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10 EVERETT RD - BUILDING JACKET The Commonwealth of Massachusetts j Board of Building Regulations and Standards CITY I4 Massachusetts State Building Code, 780 CMR, 7'edition OF SALEM y✓hr IV i Revised Junnury �I Building Permit Applicall To onstruct, Repair, Renovate: Demolish a /. 201AV One-or T vu-Fumi. Ow 1Gng This Skction For 90cial Use Only Building Permit Nu r: Date Applied: Signature: Buildrn C missioner/InsplykarVXuildings f}rle S CTION 1: SITE INFORMATION L rty Address: 1.2 Assesaon Map b Parcel Number61160-em 4�s an acce ted street?yes no Map Number Parcel Number glaformatloo: 1.4 PropertyDlmenaloos: rict Proposed Use Lot Area(sq 11) Frontage(11) ng Setbacks(R) Front Yard Side Yards Rear Yard 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: Public G , Private❑ Zone: _ Outside Flood Zone' Municipal 13-&site disposal system ❑ Check if es❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Ree +inn s�u�1 ord: LrY � -V&98-77- 2 Name(Print) Address or Service:� r� /0/2 3?" 6 ] Signature Telephone SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all pat apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alleration(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description o��f�"Proposed Work': OnIn&X r=4-45A0f7ranE.v?" G(-V-1�i azpQf �GXnJinJf+/�Y7S�n'rLNrF!M S3HN�liS � _�/) C�I '�-� F/Ar1Sf/ 77) LS l/fly /93!} j�fINVGV 4 h SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costa: 0mclal Use Only Labor and Materials I. Building S Z 1. Building Permit Fee:S Indicate how fee is determined: �. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost (Item 6)c multiplier x 3. Plumbing Is 2. Other Fm: S 4. Mechanical (HVAC) S List: 5. Mechanical (Fire S Suppression) Total All Fees:S Check No. _Check Amount: Cash Amount: 6. Total Project Cost: S Z �Zr? ❑Paid in Full ❑Outstanding Balance Due: • SECTION S: CONSTRUCTION SERVICES $ofC. onstruction Supervisor(CSL) �l/�13 License Number Expiratiion fluic lderList C'SL-type 1s. below)f Descri ion � U (InresiricteJ u to 73,000 Cu.Ft.R Restricted lag Famil Dwellino �y j F Re (MI J% RC Residential Roufin C'overin I"clepMme WS RniJentiol Window and Siding SF ResiJentiel Solid Fuel Bumin Appliance Installation D Residential Demolition E1 provemeot oatraetor(HIC) , 3X V—? ytaRegistrorion Number ICRrgyt e / ?l Expiration Date ' e ephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 132. 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 lssuancF of the building permit. Signed Affidavit Attached? Yes .......... No...........0 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 Aa/OJl ��a'iQitll/+�'� S to act on my behalf,in all matters relative to work authorized by this building permit application. Si"un:of Owner Dote SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION 1 it!y ,as Owner or Authorized Agent hereby declare that the statements and i formation on the foregoing application are true and accurate,to the best of my knowledge and behalf. � '/ Print ee G••/ Signatu of( A hori ent Date Si t sins and nalties of 'u NOTES: 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 ag have access to the arbitration program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and Construction Supervise Licensing(CSL)can be found in 790 CMR Regulations 1 IO.R6 and 110.R5, respectively. ?. When substantial work is planned,provide the information below: Total floors area(Sq. Ft.) (including garage, finished basement/enics,decks or porch) Gross living area(Sq.Ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half7baths -Type of heating system Number of decks/porches Type of cooling system Enclosed Open ). "Total Project Square Footage"maybe substituted for"Total Project Cost" CONTRACT Customer Name � DLur4 L 'z P+- enJ��G�ye .p� Customer Signatautrie SKETCH Contract Date / a Sales Represenve Signature ATTACHMENTCustomer Phone 1172jZ9CULZ u IC u n le m xo m a a V ts n Is is m ex m n Is n a6 el ewx ✓as 6f IFJI jot. a e ' j (I'1 : o" (VA(( Sys/gym whir Y. 110 w"( sivds to ie T't'i n` dee( • �'x .g -w iIZG—.biS i L rc'(PSS:&, chi/) krl,47.5\ . r�/1 y 7Gb o u�i Y II 00flel-s �- fnq) e xo .'� I_ Z JI hk reg er S w)4! A es rX. C)aU PCs OizU rCi�( ' .S�i Adle ze rc4/(° im-ti xa phone � acGt 00 xx LN Yo,e v xs NOTES: I J/ G N 'Each box equals one fool unless othoWso noted.This sketch Is a good fallh representation of the work to be done,it is understood that all dimensions CSO e2 a 11 h pc: rlt/ / h ron xYl demand from this sketch are approximate,and that all locations of outlets,light fixtures,plugs,lacks and/or switches are subject to change it necessary, CONTRACT Customer Name Daum u 1 '7 w04enOeI Customer Signature y' SKETCH Contract Date $t �2u 11U Sales Representative Signature z ATTACHMENT Customer Phone bo. SRN- ng9S eel( D6b.ld. Contract Price 1,el ➢�9_,_s�0_i__➢_B_.�9 1➢ Ip ,L 1) 1$ 19 M 91 ➢_ to N M x$ =r =B =9'. N ➢1 y In N 15 i ]_ ]➢ n 1p 11 4 ,] 11 ,! aE ,) ,. ,9 0 11 5= 6t M Ss al sl a. 59 W CC- I P `N I aQ guWfr�O 1 . MT �00 y q�v hem' / uc �u(l Sys1�m wl�r u 1 ACV � G6 1 0ecnrb.S;laf 19 rr" A,L( I I i, �izvbrs Z frressecl ens hY1,:E5' OWL — --` SvG ca PcS dnU r I 1 SFI'AVr5 SNke Je4rfnr :-v / Co =9 /hone � acGt (eco Oo-f 61� Psnel nJ 9= L,; YO, Pole 90 - i5 NOTES: - x I� PVJr4t� Refore 'Each box equals one loot unless othonvise noted.This sketch,is a good faith represenfallenof the work to be done, it is understood that all dimensions �f V n t\ h[JC. Ae/ r h /•[k'x M derived from this sketch are approximate,and that all locations of oulleta.light fixtures,plugs,lacks and/or switches are subject to change it necessary. II.