21 FLINT ST - BUILDING INSPECTION (4) t
5o
-- The Commonwealth of Massachusetts
x: '� Board of Building Regulations and Standards CITY OF
'r MUSSaChuSCUS State Building Code. 780 CMR tiALGMI
ti.,.. ReriseJ.lh„•21)lr
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Two-Fantiry UtrellhW
This Section For Official Usc Only
Building Permit Numbcr: Date Ap lied:
luilding 0111cial(Print Mane) . igtt• I ate
SECTION I:SITE INFORIIIATION
11I pert Address.� 1.2 Assessors Nlap& Parcel Numbers
I.la Is this an accepted street?yes no—
NNlap Number Purcel Numinr
1.3 Zoning Information: 1.4 Property Dimensions.
Zoning District Proposed Uw Lot Area IN 11) Frontage 111)
1.5 Building Setbacks(rt)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:( . I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifcs❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 O nett of�g�eord-
Torn -I rI(�rQe�W SA2 G�+/3
N;- IPnnt) City.State,ZIP
i
No.mJStrcetGf�Y S'r 7 kff (-( 11•1--
Telephone &nail Addmss
SECTION J: DESCRIPTION OF PROPOSE WORK'(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied Repairsls) ❑ Alterationls) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Nuntberof Units Other Xspccify
Brief Description of Proposed Work-,
ULrtsfl
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
'. Electrical S ❑Standard CilytTown Application Fee
1. Plumping 3
O Total Project Cost"(Item O x multi x
S multiplier - _ -
_. Other Fees: S
a. \Icdrutical (II\'.1('1 S List:
5. Mechanical (Fire - — - - -
tiu,uession) S Total ,\11FeevS
n. Tidal Project Oust 5 Cluck No, _---Check Amount: - --- Ca, h \mount:
..
IDOOt ❑ Paid in Fuli 13 Outstanding Balance Due:
SECTION 5: C'ONSfRUCr10N SF:RVIC'F:S
5.1 Construction Supervisor License(CSI.)
Liceaw Nualhar Fq it ❑'o Dale
Nance Oft.St. Dulllef
3 O Cf� /}�L l ist CSI. 1')pe Ucc heluwl
___.._-`----- T)ql Icscrip(iun
NU, anJ Slfa¢t
i i •stride) DuilJin's tipto)S,UI)0 eu. Il.)
l I me 1
(M!'�' - It Restricted 1&2 Family Doellin
C il)ikmn,Suue.LIF ,kl klasoory
lic Rlwlin Coverin
-` WS Window and Siding
SF Solid fuel Burning Appliances
Insulu(iun
l'ek hone Ismail address D Danutition
5.2 Registered Home Improvement Co C'Registration tractor(HIC)
� 6i ( � y
MRSS tAJ le'!2t4'tlb III Nunllxr 1 Ulm Datc
I IIi;,Col an N;n •or I II��istrant Name
NU1 S •c A „ lY `](��.3 y'f Email aJJlevn
City/Town.State,ZIP rele phone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No........... O
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 I C-s404 D g y to act on my behalf,in all matters relative to work authorized by this building permit ap lication.
Print Ownci s Nall:(Electronic Signature) Dale
SECTION 7b:OWNER( OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
con a(ned in this application is true and accurate to the best of my knowledge and understanding.
�C tc fr�Ml � 6y A by
I'riN Ihmcr's or.\utharireJ Agent'.N;nnu 11.(cdnnuc Slgnanucl Dut
NOTES:
I. \n Owner whu obtains a building permit to do his.her own work•or an owner who hires in unregistered contractor
(not registered in the Hume Improvement Contractor(HIC) Program),will no have access to the arbitration
program or guaranty' fund under I.G.L.c. i4_'A.Othcr important information on the HIC Program can be litund at
olla m,n. �.1 ;a..l Infornna(ion on the Construction Supervisor License can be found at kt
2. \Phan substantial work is planned,provide the information below:
Total flour area(sy. R.) - I including garage• finished basement attics.decks or porch)
Gross lk ing area I sq. tl.I Habi(able room count
Nomher of fireplaces -. Numhcr of bedrooms
Numhcr of hadlroums . . Number ul'hall'hutiu
I)pe of heating i)stem Numhcr of decks, porches . . . .
I\pe of coolillu Nl item - - 1711closed
i
1. "folal Project Square Foorage-nuq he subsithiled for"folal Project Cost-
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information t (J/ al Please Print Legibly
Nalne(Busincss/Organization/Inndivviidual): ® • � L 1 01f �Z�I 20 CM�
Address:'3 d C* 4 ue,
City/State/Zip: 5A"L� Iti A' 00LOPhone#: % 7p' 7�l" 3Y7I
Are you an employer?Check t appropriate box: Type of project(required):
NI am a em to eye with 4. ❑ 1 am a general contractor and 1
p y + have hired the sub-contractors 6. ❑New construction
employees(full and/or pa time). t 7, ❑Remodeling
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.
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. ❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work- right of exemption per MGL I LF]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' 13VOther �11 J Oc"0
comp. insurance required.]
"Any applicant that checks box NI must also fill out the section below showing their workers eomperuation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contraction must submit a new affidavit indicating such.
lConuactm that check this box must attached an additional sheet showing the name of die subt ntmeters and their workers'comp.policy information.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name: I�VcIK�r—
Policy#or Self-ins.Lie.#: V �� 7 �t 1 It} �3 Expiration Date: t \
Job Site Address: 6k I P`I/4'f- ?� City/State/Zip:
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$1,500.00 and/or one-year imprisonment,as well m civil penalties in the form of a 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 of the DIA for insurance coverage verification.
I do herebyi{Leder t=9r�d penalties ofperjury that the Information provided abov is true and correct.
Signature "P ' '— Date: ��i/1.3 ,
Phone#: 11 - _74
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
128 NORTH STREET 517-14
COMMONWEALTH OF MASSACHUSETTS
CITY OF SALEM
rGIs#: 1082
Map: 27
Lot.t: 0277
B' SIGN PERMIT
Permit Sign
Category: 'SIGN d I
Permt# 517-14 PERMISSION IS HEREBY GRANTED TO:
Protect# JS-2014-001130
Est. Cost: $0.00 Contractor: License: Expires:
Fee Charged:$0.00, - _ Signs Plus
Balance Due:$.00 7,7 a ''VI Owner: HIOU ARGEROS G, LINDA A
#�of Fixtures: g§° Applicant: Signs Plus
IDigSafe# AT.* 128 NORTH STREET
UseGroup
ConstClass
'ISSUED ON: 08-Jan-2014 AMENDED ON: EXPIRES ON: 08-Jul-2014
TO PERFORM THE FOLLOWING WORK:
SIGN PERMIT AS APPROVED FOR: SALEM 7 @ 126 NORTH ST
THIS PERMIT MAY BE REVOKED BY THE CITY OF SALEM UPON VIOLATION OF ANY OF
ITS RULES AND REGULATIONS.
Signature:
GeoTMS®2014 Des Lauriers Municipal Solutions,Inc.
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