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18 FAIRMOUNT ST - BUILDING JACKET �10 �— CC- The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair, Renovate Or Demolish a �— One-or Two-Family Dwelling nf� This Section For Official Use Only 1.1 Building Permit Number: Date Appl' d: = ta 1 0 0 Building Official(Print Name) Signature DZc I SECTION 1:SITE INFORMATION - ;I 1.1 P•ope Address: le 1.2 Assessors Map& Parcel Numbers iz�//Jrry? 2 IV 1.1 a Is this an accepted street?yes no Map Number Parcel Number tv 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.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 qer'of ecor c Name(Prin) _ Cir/,�St Ate,��ZfP �� cc��.. // UU�� /Ib�/i//rr/�Q�I.4lro,i.��✓Yr No.and Street Telephone - Email Addresf SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brie escription o Prop Scd Work 2: i ' SECTION 4:ESTIMAT CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials Official Use Only 1.Building $ 1. Building Permit Fee: $ Indicate how fee is determined: 2.Electrical $ ❑Standard City I own App icRion Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4.Mechanical (BVAC) $ List: 5.Mechanical (Fire $ Su ression Total All Fees:$ Check No. Check Amount: Cash Amount: 6.Total Project Cost: $ ❑Paid in Full ❑ Outstanding Balance Due: (Y1n4t_ 'I10 OFf=ILA / CF'2L-%- f'6iZST �11'(YR/;Ts �(g�-lobs 32to� 1'ZI 1 G(a u — rWt✓t� wlu, P u SECTION 5: CONSTRUCTION SERVICES 5.1 uti sor License(CSL) n License Number Expiration Date / Name of CSL HoJJJJrrc���{er !I „_... List CSL Type(see below) No.and Street n �/( Type Description Unrestricted Buildings up to 35,000 cu.ft.) City/' d'" State,ZIP / R Masonry s red l&2 Famil Dwelelling in M RC Roofing Covering / . ��l �,3 /� WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation Telephone �— Email address D Demolition 5.2 egiste91 re /Home Improvement Contractor CHIC) --�/� MHIC Registration Number Expiration Dale HICpany ICH strantame roWPllltr �r�r) No.a 1 tr-et ,r Email address Ct / own,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 .......... ya 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 4A&la &el - 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: 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 application is true an rate to e best of my knowledge and understanding. �� is-6 I6 Pant Owner's or Authonze Agent'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 www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dpss 2. When substantial work is planned,provide the information below: Total floor 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 of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" Dec 081Fna;78p Rudainski 97859459G3 p.1 SECTIONS_ COPISTRUCTIONSERVICES 5 I ' u ttctierr S r License(CSL) II � ga f lacenseVumba rmpiradouDate sinee or US;[. er f � t l f�!`t✓C� ' 1�.1�5�L List CSL Fgpc(srcbelow) No.and Sneer T Description r unrestacxals»aaup 35.m t1tiaca.fl. k19 ���.___�- I( Ratricrm t&2F Dw lin ca) state,ZIP ' nit mummy RC goolinz Covert -- — WS Window and Siding ' -f �1,�,J SF Solid Faet RmfingApplianoeS Ili AT4(5A' 1417 "` ,P _ I Insulation Te? huge Email address D D=WUMa 5 egMistere Home Improvement Con.ir�m_ctor �FI�IC} 2 .2 40 I H1C/ any HCC a CRe@igretioa F.Vira6onPate Frmil address lNo et Ct own,State Telephone SECTION 6. WORKERS-COMWENSATTOY INSURANCE AFMAVIT(NLGJ_c.152-5 ZSC(6)) Workm Cotapeasation Insurance affidavit must be completed and submitted with this applieatimu Failure tnprovidc this affidavit yrO result Li the denial ofthe issuance of the building pctmi*_ Signed Affidavit A ached? Yes---,------Q Fo...........