ucet , —70�. Email address
City/Town.State,ZIP "fete 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 .......... ❑ No........... ❑
SECTION 7s: 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 relative to work authorized by this building permit application.
Print 0wner's Name(Electronic Signature) Date
SECTION 7b: OWNERI OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
col In this ap teat' nn ss true and
accurate to the best of my knowledge and understanding.
Print 0%%ncrb or:\uthd r ieJ:\genl's Name it lectrume Signature) 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 Cuntractor(HIC) Program),will nu have access to the arbitration
program or guaranty fund under I.G.L.c. 142A.Other important information on the HIC Program can be found at
\%\\,s m.r.. ,,.I Information on the Construction Supervisor License can be found at ioo,+gt,% .h?,..
2 \Then substantial work is planned, provide the information below:
Total flour area Isy. R.) _ I including garage, finished bascment'attics,decks or porch)
Gross living area(sy. 0.) __-- _ Habitable room count
\umber of fireplaces ._ _ .-- _ Number of bedrooms
Numher of bathrooms _ _ Number of half haths _
1)lie uthealing s)stem _. .__ Number ofdecks, porch"
I')pcofcoolinu system - 1'11closed _ .. - ._.Open
1. "1otal Project Square Foolagc ntlty he iubstitutcd t'or"folal Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DE
PARTMENT
\lll,w
!C 1t/n Hu.\1.1u.\il:r Ct 1' • i.11 l•w, tf.111.11.111 W I
Workers' Campenaatlon Infuruncg t 1 lllcunt In urinrtlo UOdavit: llullden/Cdntractur3/Ele trlclansIPlumben
lat int Le 'hl
�(.11T1CIOua,wrrr)r;lanvalinrir lnJr r,duull: - - � nn
Cily,Staic.7.ip• Zflc� �.
Phone;J:_1lf/�. %j3S` 7tI_�5�
I .tre%uu at uogilayer:I Check the apprnprlaw box.
I. :all a emplu)ur with _ 0. ❑ 1 "In a jenural anluaelor and 1 hIM o/pro)act(rellulrod):
vnI h4vus(lull nid/ur part•time).a have hired IN,rub-eumrcwr rf• ❑New consitueliun'•O I,un a sots prnprilam or partner• listed on the anached shevt 1.rhip;lull have no atnpluyevrl These subcontractors have y' Remodeling
barking nit Inv 1n any capacity, workers'comp, insurance. g' n@molition
I NO worker'comp. insurance J. ❑ We are a calponstion and its 9' ❑Ouddind additiun
1.❑ nyuind J on4cers 114ve vrereis rl their
I am a hutncuwncr Joing all work riyhr of cacm Lion 10.0 Elaerrieal repair or additions
myself,h'o Ivnrker'cum P par MQL 11.0 Plumbing rupuirs or addilinna
P• e. 1 J7, 410).and Iv@ have no
insurance required.) t .mplvyees.h'a worker' 12.0 Rool'mpuirs
comp. inrurncu rcyuinrl.J I10 Other
1q) Ilk ILrf�
e�ir.cYs ay VIM .aW,ar WI Inv WCIWm L Iuw dw.,ne'hea errklel'eunrlMvuYlun
'I lumw,q,gn any uJmrif IAis nal,levie irmlka,in ,
(.Mi/.Iflmn,hM fhrre lnq lra nlwa ma•Aei.,nWJ,A'roy�'ruina Jl wu,nrllµ*Alp uuruMruvrnr Inrlicrudmreyliu,�
Ivw1 aluwin 1M manM oI rM rllaW@nV rare mwI.u1wrY a nrw unyrn inJiyl,ne vl\►.
/urn un vnlpleyn that Ira prvv/Jlnr rvrrrAeri'rurnprnmN@n lu.rffnrfrc@/ar fry nn and thew
4UAdm''IV,�Jwy
inlurinullul / ��,,,�,��o pl Jeet Bdarvli!hope/!4yunf//u1.li/e
Imurancl:C'umpany,Valnt�—v-�-��_
Policy v or Sulr-ins. Lic.re: - ! - ----------------
/q,��, I Efipirarlon our@:
lab SIN �tdJn•c.r: `I�r{---cc-r'-/oN . .. . �
.NtacA a copy of fh@ Irsrkers' uwnpvmatius pulley duelurallun pay@(showing the policynumber and
data).