-*NS-MOST13f f4L+0-*N0 AP 1ROVE0 BY T+IE LNS.PFXTOA ,PFWR TO A.PERMIT.B EW G GRANTED CITY OF SALEM \ \ lemr �•`? �''�'�� Date - V. y a , � -�. • ;i _�� Ward \s y \9fomNeuo'° Zoning District Is Property Located in Location of the Historic District? Yes_No Building { r e Is Property Located in J- /r/ the Conservation Area? Yes_No BUILDING PERMIT APPLICATION FOR: Permit to: (Circle whichever apply) Roof, to of, nstall Siding, Construct Deck, Shed, Pool, Repair ace, 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 } r=te/5 /�n� Avt// Address & Phone 'i o iv U r i e 4 l —c! tP 55 Architect's Name Address & Phone ( ) Mechanics Name t o Address & Phone e--11 cc oaek1u What is the purpose of building? T Material of building? If a dwelling, for how many families? Will building conformtolaw? Asbestos? Estimated cost City License # State License # / Home Improvement Lic. / Signatu a of Applicant SIGNED UNDER THE PENALTY OF PERJURY DESCRIPTION OF WORK TO BE DONE ��1 ',//j 4:42 MAIL PERMIT TO: U& e1W No. APPLICATION FOR 1PERMIT jTO LOCATION PERMIT GRANTED 19 V�D APD 'J INSPECTO OF BUILDINGS PUBLIC PROPERTY DEPARTMENT 120 WASHINGTON STREET, 3RD FLOOR SALEM,MA 01970 TEL (978)743-9595 EXT. 380 FAx (078) 740-9646 STANLEY J. USOVICZ, JR. MAYOR DISPOSAL OF DEBRIS AFFIDAVIT In accordance with the provisions of MGL c 40,S34,I acknowledge that as a condition of Building Permit# ,all debris resulting from the constriction activity governed by this Building Permit shall be disposed of in a properly licensed solid-waste disposal facility,as defined by MGL a III,S 150A / The debris will be disposed of at Location of Facility Signature t Applicant Date FULLY complete the following information: (PLEASE PRINT CLEARLY) Name of Permit Applicant Af Z,11?" - k"/ Firm Name, if any . r Address,City&Sta16 The above statute requires that debris tom the demolition, renovation,rehab or other alteration of building or structure be disposed in a properly-licensed solid-waste disposal facility as defined by MGL cIII, S150A, and the building permits or licenses are to indicate the location of the facility. G� 11397 $256=' The Commonwealth ofMassachus DECEIVED 7 , PECTIONAL SERVICE �M a_ ;v Board of Building Regulations and Standar hs Massachusetts State Building Code,780 CMR Revised Mar 2011 101500 OCA i>li 0` tt�e ► Building Permit Application To Construct,Repair, Renovate Or e o is 4 0 One-or Two-Family Dwelling - - This Section For Official Vse Only Building Permit Number: I Date A lied: f \� Building Official(Print Name) - Signature - Date SECTION 1:SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers .//1 �_ n^��� . L1.1a 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(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.G.L c.407§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Oyvnert of Record• l-ef'H W Name(Print) City,State,ZIP l r� ey-e yr oi- Rd 617 No,and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORIO(check all that apply) New Construction❑ Nisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other pecify: Brief Description of Pr9posed Work: JO M ce)r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ ���. 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ 13 Standard City/Town Application Fee - ❑Total Project Costa(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ per(-700 ❑Paid in Full ❑Outstanding Balance Due: M CA( L-ES'D IC)IZZ To PA-L- , 5tases SECTION 5: CONSTRUCTION SERVICES rName nstruction Supervisor License(CSL) Y7�T7 y1Z3/1(y ., License Number Expiration Date f CSL Holder !' r�Enc W.Palm - List CSL Type(see below)Street 1 tOD (feet Type Description Salem MA 01970A tri&M(Buildin ., to 35,000 cu.ft) city/I'own,State,ZIP cted 1&2 Famil Dwellin Mason-, ow and Sidin9�� ��r�t-�/�3 Fuel Burning Appliances tion Tele hone Email addresslitionG 5.2 Registered Home Improvement Contractor(HIC) t4 Z U 0 g 3 �Z 7� Atlantic Weatheriiaation LLC HIC Registration Number Ex ration Date HIC ComP��Y�`r�� I�� Name P No.and StreetSalem Email address Ci /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 o e building permit Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize C4,1 �Cv/ki-n to act on my behalf,in all matters relative to work authorized by this building permit application. Print On ame( ontc S � /a" Date SECTION 7b:OWNER`OR AUTHORIZED AGENT DECLARATION By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information contain d in this ap licatr s e and accurate to the best of my knowledge and understanding. / /o Print Ownec s or Authorized Agem s Name(Electronic Signature) Date NOTES: 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 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 Information on the Construction Supervisor License can be found at 2. When substantial work is planned,provide the information below: Total floor area(sq.$.) (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 of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost"