20 CRESCENT DR - BUILDING PERMIT APP t
t
The Commonwealth of Massachusetts RECEIVE
OF
Board of Building Regulations and SlWfi�ETIONAI. SE01 ES CITY M
M pBuilding
Massachusetts State Building Code, 780 CMR SALEbI/� � atrrviseda/ar 20luilding Permit Application To Construct, Repair, Ren (teD�tt�olEtf a CSOne-or Tiwo-Family Dwelling
This Section For Official Use Onit Number. Da .Applied, -Zal(Pont N;une). - . .'- Signature e
SECTION 1:SITE INFORMATION'
r1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1— `2 cYcat-:-See wr W
- 1.[a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
"Coning District Proposed Use Lot Area(sq R) Frontage(11)
1.5 Building Setbacks(R)
^ Front Yard Site Yards Rear Yard
Required Provided Required Provided Required Provided
I1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
1 Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesO
SECTION2: PROPERTY OWNERSHIP,
2.1 Owners or Record:
I 1� "lr(- Gt4Gwa.J -s Yh t-l? ✓" r Mph Ot47'+3
N)me(Print) City,State,ZIP
';k-O !2L%sC�,,.r 'tJ CC 8' a'73—Ibyq 7lA w n rr.. 16M
t No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Altemtion(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work2: S,r i t 14c n - 0 re 4C !o v 5Td2
Cr9ST C
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee:$ Indicate how Ice is determined:
❑Standard City/Town Application Fee
2. Electrica $
i ❑Total Project Cost'(Item 6)x multiplier x
l
3.Plumbing S 2`s quher Fees: S ^�L
4.XNchanicnl (FIVAC) S List: \ �[I 'G c
5.Mechanical (Fire Su ression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project cost: S y6D ❑Paid in Full 13 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES r
5.1 Construction Supervisor License(CSL)
License Number Expiration Date
Nance of CSL holder
List CSL'fype(see below)
r Type ., - Description
No. and Street
U Unrestricted DaiWin a to 35,000 cu. 11.)
R Restricted I&2 F:unil Dwellin
Cityll'uwn,State,ZIP Nt masonry
RC Roofing Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
1 I Insulation
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or IIIC Registrant Name
No.and Street Email address
(
City/Town, State ZIP Tel e hone
t SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.ISL 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...........O
r SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOIEAPPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
1
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW ORAUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
/ contained in this application s true and accurate to the best of my knowledge and understanding.
V �>! ��/J/� 3 r
Print Owner's or, ,,,zcd,\' cift's N una(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to Jo 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. 1 d2A.Other important information on the HIC Program can be found at
www.mass. roy y 20 Information on the Construction Supervisor License can be found at wwtv.mass.eov:'dns .
2. When substantial work is planned,provide the information below:
'total fluor area(sq. ft.) (including garage, finished basetnendattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
Type ofcooling system Enclose) Open
3. `"Total Project Square Footage'may be substituted for"Total Project Cost"
` FILE NO.: 206815
I
NSF SHAPIRO
y130.60'-- I,1:---- 4449'
l 9' LOT 5 B
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m
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' I EC ENCLOSED
PORCH H
LOT 17A " > `<' OWNER UNKNOWN
m:
SPLIT LEVEL
1 DWELLING
I ,
I
I
Av:
»5270'-
L 22,30, I 45:00'
CRESCENT DRIVE
( FORMERLY CRESCENT STREET ) '
SH OF
JOHN S. m
LAURETANI
✓e 34311 N
gsso� MORTGAGE LENDER
USE ONLY
plotplans.com KAIKO WESMAN,COLASANn&SI'EIN,L,P
L-
e ATTORNEY AT LAW
` DESLAURIEmRS WWW.MASSFIRM.CON
L&ASSOCIATIS,INC.
101 CONS99SI ON BLYO,SUITE D 43013etIm6S
PRANKIIII.MA 020BR 4vc4 Seim 190 Ph.(TIN)325-1786 ,
(BW)zC!-8800 PAX.:(5UB)52B-40I1 Is%noo,N OM20 Fu:(]SI)861-183J
y MORTGAGE INSPECTION PLAN THERE ME NO DEEDED IN
�. OEM OR
ADDRESS:20 CRESCENT DRIVE SALEM MA ENCROACHMENTS WIN RESPECT TO
LENDER:PEOPIE'S UNITED RANK DW NG SITUATED ON NIS LOT .
EXCEPT AS STATED ON THE DEED OF
ATTORNEY: KAJKO. WEISM , COIASANR h SMNI RECORD SHOWN.