I;ullury to rucury"itrug@ ar required under Sci;tiun?JA ul'SICL c. 152 wu lead to nu im
li"� up nI l'l Jno,tM unJ/ur unt•yeu nnprirumncnt, wall ar vial pvnalhu in Ihu turn)Ora 5TOp %V( GRDER snd Rne
i up m i1JQ 00.I Jay, quinar Illy* ri,Il.uur. Ile advLv J IAm a,•„ Position of criminal penalties a to
141�nln' py urlht\,laicmum may bo turwarJad lu the U11ico ul
va ..nra a1 :Iw UI,1 :9r In.nr.u•c.c„\;ruyu 1 a 11i\.Inun.
/Flu/l:rvby i.r wider the/.ring prnu/tier u
/prr/nry that the in/urtnvl/ III�illillillillilllllllll111111111�illillillillillI
on yryriJaJ u0ure is true rut,/uorrcct
�• I. GLtao Urn U
iuJ rnI v.t/y. /)u n,I ,rite in thir�rrv, ru Ae rmny/rtrJ dy illy ur fawn
rift pf iV4n:
L.uiny .\uthurily ( ircla , —'�-- Yennittl.lernre 1
e n1a1:
I 1 •,rllr.dNl !. Ihuhh,y I11p.,rtulenl 1. CiU.'runn Clerk J, l•'Icefrir.111mpccfur i, Mumbin
G. 171hlllvr vr
Y hnycctar
II I .'"t ,c1 1'1 nuu:
1.
information and instructions
ye is detineJ as" elsan In hit service of another un,ler.uty conlnct of hire.
.its l,icncral laws c�Ypter 1 i2 tcqulres all cngllu)4(s to provide Vufkcrs• compensanan tut thou cnlp uyees.
every P
I•u nu.utt tU HIM +utule, an nnD
:.Preis ur unpheJ, oral or wrllten ' orahun ur ither Icgal cnnry, Of any two or inure
artnenhip,associalido.carp to Ct Of the
�n ,•,nplupar is droned as"an mJgvidual, P ,nit em luytne employees. However the
�t the I�t(CyJtng M`ag:d m a I Ind idu 1. P a, and mcl-,ilij the 1,:Vl rcpre*eolauve*ut a deceased emp )
who resides therein,ur the oCcupang of the
,ecelver ur(taster of an iudivtdual, pagmenhtp, a$satauuo ut othCt legal UM Illy,
owner u1,a dwelling house having not snore than three aparvnenu and t rent be deem
to W an employer."
la + nono to do maintenunceor'�h°employr f epab der an suuh dwelling{ u+re
.Iwclhng house of another ng a unM+nt thereto shall uo1 beeauN
or,,n the;rounds or building app a ese shall withhold the Iswanee or
\Iva chapter 132. Q23C(b) also slate*thug"Ivory sga o or local Itcenilal{ R Y
table evidence of cumPllance wlgh the Insurance covera{e required.'
of its politiesi subdivisions.+hall
renewal of a Ilo:nse ur perntlt go Operate •huslneu or to eoestruet buildings le the oommoasveultY for
an
•tppllcaa, "lie has nag produced acceptable
sral $"Neither the commonwealth not ally
Wditionally. �IGL cllupter I S- i- t
.untrad tar the periumtanes ui public work until acceptable evidence of cwupli;mcl w ith the utsuranc
enter into any ' t d of Pd ro the :ontraclilill authority."
r:qulremenls of this chapter have been p'
\pplicante checking the boats that apply to your situation and,if
adJraslcs)and phone nuntbst(s)slong with then cegoploatelA other
Of
pl::l++ lilt out the workers' cumpsttsaaon affidavit completely,by partnerships(LLP)with no emptoycgtl other than the
necessary, supply sub-eontractor(s)^ rne14.