❑ -- SECTION Ta:OWNERAUTHOR►ZATION TO BE COMPLETED WHEN OW-KER'S AGENT OR CONTRACTOR APPLIES POP BUILDING PERMT i 1,as Owner of Lie subject property,hereby authorize to act on my behalL in all roasters relative to work authorized by this building permit application_ G J,zz-/ A ' Sri, G 1 it. Print Owner's Name(Dec rink Signatm'e Date 1--Ly ..U6 1....1w dN Nalun and y.ntuhiw vPH•cc}my duu u!t of dx luhutnnuun BUutainud in Ikie upplieation is true a •ate to_ 1.1. r, y know 6 gc and uudcrstan/!dntg: f Ive r � Id—h f ee's or 4ntlpriu' Agent's Name(Elecutaic Sipatmc) Bate VOTES- _ 1. An Owner who obtains abuildingpetmit to do bis&er own wod4 or an owner who hires an turregsstered contractor (urv!rr:,A,isirt':.A;,.IT.c TTntT)•.t4aurcurtui Cuuh ucLtn(HI{:)t'rn�m},wll(trnrfixatr accsr�to t►ta nr6rirattmt j program or guaranty ftnid tinder M-GL c 142A.Other imporranimfir®ation on the HIC Program ear,be found ea w1'.zc.ma}°s-rrovfae l ltrform ion on the Conshttction Supervisor lacrn�e eanl7e fouml ate�.zv.ma�.emrldmr 12. When substantial work is planted,provide the information belov . Total floor area(sq.ft) (including garage,finished basarnent/aties,derma or parch) Gross thing area(sq.fL) — UaYaable nwa taunt Number of fireplaces Number of bedrnoms Number of bathrooms Number ofbaiUbaths T Te ofbeating systecr Ntmmber ofdedaf porches Type of coaling sy er Enclosed Open _ 3. "fatal Project Square Footage"maybe substituted for"TotalProjed Cast The C'ommotmealth of Massachusetts I u K y Board of 131.111ding Regulations and Standards \It VI('[P \I.III ,+ j%4assachusettS State Building Code. 780 (AMR. 7 ' edition I 'SI: l3uildin" Permit Application To Consu'uct, Repair. RrnoN ate Or I)rmulish a Rrt nrd f10S n One- or Tiro-Fancily Du ellin,G 1. - na\' OThis Se ton For O ticial Use Only Building Permit Number e Applied: Signatwe: Building Coni nissioncr/ upector of mldin Dale SECTI U . ITEINFORMATION 1.1 Property :address: 1.2 Assessors Map & Parcel Numbers i$ Fa I C"urn are e, ---- a I.I❑ Is this an accepted meet? yes nu Mp Number Parcel N'umhei _ " 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sy to Frontage IIiI . 1.5 Building Setbacks(ft) Fount Yurd Side Yards - Rear Yard Required Provided Required Provided Required PruaidcJ 1.6 Water Supply: (M.G.L c.40, §S�i) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone'? Municipal ❑ On site disposal system ❑ Public❑ Private ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP[ Owner[of Record: MI-Lk MI -o ►� Cl�rla I8 Fnlrlm�llfTf Stre�� Name(Print) Address for Service: Signature Telephone- SECTION 3: DESCRIPTION OF PROPOSED WORK' (check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) d Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units_- Other ❑ Specify.: Brief Description of Proposed Work': _�� S-Miirt��l1U D[)rl' h vnlQ r r v J SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item - flabor and Materials) I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined: ❑ Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost (Item 6) x multiplier x i 1. Plumbing $ 2. Other Fees: $ 4, Mechanical I HVAC) $ List: 5. Mechanical (Fire S — - T�,tal All Fees: s Suppression) Cheek No. —Check :\mount ('ash :\nunun _.__... .. .. ib. Total Project Cost: S g✓0 o�- O W 0 Paid in Full 0 Outstandine Balance Due:.___ SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor (CSL) '5-7-733 --- _ �/�/� /DC> hri I LJ17�f�r Llnnse Number I'. puau n Dale N -7�ome of C'SL- I IulJer Llet C'SL 1'%pe tee hch m) -- - Tv e Doti tuon .. \JJrrss C l.'nresolcicd oft to I' WO C'u. Fl.1 R Resuicmd I&'_ F:mule D%\elbne Slenmu-e 7 \1 �tawnn Unh tCJRC Residential Itoulinc Cut enng Trlrphultr w'S allJ SF Residenual Solid F.lel Rurnme \t tlrmre Imlall.m�m D Re.IJcnual Demulwom jA Reg vred dome Improvement Contractor (I-IICI ).p)bc) �e-fVI�D� =P1C' Reglsuatiun Number IiIC Company Naine or HIC R•grant Name Cn ldlo 11 D _-- .Address /p-�q 7AI--JAM �atiun Date ISignature t. Telephone SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 2506)) 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-':- .:-.Cd� -No . 13 - SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN - " OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I �� jrb rQ (t CIOI yl - , as Owner of the subject property hereby authorize L. rl5'fT�l'��'1PJ' r zU at act on my behalf, in all matters relative h to work auth trued by this building permit application. XAI, Signature ol'Owner Date 60, . SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION [, C r n5i- �Dh 0 r 7cd as Owner or Authorized Agent hereby declare that the statements:utd information on the foregoing application are true and accurate, to the best of my knowledge and behalf. rZ •Print Na ' (�'/R'/�� Signature uF Ownrr or Au orizeJ .Agent Datc l Siened under the gins and enalties of er'u ) - NOTES: I. An Owner who obtains a building permit to do his/her own work, or an owner who hires tin unregistered columllur (nut 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 and Construction Supervisor Licensing(CSL)can be found in 730 C•MR Regulations 110.R6 and I IO.RS. respectively. '- When substantial work is planned, provide the information below: "total floors area ISq. Ft.l (including garage, finished hasement/attics, decks or porch) Gross living area iSq. Ft.) Habitable room count Number of fireplaces - Number of bedrooms Number of bathrooms Number of half/hmhs - fvpe Ut heating s1'>trtT Number tit decks/ porehe5 Type of cooling system ___ Enclosed 3. "Total Project Square Footage- maybe substituted tor 'Total Project Cost' 71 N0. 'L'�'-6l- -) APPLICA ION FOR ' PERM TO a/fie e d q� LOCATION ze �Arerrto-cli/7 �K t PE MIT GRANTED 6 ZeO7 ` APP VfD rptCTOR OF ILDINGS CERTIFICATE OF OCCUPANCY . YES NO �. a! _ t DATE: 0 7 Citp of C'�)al*pm, lRam5arbu5ptt5 PLANS MUST BE FILED AND APPROVED BY THE INSPECTOR PRIOR TO A PERMIT BEING GRANTED �" Location of Building_/g ra 1 r/QU/� VfYP2T Building Permit Application For: '(Circle whichever applies) Roof,Reroof, Install Si ' of Deck, Shed, Pool Addition, Alteratio epair/Replace oundation Only, Wrecking 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: Owners Name r rQ h l br 4_ Contractor: A 9- A 5e-rvICp5'(2 nt> b r7,LL Street` FnirrYlnlJ&) -%. City Street 1� NQ(}h ,5{ . _City. xa (P_m State, MR Phone (q`S) 7)15 - W Lo 5 State M A Phone• M'9) 79 L-_0�102 H Architect: City of Salem LicCJ H D 5 Street City State Lic D57 HIP# ©1 to 09 State Phone ( ) Homeowners Exempt Form_yes-.�Lno Structure: (please circle) Ingle Famil}, Multi Family# Other Estimated Cost of job S_Z Jq 7= Will building confirm to law?,Z_yes no Asbestos?__yes/oo Description of work to be done: spaIr exl5fi�c �1�� i� T�c�ii11 One, L) � r-J2/ rUZersf or eh422u d nr-rr-. A&A SERVICES, INC. Drawing u m' ed:_yes no Mail Permit to: 1 SALEM,MA_01979 41-0424 X WWW�A-AAS . Signature of Appli ation,SIGNED UNDER THE PENALTY OF PERJURY CONSTRUCTION TO BE COMPLETED WITHIN SIX (6)MONTHS OF PERMIT ISSUED DATE