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4 FEDERAL CT - BUILDING INSPECTION (2)
35 lob Ucygb . The Commonwealth of Massachusetts qlb Board of Building Regulations and Standards Et CITY OF Massachusetts State Building Code,780 Clv>��EE tflNAt :�j �4EM Revised Mar 2011 ^, Building Permit Application To Construct,Repair,Renovanj �¢o One-or Two-Family Dwelling J!"` 2' 2 , Q This SectionFor Official Use Only "Building PermifNttmber DateA Vp 1 Building Official(Paint Name) gigoature -. ' "5 'Date : SECTION L•SITE INFORMATION", 1.1 Prop %Address: 1.2 Assessors Map&Parcel Numbers T.l.laTS t n Map Number Parcel Number this an accepted street? es o -n eP Y 1.3 Zoning Information: 1.4 Property Dimensions: 2-R 1 Rr�,sNJGC6 t t y 1 a n cozE Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(11) O/A 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 13Zone: _ Outside Ftoodne? Munici Check if es P� On site disposal system 13 SECTION k PROPERTY OWNERSHIP 2.1 Owners of Record: $hFE1 ayOUNU 5.# M, N1�1`�5. oL974 Name(Print) City,State,ZIP Air fvy� GT. 1S k-7135 e-I&IE+pTca6MA-n—eat No.and Street Telephone Email Address SECTION 3:DESCRWftON`OF PROPOSED WORKZ(ctretk all that.apply) New Construction 13 Existing Building Id Owner-Occupied O Repairs(s) 9f Alteration(s) E Addition 13 Demolition 0 Accessory Bldg. 0 Number of Units_ Other O Specify: Brief Description of Proposed Work': REMa9t;t. F;,ct9hia kt't- -hl•MtN.s'v„tt�•rc tNSi+tu rhbY-N'[is�avty SECTION 4-ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: OBicial Use O (Labor and Materials 1.Building $ 706,°e 1 "Building Permit Fee $', Indicate ho W fee:is dctemtined: 2.Electrical $ ❑Standard City/Town'-Application Fee 0 Total:Project Cost'(Item 6)z mutt pfle� is 3.PlumbingOthec Fees 4.Mechanical (HVAC) $ is . �a a 5.Mechanical (Fire Suppression) $ Total All Fees:$ Check No. Check Amount.' - 'Cash`Amount: 6.Total Project Cost: $ ❑paid inOutstanding Balance Due: SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) &4tSb'75 527-17 'W ruRhh'1 i /A-G'MrOfa-N License Number Expiration Date Name of CSL Holder 1'� List CSL Type(see below) No.and Street Type Description ,a�G-�I{�,ly IA,.� a 14�z j U Unrestricted(Buildingsu to 35,000 cu.ft. R V Restricted 1&2 Family Dwellin City/Town,State,ZIP M Masonry RC Roofing Coverin WS Window and Siding �1�� SF Solid Fuel Burning Appliances '1."t$-q'2.Z-6Z�'b pt�t.«DIEt`1t�Nk t7fLt'�F<jE�AltdU. I I Insulation Telephone Email address eom D Demolition 5.2 Registered Home Improvement Contractor(IIIC) Ak ze t7 A�m kpi~lN�b1 fl�Vrxt�yJL t-ygrF�d 7 x IncHIC Registration Number Expiration Date HIC Company Name or HIC Registrant Name Af uorkhtN4 §vt�DERs �gifm-c<Mt No.and Street Email address 4z8'�G2 Zti71( 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 .......... d 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 �vsZ I 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 and accurate Co the best of my knowledge and understanding. ( & ��w>-mot -- lh Print Owner's or Authorized Agent's Name(ElectronicSignature) 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 m 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.eov/dpss 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (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 system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" n CITY OF S.U.ENI, NLksSACHUSETTS BL'II.DLNG DEP1R- LENT j 130 WA\SHNGTON STREET,310 FLOOR T - (978) 745-9595 FAX(978) 740-9846 IO5ffiERLEY DRISCOLL MAYOR THomm ST.PmRRE DIRECTOR OF PL:BLIC PROPERTY/BUnDLNG COMMISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c L 11, S 150A. The debris will be transported by: 1�tpifi-�.1 �e��wu:••�-t�rJ (name of hauler) The debris will be disposed of in : M¢w r .�tsNt� r�N Ct (name of facility) GIN w1��s. (address of facility) signature of permit applicant date �cbrivlrIuc i CITY OF S.U.&NI, NUSSACHLSETTS BUILDINIG DEPART%IENT j 120 WASHINGTON STREET,Yet FLOOR a TEL (978)745-9595 FAX(978)740-9946 KINIBERIEY DRISCOLL MAYOR DIRECTOR ST.PIERRS DIRECTOR OF PUBLIC PROPERTY/Bl'1LD04G COSLNDSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Business Organization/Individual): KeKo7t*J,4 y h'n6 Address: tithe 5'i"' City/State/Zip: $elf (,4 AA----, Phone#: v�s� �lZZ gaga Are you an employer?Check the appropriate box: Type of ro ect P i (required): 1.E6 1 am a employer with 'Z 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time)." have hired the subcontractors r�t 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet: 7. CJ Remodeling ship and have no employees These sub-contractors have & ❑ Demolition working for me in any capacity. workers'comp.insurance. 