OWNER:CHRISTOPNER P. OLSON THE LOCATION OF THE DW NG AS
APPLICANT:DANIEL GAGNON SIDWN HEREON EINER WAS IN
DATE: 1 2f 2014 SCALE:10=20' COUNTY:ESSEX CUMPUANCE WIN THE LOCAL ZONING
BY-LAWS IN EFFECT MEN
UNREGISTERED LAND CONSTRUCTED(VIM RESPECT TO
STRUCTURAL SETBACK REQUIREMENTS
FLOOD HAZARD INFO% DEED BOOK:31955 PAGE:4N ONLY),OR IS EXEMPT FROM WOATION
ZONE_2_OAIED:] 3 2O1PLAN BOOK:109 If 5947 PAGE:12 LOT ENFORCEMENT ACTION UNDER MASS.G.L
(S) TITLE MI.CHAPTER 40A,SECTION 7.
COMMUNITY PANEL:29102 0418E PLAN NUMBER: .. OF
THE LOCAnoN OF THE DWELLING SHOWN REGISTERED LAND CERnFlCATE OF TITLE
DOES NOT FALL WITHIN A SPECIAL REGISTRATION BOOK: PAGE: ASSESSORS MPP:
ROOD HAZARD ZONE. EXCEPT AS MAY
BE INDICATED. PLAN NUMBER:23M-C LOT(5): BLOCK: LOT:
GENERAL NOTES: (1)THE DECLARADONS MADE MOVE PRE ON THE BASIS OF MY KNOWLEDGE,INFORMATON;AND BELIEF AS THE RESULT OF A MORTGAGE INSPECTION TAPE
SURVEY,NOT NE RESULT OF AN INSTRUMENT SURVEY MADE TO THE NORM&STANDARD OF CARE OF REGISTERED LAND SURVEYORS PRACDCING IN MASSACHUSETTS.(2)
DECLARADONS.ARE MADE TO THE ABOVE NAMED CUENT ONLY AS OF NIS DAIS(3)NIS PLAN WAS NOT MADE FOR RECORDING PURPOSES,FOR USE IN PREPARING DEED
DESCRIPTIONS OR FOR CONSTRUCDON.(4)VERIHCADONS OF PROPERTY LINE DIMENSIONS,BUILDING OFFSETS,FENCES.OR LOT CONRGURANON MAY BE ACCOMPUSIED BY AN
ACCURATE INSIRUMENT SURVEY.(5)NO RESPONSIBILITY IS ASSUMED HEREIN TO NE LAND OYMER OR OCWPANT.
CV04l L ]O[t{On lo(wp A Amc.Inc
r
r QTY OF SALEM) MASSACHUSE M
y '� BLU DING DEPARTMENT
120 WASHNGTONSTREET,3'DFLOOR
TEL(978)745-9595
KDOERLEYDRISCOLL FAX(978)740-9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OFPUBIICFROPERTY/BUILDING WMMISSIONER
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 111.5 Debris,
and the provisions of MGL c4q S 54; Building Permit# is with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
N a r--V
(name of hauler)
The debris will be disposed of in:
S g-n,e
(name of facility)
/ - SGv 4 N jOjl v -/ /ag n SVYL c1nn, Vv\✓q
(address of facility)
Signature of*.jnnN-,,nn+
Date
i
QTY OF SALEM, MASSACI IUSETTS
r � �S
f BUILDING DEPARTMENT
��ly s;ihY' 120 WASHNGTON STREET,YD FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
KINIBERLEY DRISCOLL
MAYOR TrIOMAS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COIVMISSIONER
HOMEOWNER LICENSE EXEMPTION
PLEASE PRINT:
Date 312 u 1 i'c- \
Job Location 7 d G 2(Z Sct,vr p 9
Home Owner Address 20 C fLEse e wT (PL
Present Mailing Address
The current exemption of"Homeowners" was extended to include owner-occupied dwellings of two
Units or less and to allow such homeowners to engage an individual for hire that does not possess a
license, provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s) who owns a parcel of land on which he/she resides or intends to reside, on which there is, or
is intended to be, a one-or two-family dwelling, attached or detached structures accessory to such use
and/or farm structures. A person who constructs more than one home in a two year period shall not be
considered a homeowner. Such "homeowner' shall submit to the Building Official, on a form acceptable
to the Building Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner" assumes responsibility for compliance with the State Building Code and
other applicable by-laws and regulations.
The undersigned "homeowner" certifies that he/she understand the City of Salem Building Department
minimum inspection procedures and requirements and that he/she will comply with such procedures
and requirements.
HOMEOWNER'S SIGNATURE
APPROVAL OF BUILDING INSPECTOR