aired cu carry worksn' eontporwttion ityuranee. If an LLtor�+11 of ,strisl
LF do"have
nsurance. Limuad Liability Companies Cary)of Limited"pant M subingnod to the Dep
,netnbers or partners. are not req lotting of
employees.a policy is required 8e aJvl,aJ that this affidavit may
AIIe be Lure to slgtl aid data
the ulOdevl6 Tlu sfllllavit thou
ld
portrait tar license is bein4 requested.to obtaone lnlit workers'
\ccidenu for contlrmngiun of insurs^eo coverage. 1M law or if you are rey
hu retttnteJ to die city or town that
In►veaunYlcation
4Yeniofna regardinl{ allies should enter their
InJustriul .\ccidenu. Should y uy 4'ads a the number listed below. Solf"noured comp
compensation policy.plea"Call the Dep
self-insurance license Mumble. un the a pro ruse line.
clry or'l'owe OMelele P provided u space ut thu buttum
tinted Icgtbly. 'fhe De ironing hasp the applicant.
Please he cure that the amdavil is oanpleee and phas Itcam
Of a.s affdavit fur you to t111 out in the event the Otlko of Invbe u3dd;i estigations red only reference Il nn You
Y addition-
i An a'It curie
I'I:ase be+are 10 till in the pennitili"llse'to& a Which any d en yearlrunt +hnulJtwrite'iil lucuuns in n app (oily ur
that,nu,t submit tnultipb pannitlli- `tre "P?,lab Sits Addicts"the uDP • " be roviJ:J w the
Policy.. (it necessary) vJ or marked by dle city or town may D
Poto%licy..,\ copy ,)f the uMdavit that has bun officially sump' business or A be Herod venture
applicant as proof that a valid affdavit is on rile lot Nlure pmmits ut licenses. A new utlWuvit must be tilled nut each
a license or Permit not related to any
arson is v0T required ro complete this affidavit.
y e:tr. W hers a home uwnor Jr eillaen i3 abmining
day licenae ar Permit to burn leave ae.) +al D
ueattans.
ti<c kit Inveaiyatiuny would Itwe ro Ucwnk you in advance for your cooperation and should you have ,tray V
pica,e do nut hes,lare to give us a call.
rh: U:P•truncnt s addre+.e, t:lephune and race number
The Comrnonweallh of Mmsachusetts
C)epument of Industrial Accidents
OfIIee of IavndQsdons
600 wasidnaton Street
803101111, MA 02111
rel. N 617.727- 617 7
00 Cxt 02 of 1-977-MASSAFE
d s arww,mau.jav1tie*
CITY OF S,V-F.Nf, Aus.kcHL'5ETTS
JLtLDNG DEPAAT%tE\T
120 WASHNGTON STAE IT, SiO FtOOA
rRL (978) 745-9599
KIJ13EJtLAY DUXOLL Fla(978) 1#984d
MAYOR T)Ioxtu ST.PIEAAt;
DIMcroA OP PLat.lc PROPEATY/gt:MDLYC CONNISSIONHA
Construction Debris DtSposa! Atfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.S
Debris, and the provision.,of MGL a 40, S 54;
Building Permit AI is issued with the condition that the debris resulting from
INS work shall be disposed of in a p
111, S I JOA. roperly licemed waste disposal facility as defined by PYIGL c
The debris will be transported by:
(numa of hauler)
The debris will be disposed of in :
(name of facduy)
f�ddre» of Pocdi�y)
+'tln+mre of permit ipphunt
PROPOSAL Page# of pages
7
S'vle�i , s� 9 a� 97a
978-335����5
Proposal Submitted To: Job Name Job#
Address Job Location -
L
Date Date of Plans
5�
Pax# Architect
We hereby submit specifications and estimates for:
4.1
We propose hereby to famish material and labor—complete in accordance with the above specifications for the sum of:
$ 0 Dollars
with payments to be made as follows: Ze
Any alteration or deviation from above specifications involving extra costs will Respectt}'uu Y su mute
be executed only upon written order,and will become an extra charge over and tJ /
above the estimate. All agreements contingent upon strikes,accidents,or delays
beyond our control.
Note—this proposal may be withdrawn by us if not accepted within days.
ACCEPTANCE OF PRO O A /^� II
The above prices, specifications and conditions are satisfactory and are I„
hereby accepted. You are authorized to do the work as specified. Payments Signature .�� n A A
will be made as outlined above. r/r '
Date of Acceptance: , `/ I Signature
A-NC3819/T-3850 -
f