9. ❑Building addition [No workers'comp, insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.)t employees.[No workers' 13.0 Other COMP.insurance required.) 'Any applieam that chocks boa in most also fill out the section Wow showing their workrn'compensation policy infum pion. 'I Inmeownas who submit this affidavit indicting they as doing all work and then hire outside contmeu. mast submit a nue,alRdavil irtditmittg end, :Commtton that chalk this brat most anadsed an additional shad showing the—of the sub-conusctma and thew workem'comp.policy infannatim. I am an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and jab site informations. Insurance Company Name: W'rroAp Policy#or Self-ins.Lie.#: 6638-117 Expiration Date: )d l to ' Job Site Andress: A ftwvm, C�—I • City/State/Zip: -&MVA Molt- 6lg76 Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations or the DIA for insurance coverage verification. I do hereby certify under th"ilns d penalties of perjury that the fuformadon provided above is true and correct n Sitnantre: c [)are: 6-45'](, Phone#: 479 -9•.L-7-a7,qi5 OJTciad use only. Do not write in this area,to he completed by city or town afcial City or Town: Permit/License# Issuing Authority(circle one): 1. Board of health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person Phone#: ®t Massachusetts-Deparbnent of Public Safety 1 _, r Board of Building Regulations and Standards = " OtSee�CoABius&BQ� d'� . Begabtioa LicAnse:CSFA-04SBYS 3 CONTRACTOR ry OM ``��e '- 428�017 DBA PAIDLFURNARI 's. �[A 12 dACXSDN Sr: IMF 11411721DLANC0NSTkkffiW Bereriy MA 01913' ib®) Ae oAIP.fl - - PAUL R)RNAM - y� 72 JACY' 12 JACKSON Sr " Expiration - BE{/H2L BEVERLY,MA 01915 Cwrrnisi;ioner 05/L7RM7 f - wry - 71=c!; ;- o�,:oaa. ty�ttr�aT�g�a, ' _ Consirm�naSa�yandti� _ - ,. - 77 ARMANDO,:r-A� oi7(Il -_--� t' r�ri��ndn-ud cz zu - Office of Consumer Affairs and Business Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement Contractor Registration Registration: 181777 Tvoe: DBA .. - Expirelon: 4r28=17 Trta 25550 MERIDIAN CONSTRUCTION PAUL FURNARI 12 JACKSON ST BEVERLY, MA 01915 updstcAddren and return card.Mark rrawn for dainge. _ -- --. �, 0 za.as,,, Addrew C Renewal El FAnployment CI L&ACard - 6/9/2016 saie deeds.com/salemdeeds/imageDetail.aspx?stype=recdoc&machine=&year=2016&month=5&day=4&docnum=527&segnum=8book=34898&page=0... Return to Start: ■K- Go to BooWPage: , Bk:34898 Pg:064 >v�rlew rrevr.,,. Current: aeveh Bk:34898 Pg:064 --- Pages to be printed: $B. W Bk.g189g Pq'fA Zoom Miso0ue81H IXetS[1Wt 6eaaalM: 06 l"MI.Mae Cavern)xrmrs. +a Z'Werae Cav: fat6pa.a9 Zoom Out QUITCLAIM DEED 1,Michael N.Digris,a sing lem le person,of Sakai,Essex County,Massachusetts Downbad/Pnnkdc q for consideration paid of She Hundred FiReen Thousand and 00/100($615,000.00)Dollars J Downbad/Pdntcu q grant to Shelley A.Young,individually,of 4 Federal Court,Salem,Essex County, Massachusetts with Quitclaim Covenants, Downbad/Pnntse The land,together with the buildings and improvements thereon,situated in Salem,Essex O TIF ©PDF County,Commonwealth of Massochusetts,raw krawn sort numbered as 4 Federal Court,and being bounded mod described as follows: I. Ix'1 I..IF7 Beginning at the Northeasterly coreer thereof by lad aow or formerly of Wild or late of Colby V`.� 7Dse and thence running: Doc date:5/412016 Ada Delete Page Document Page SOUTHERLY by Federal Court,75 feet;thence 121 Grantors: lard ro WESTERLY by law or formerly of Felt,about 60 feet,two inches,thence DIGRIS MICHAELN NORTHERLY by land mw or formerly ofPickman,now or late ofSchrevc,75 feet;and thence EASTERLY by said land now or late of Colby,59 feet to the point begun at. Grantees: All rights of homestead by Domain;me hereby released. YOUNG SHELLEY A Being the same premises conveyed by deed recorded with the Fsses Southern District Registry of Deeds in Book 26017,Page 422. See death certificate of Michele K.Washburn recorded in Book 34807,Page 298. Grantors/Grantees Abstract References I I http://salemdeeds.com/salem deeds/Im ageDetai i.aspx?stype=recdoc&m achine=&year=2016&month=5&day=4&docnum=527&segnum=%20&book=34898&pag... 1/1