6 EDEN ST - BUILDING JACKET S-MOST-BE ff'L-Eg-� APPROVED BY T44E
.UalSpFXTDR ,PRWR TD.A.PERMIT.BFJNG GRANTED
CITY OF SALEM
SD` T\ 7 3 No. / ZQb� F";`�� "W, '•\, Date d o 3
pg Opy�
Is Property Located in / Location of
the Historic District? Yes—No Building
Is Property Located in
the Conservation Area? Yes No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) Roof, Reroof, Install Siding, Construct Deck, Shed, Pool,
Repair/Replace, Other:
PLEASE FILL OUT LEGIBLY & COMPLETELY TO AVOID DELAYS IN PROCESSING
TO THE INSPECTOR OF BUILDINGS:
The undersigned hereby applies for a permit to build according to the following
specifications:
Owner's Name MR5 3;gLb ,
Address & Phone rD GQen 5 -e� (9?g)
Architect's Name
Address & Phone
Mechanics Name pe((vex Pia L,y (rn t3 - 22_5
Address & Phone 3s-14 Nog-n4 gPnrpu>taq L ) St ►�-ty1 t\1 H .
What is the u 3a
purpose of building? e(J(a"4- l),jmr S
Material of building? IJ66A If a dwelling, for how many families? /
Will building conform to law? Asbestos?
Estimated cost /o2, - as City License# N " State License tt CS 03? loa 3
�1 o_ Rome Improvement
J Lic. i Lam— Signature of App icl ant
G� W080 SIGNED UNDER THE PENALTY
OF PERJURY
DESCRIPTION OF WORK TO BE DONE
�7 MAIL PERMIT TO: fed,,.tl 5:a4 35-ze AJ Ja.�. A.G W D307t
No. / SO- Z co o
APPLICATION FOR
PERMIT TO
j LOCATION
PERMIT GRANTED
APPROVED
INSPECTOR OF BUILDINGS
r V'
4 The Commonwealth of Massachusetts INSPECT' 1A CITYROFI
� Board of Building Regulations and Standards
d71 / Massachusetts State Building Code, 780 CMR T�� aAU r ?EZ, �
Building Permit Application To Construct, Repair, Renovate Or Demo rs
one-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date A lied:
q P
` building Olticial(Print N:tme). -; Date
Signature.: -
SECTION t:SITE INFORMATION
1.grope Address: 1.2 Assessors bfap&Parcel Numbers
1.I a Is this an acce ted street?yes CK no Map Number Parcel Number
1.3 'Zoning Information: IA Properly Dimensions:
Zoning District Proposed Use Lot Area(sy it) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.21 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yesE3
SECTION2: PROPERTY OWNERSHIP!'
2.1 Owne r of Recorll:�u ��� n A A 1 c LC7
-t�t5) V'n 5�hme(Pr(nt)/ _ �Z f _ City,State ZIP
/Lr� �(/I/�'( SuS��n .C. s, Sh �l,Con'l
val� a
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building Owner-Occupie epairs(s) Altemtion(s) t Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Un is Other ❑ Specify:
Brief Description of Proposed Work': O r
G!/ ( / GLC /mt i/LGG ✓U/I //R
SECTION J:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard Citylfown Application Fee
2. Electrical S Cl Total Project Cose(item 6)x multiplier x
3. Plumbing S P Qther Fees: S
d. ,mechanical (BVAC) S List:
5. ,,\feehanical (Fire S rotai All Fees:S
Suppression)
yr �� Check No._Check Amount: Cash r\maunt:
6.TuCtl Project Cost: S[�+�/� ❑Paid in Full ❑Outstanding Balance Due:
� I3
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) _ ,C�53� -
( ) 13 �i 6
License Number Expiration Dale
Name of CSL Holder yp �_�F List CSL'T a(see below)
( 0 �eA — -Type - -- Description
No. and Street ..
U I Unresuicted(Buildings a -to 35,000 cu. It.
)4 S1_fA ML R I Restricted 1&2 Family Dwelling
Cityfrown,State,ZIP M Masonery
RC Roofing Covcrin
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home improvement Contractor(HIC) d 6 �� d
ei+ / 5 h n� �K-5 tlC Registration Number Exp Lion me
I ll( Cum .my ama or HIC Registrant Name
Email address
City/Town,State ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION 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 ..........O No...........❑
SECTION 7a;OWNER AUTHORIZATION TO t3E.COMPLETED WHEN)
OWNER'S AGENT OR CONTRACTORAPPLIES'FOR EIMLDING.PERMIT`
I, 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.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED 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 applicationA'true and accurate to the best of my knowledge and understanding. .
