95 DERBY ST - BUILDING PERMIT APP JACKET SECTION 5 r=(�01VSTRTdCT3T0 n SE}tYYCLrS.,-
5.1 Licensed Construction Supervisor(CSL) '� /4�7L2
L License Number Expiration Date
Name of CSL-Holder V\- List CSL Type(see below) y
hSGQe DSsct `'tion
Address G U Unrestricted(up to 35,000 Cu.Ft.
)Z A.! ^^-� R Restricted 1&2 FamilyDwellin
Signature !tom M Maso Onl
' t:— =3 j 13 RC - Residential Rqq,fu,g covering
Telephone WS. Residential Window and Sidin
SF Residential Solid Fuel Burning A liance Installation /.
D Residential Demolition
5.2 Re 'ster H e I provement Contract rPIC) �D S—�
LL Registration Number
HIC Co Name or C Reg t e
AddresL7k 74,��?3 Expiration Date
Signature �/ Telephone
SECTION 6 WORT{EIFS'COMPENSAT19N INIRANCE AFFIDAVIT(M.G.L:.e.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 Issuance of the building permit.
Signed Affidavit Attached? Yes No 0
SECTION 78 0WfV11 R ACJ 11 Ht1It A ON; . BRgC f MPLE rf WHEN ..;
pVV1YER'SAGENT.OR;CONTRiCCTORAPPxISSFUR=> fII INPiF 1T
I as Owner of the subject property hereby
to act on my behalf,in all matters
authorize
relati to work authorized by this bu' permit application.
Si" of Owner Da[e
sEOI IiTN 7�', �S7vrE?TLy „a3 ,4 1 .,,44AGE1 T DECLe Rt.
I, M as Owner or Authorized Agent hereby declare
that the statements and informatiot on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name LJ.
Signature of Owner or Authorized Agent Date
Si ed under the sins and penalties of
1. 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 nor have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I10.R6 and I10.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (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
Type of heating system Number of decks/porches
Type ofcooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts CITY
n Board of Building Regulations and Standards OF SALEM
Massachusetts State Building Code,780 CMR, 7a'edition Revised January
n`}p Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
"ty One or Two F e mg
Budding l'eftnu Numbec
n$1 ature
Building Cotnniissmnerl 14spacto�'nf w �� v.' � �a�'
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
C7? %c,606 t/ 5
.I.l�s an accepted street? es�6o Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District; - - Proposed Use - Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(it)
Front Yard' _ ,. Side Yards - 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:
Zone: Outside Flood Zone? Municipal❑ On site disposal system. ❑ -
Public❑ :Private❑ Check if es❑
2.1 Owner'of Record.� �.� �•���� .
e(Print). - - Address for Service:
Si a Telephone
SECTION 3 ,D,E ERIP t I!7 OF 1 PSEi)_,_Q", (ej eck al1'that apply)
New Construction ❑ Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': 17
L '
.� /Qn T .Q n (✓_,ice
SECTION 4,:_ESTIMAl31 COAIS�}t17!✓TION, STS
Estimated Costs: peal Use Only
Item Labor and Materials
1.Building $ 1 8t ddmg errrttFee $ - Indicate how fee is determined:
Wtmdat CrtyGiawnAppircationFee
2.Electrical $
q Toni je trGgst° fditf,6)xE b tiplier x
3.Plumbing $ Z)tklo
4.Mechanical (HVAC) $
S.Mechanical (Fire $ otalrAllFees suppression)
Chaglc Na Check Amount: Cash_Amount:
6.Total Project Cost: /. Q l7 Paid Cl Outstanding,Balance:I)ue:... �1..
Y .