0088 1/2 FEDERAL STREET - BPA 10-509 The Commonwealth of Massachusetts
� '. Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 7n' edition OF SALEM
Revised January
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 2008
tf V I One- or Two-Family Dwelling
V Thi ction For Official Use Only
Building Penn t Number: Date Applied:
Signature:
'22/ bb
Building Commis.inner/Inspector of 11 s Date
SECT I N l: SITE INFORMATION
1.1 Property.Address: -tom 1.2 Assessors Map& Parcel Numbers
r. I.la Is this an accepted street?yes no Map Number OPrcel Number
%1.3 Zng Information: it 1.4 P2�9rty Dimensions: `
Zoning District Proposed Use Lot Area(sq ft) Frontages(_R)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
6 /00'
1.6 Water upply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
lic Pub Private ❑ Lone: — Outside Flood"Lone?
Check if ycsftd� Municipal On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ow ert of Record: n/� p ec#1eru,�
I a L4�><PF�(t , GG !') P—
Name(Print) J Address for Service:
(It > -
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building R1Owner-Occupied Repairs(s) ❑ I Alteration(s) EK1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed,Wpork':
Q
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Building I. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical g ❑ Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ go 2. Other Fees: $
4. Mechanical (HVAC) $ 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:
433 - 0 U
i
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expiration Date
Name of CSL-Holder
List CSL Type(see below)
Address Type Description
U Unrestricted(up to 35,000 Cu. Ft.)
Signature R Restricted 1&2 Family Dwellin
M Masona Only
RC Residential Rooting Covering
'I WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
1-IIC Company Name or I IIC Registrant Name Registration Number
Address
f. Expiration Date
Signature Telephone
t 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 .......... 0 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 to act on my behalf, in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
4 �q G G //tV ,as Owner or Authorized Agent hereby declare
that the statements anA information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
0 Pre6 )v
Print Name
Signature of Owner or Aut ized Agent Date
(Signed under the 2ains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"
CITY OF S�UEM, N'LxSSACH1USETTS
BUILDIING DEPART IUNT
120 WASHINGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KimBERLFY DRISCOLL
;MAYOR THoMAs ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COM MSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information r 1 Please Print Legibly
Name (BusiiassOrganization/Individuall):: R()U
Address: V 1/1
;.City/State/Zip: .CA Q ka ME QM0 Phone d: q 78— LILT f of
Are you an employer?Check the appropriate box: Type of project(required):
tO I am a employer with 4. ❑ I am a general contractor and 1 6. El New construction
(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
[No workers' comp. insurance 5. [1We are a corporation and its
,/equired.] officers have exercised thew 10.El Electrical repairs or additions
3.Lid 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,❑ Roof repairs
insurance required.] t employees. [No workers' 13 ❑Other
comp. insurance required.]
•Any applicant that checks box ill most also fill out the section below showing their workers'compensation policy infurmation.
*I hsmeowncs who submit this affidavit indicating they arc doing all work and thm hire outside m1melors most submit a now affidavit indicating such
:Contmion that chick this box must attached an additional steel showing the name of the sub-contactors and their workm'comp.policy information.
l um an employer rhat is providing workers'compensadon insurance for my employeesS'Below is the policy and fob site
information.
Insurance Company Name:
Policy a or Self-ins. Lic. 0: Expiration Date:
Job Site Address: City/State/Zip:
ktiacb 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 S 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 S250.00 a day against the violator. Be advised that a copy of this statement may tie forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby certify under the pains and pertahies of perjury that the information provided above is true and correct.
Sitinature' I v a Alf- Date' -.:I
Phone#:
Official use only. Do not write in this area,to be completed by city or town official
City or Town: _ Permil/License
Issuing Authority(circle one):
1. Board of Ileaith 2.Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone M
CITY OF Si-1 zm, iNLxSSACHUSETTS
BUILDING DEPARTMENT
130 WASHINGTON STREET, 3"FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI\tBERLEY DRISCOLL
MAYOR THOMAs STYIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLUISSIONER
Construction Debris Disposal Affidavit
f` (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
111, S 150A.
The debris will be transported by:
r
kAn v t L
(name of hauler)
The debris will be disposed of in
NAer�c,av� W
(name of facility) 'n
�L( G0In9 M e—rCt'CJ 9t, LV A4, M rr
(address of facility)
signature of permit applicant
date
dcnri,all dix