Print Owner's or Authorized rlgent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or art 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
Ajvw mass cov;'oca Information on the Construction Supervisor License can be found at www.mass.00v-'dns
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) y000 S� 9 ;(including garage,finished basementlattics,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 systern Number of decks/porches
Type ofcoolingsystem Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
'10 zgofz,
:( The Commonwealth of Massachusetts
q, Board of Building Regulations and Standard Prm'e'firz) � , OF
M
00 �� Massachusetts State Building Code,780 CMR Rer sed A/m 20!!
v
Building Permit Application To Construct, Repair,Renovat9uh loco l( aA la, 30
One-or Two-Family Dwelling
1 This Section For Official Use Only
Building Permit Number: Date plied: _
Building Official(Print Name) Signature Date
SECTION 1.: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
_� E E)�S_L/SAL EM N1�
1.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required I 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?Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
4g45-_.E SNo(Ai
m , rYI.4 c/97o
Nae(Print) City,State,ZIP
6 EBegV :;Ir 2--03- 71-" 8 i4+44YtFwH*� .4/� .cay,
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) R1 Alterations) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':__j)( t, (. CU_ �rfr:n c f`r+i
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ Q U0d 1. Building Permit Fee:$ Indicate how fee is determine
Rd:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ K List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
y�15 Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ [D 000 ❑Paid in Full ❑Outstanding Balance Due:
M la Lt- -1-0 G.C .
SECTION 5: CONSTRUCTION SERVICES
iI (5.1 Construction Supervisor License(CSL) GS'071-7/j �dB Zo//8 '
C S — 0T l3 �/. Rice—) License Number Espiratio Date
Name of CSL Bolder
/ R • - A List CSL Type(see below)
No.and Street
L �"5'—"'&— � Type Description
O Unrestricted(Buildings2 Fm u el ing cu.ft.)
R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Rending Covering
WS Window and Siding
�yy A� SF Solid Fuel Burning Appliances
LP g��J 9/_3_S /TrA"p'(1e�1ICLLftb1.�,.[ I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
��is6 7
f�i}Iy_..ICI_C.G_1.�E51��CQI11$'j)eUL�/p.1�__/�Iv1JQtCLI -HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name .I
I re-$l{�6J.2 E Ie b /4' �l�'L!C @ /-BG9GC•Cai�'L
No.and Street Email address
No — �W-WA_/.MA o_j 86Y-J77
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 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 ..........OK No—.........❑
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 A&.n.Ve cc 1
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
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
contained in this application is true and accurate to the best of my knowledge and understanding.
ka , 2 Cc � _
G .0i— Date
Print Owner's or Authorized Agent's? ame(Electronic SignaNre) Date
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 Home Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage,finished basementlattics,decks or porch)
Gross Iiving 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 of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
!p
NA The Commonwealth of Massachusetts
Department of Industrial Accidents
I Congress Street,Suite 100
Boston,MA 02114-2017
www mass.gov/dia
Workers'Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information /J p Please Print /Legibly
Name (Business/Organintion/Individual): ngda(✓x ((.�( CC t p
Address: ) 72 Shc)r,( (20c-14
City/State/Zip: NO,4 h 0601/1 lqM 0A Phone#: 0[ 6 3 S
Are you an employer?Check the appropriate box: Type of project(required):
1.M-[am a employer with employees(full and/or part-time).+' 7. ❑New construction
2.❑I am a sole proprietor or partnership and have no employees working for me in
8. ❑Remodeling
any capacity.(No workers'comp.insurance required.)
3.❑1 am a homeowner doing all work myself.[No workers'comp.insurance required.)'
9. ❑Demolition
4.❑1 am a homeowatt and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole I I.❑Electrical repairs or additions
proprietors with no employees. 12.❑Plumbing repairs or additions
5.❑lama general contractor end I have hired the subcontractors listed on the attached shecL 13.❑Roof re((p��al!ir--s (�
These subcontractors have employees and have workers'comp.insurance.= 13.f( Roof pairs 2C-p�f aP
6.❑We area corporation and its officers have exercised their right of exemption per MGL c. M-Other
152,§](4),and we have no employees.(No workers'comp.insurance required.) ,
"Any applicant that checks box 4I must also fill out the section below showing their workers'compensation policy information.
i Homeowners who submit this affidavit indicating they are doing all work and than hire outside contractors trust submit a new affidavit indicating such.
tContruclors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. If the sub-contractors have employees,they no ust provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for rrry,employees. Below is the policy and job site
information.
Insurance Company Name: Lcbir` i / `(jf UR 1
Policy#or Self-ins.Liic.#: (C] fi-- S( S — ,O b Expiration Date: — —( n
`� �
Job Site Address: /O C t!�!� S City/State/Zip: (e1K7, (�'/t 0[ i.c�
Z 0
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofperiury that the information provided above is true and correct.
Sipnature: ��� Date:
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6. Other
Contact Person: Phone#: