78 ESSEX ST - BUILDING JACKET What is the current
use of the Building? �GS�'� ^� ` °`
Material of Building? If dwelling,how many units?
Will Budding Conf "to Law? Asbestos?
ll to
Arehit ds Name
Address and Phone
MochanWs Name k
. Address and Phone a`r1Fs
CanSbVC*M Supervisor License g HIC Registration df
Estimated CM=ost Pema Fee Calculation
Permit FeeEstimatedcost X:7/$1000 Residential Estimated Cost X$111$1000 Carnrnercia4--
An Additional $6.00 is added as an
Administrative
Make sure that all fields are properly and legibly written to avoid delays in processing.
The undersigned dose hereby apply for a Building Permit to build to the above stated
ifio specatlons. Signed under penalty of perjury X
Date
N
13
- C6 -
r
EITrOF
PUBLIC PROPERTY
DEPARTMENT
�rwroa 120 W&%UKC cw a�cr•sMb1.,wn Aaa:srra 01970
TX1.9. 74S.""•FA=9711.740-9Ne
APPLICATION FOR TIIN-REPAIR.1tENOVATION •CONSTRUCTION
DE.rIOLITION. OR CHANGE OF USE OR OCCUPANCY, FOR ANY FMSTING
STRUCTURE OR BUILDING
1.0 SITE INFORMATION
Location Name: Building:
----
-7 1 � s5ex
Property to bcsW in s;Conswvadon Am YIN Historic Dlsttld YIN
2.0 OWNERSHIP INFORMATION
2.1 Owner of Land
Name:
Address:
Telephone:
3.0 COMPLETE THIS SECTION FOR WORK IN EKIeT G BUILDINGS ONLY
Addition Existing
Renovation Number of Stories Renovated
Change in Use - New.
Demolition Existing
Approximate year of Area per floor (sf) Renovated
construction or renovation
of existing building I I New
Bciet Description of Proposed Work:
—Mail Permit to: \XD v c c.aCA4(-,
_-_
:a the C'omnwnweallh of Massachusetts
Board of Building Regulations and Standards CI'I'1' OF
' Massachusetts State Building Code, 730 C NIR SALEM
Revised ihn '0/l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Fan)ily Dnrellm
This Section For Official Use 'Illl
Building Permit Number: Dale: plic .
fhiilding 011iciol(Print Nmnc) Signature Date
SECTION I: SITE INFORD
1.1 Property Address: 1.2 Assessor lap Rt Parcel Numbers
R Cy C,-r
I.la Is this an accepted streetq yes no_ Map Nunnber Parcel Numher
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District PropoxJ Use Lot Area(sq It) Fromuge(II)
L5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zane? Munici al❑ disposal On site dis ).
Check it' es❑ p s stcm ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
N;une(Prin')t Lily.State,,..Ir
Nu. and S' telephone Finail Address
SECTION 3: DESCRIPTION OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Buildin Owner-Occupie Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Spcciry:
Brief Description of Proposed Work-:
SECTION a: ESTh\IATED CONSTRUCTION COSTS
item Estimated Costs:
(Labor and \laterials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical 5 ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier __ x
� ?. I'lumhing S 2. Other Fees: S
J. .\Icch;mic;d ill\':\C'1 5 List:
?. Mechanical (Fire --- - --
Su 1 ttessiun) S Total \Il Fces: S ------ _...----
` Check No, Check Annount: _ C,uh Antuunc
h. Total Project Cost: 5 - 13 Paid in Full 0 Outstanding Balance Due: -
SECTION 5: CONSTRUCf10N SF.RVI('FS
5.1 Construction Supervisor License(C'SL)
L
icense Number Fxpruuon Date
Name of CSI. I lolder
Q Lisl C'SL.l)Pe(see hclulvl
;7-L 4,-S.-S ` Li:74 L»V- -I s p. Descriplion
No, and Street
p l l l h,tride l I IA.lildin,s a l0 15,11110 cu. Il.l
NG l] R Re,trictcd L@2 Pumil Dllellin
Citci fowl,Slate.LIP M Masonr
RC Rooling C'ovcrin
_ WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
I'elc hone limail address D Demolition
5.2 Registered flume Improvement Contractor(HIC) DO +E ( i Z 3
L gyp,✓ C, L b�L4- Cc»✓`T IIIC Registration Number Expiration Date
I IIC'C'ompan) Nettle or I IIC Registrant NantO
'ct ry� Email address
N 'L .n ,4 boa a W� 7 ' A
City/Town. State,ZIP 'relc hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 9 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 1 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 Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERn OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of(Ile iuful matiun
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner's or uthunre \bv `lame IElectronic Signature) Date
NOTES:
I. .\n 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 Contractor(HIC) Program), will!o 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
lotto m.l.. .;ol , c.l Information on the Construction Supervisor License can be found at lu>lll.nuh: ,Ip.
r2.—\�,—'Ihen5t;.b�siantial work is planned, provide the information below:
otal looraa(sy. ft.) I including garage, finished basemenitattics,decks or porch)
ross )icing area I sy. flJ Habitable room count
\umber of fireplaces.---- Number of bedrooms
Number of bathrooms — --- - -- Number of h:df halms
Number of decks, porches .
h\peofe00hllgslilClll - Enclosed _ _ .- - ._.011en -
1. -f'olal Project Square Foolige"Ilia) be substituted t'or"1'ot;ll Project Cost-
f
, w
s9 SfiAliSi $E APPROVED $Y T44E l;
.WSPEC141.8 4lAR D; PEFlI lT B,EWG GRANTED
CITY OF SAiLEM
No%Q\ O�\L-1
1 a/
' Gat O
in y;r}
Is Property Located In / Location of t G��� �
the Historic District? Yes_No_ Bui1ding
Is Property Located in
the Conservation Area? Yes_No
BUILDING PERMIT APPLICATION FOR:
Permit to:
(Circle whichever apply) 4�1
nstall Siding, Construct Deck, Shed, Pool,
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 CL. b q.
Address & Phone 79 052Z
Architect's Name
Address & Phone //�� )
Mechanics Name r rU T
Address & Phoned
What Is the purpose of building?
Material of bulldin ? f h If a dwelling, for how many families?
g101J
f F•I
WIII building contonn to law? �J� Asbestos?
Estimated cost Ov City License k N A state License 8
How rmprovenent
ig ture of Applicant W
�SMNED UNDER THE PENISTY if
OF PERJURY
DESCRIPTION O3WRK TO BE DONE
rid
61
o j Srfui��-P �'iI
�II
r
MAIL PERMIT TO:
y�� ���
_W
l
No.
APPUCATION FOR
PERMIT TO
29
LOCATION
PERMIT GRANTED
APP VfD
INSPECTO OF BUILDINGS 4