10 FORT AVE - BUILDING INSPECTION Tile
%IJss-l-I'k'sctts Star,: VILlilding
Code, 750 AIR, 7"' cdili,,11
Htilldirl� Pclillil Application To ('t)iisliuct. Repair. Rell('I,ale Or Demolish a H,
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'Imill. Oil"I'lill
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Bulldin9 Ile:"Ilt
D pplied:
,),urawse
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dlnEIll 0001 (It ffillkfil LIS
SECTION - , "
I �GRNIA PION
1.1 Properl% Address:
ticvag - 1�— ri 1.2 Assessors Map & Parcel Numbers
I I oi is lhls all a':k eped st'L.'t 'I"p NUnil", I"tcel Number
I J 7o,iiilioi"ioni
Pruperty
'poscL',
I.'-
ron, Vard Side Vards
—T-- I Real
Re, iovd R
ed qu I I L'LJAi
1—a-swwage Disoosal System:
1) !.7 F!�
.6 lvater Supply: om.(-� 1,C. 40 �1.7 llojd Zane Information;
one
Zone:
PUNIC 0 F.i ;Ile 0 Ou(s'de Rood Zone
che— Jr, Ile dit,1N),,I
SECTION 2: PROPERTY OWNFIRSIVIJ:
•
1944�Y-
al
Address tur Service
Felephorse
SECTION 3: DES(-WP10,v (IF PROPOSED IVOPK,2 rcj:eL. a!l t,,-"!! apply)
-
Cow I on I-J�Elx ir'tin$2 Biald"n, C
E7
L
�Nurnhci )I Units -------
ILL—
"luser 0
Brie, LI-,scrvp:;or. of Propcted
(Labor;:n', Mate jdls) Official Use Only
1. B
it Ing I Building Permit Fee: 5
ate how lee i, di ton io!n,-d
2. Electrical 0 Standard city/Town Applicanon Fee
ec
ec
o Total Project Cost' (Item 6) x multipiler
b,ng
unn
3, Plumbing Other Fees.
.1 Nfechanical! (HV,\0 S List: "CID
,vfe,h.....al (F
-5 Nfeihancal (Fire
F(I(al All Fery S
Check No ('I,e,k slin,,unt
Cost
5
fatal Vrojccl cost S a,h \111mull
16), C6 0 Paid in Ful! C3 Ot-tstandoilt., Bal.tJlLe Die.
SECTION 5: CONSTRUCTION SERVICES
-5J-Licensed Construction Supervisor (CSL)
Leen,e Ntonher I'.. nrauu1 U,ni
l Id ,AL1�.►Gr'A
Nra�nti til CSI.- Ila Wer �! /MA Lul CSI. rN pe "cc hi low 1 �(L
V1 �l .�_--JCp ' .Ls. c Dr,in iUon
\J es> U Ilue,,ted I Lit' Iii \s.1110 Cu
R � RntndcJ �;' Fannl\ Dwillmt
]it:naltue �/ \i \1:uonr\ Only
RC R,,t&nnJI Roo line Cu"iitile _J
/��--- \1'S SiJni�e
Sh. W.uual Soli) Luil liwmne \ di.in.; Imt.�l l,un ni �1
p Ri.idinn.d lli and Won ---.-1
i.2 Registered llome Improvement Contractor (IIIc)
_ — Reeulrauun Numhrr
lit -Company `amt or HIC Registrant Nome
Address F,,pou ion Dat: — --
Telephone
Signature
SECTION 6: WORKERS' COMPENSATION INSURANCE .AFFIDAVIT (M.G.L. c. 152. 4 2506)1
Workers Compensation Insurance at must be completed and submitted with this application. F:ulure to pnwtde
this affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached'? Yes ........_
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby -
p4ni1 U /_S to act on my behalf. in all Holten
authorize
relative to \ s authorized by this building permit application.
Date —
S'lnature al'Owner
SECTION 7h: OWNER' OR AUTHORIZED AGENT DECLARATION
7..v k) s ,as Owner or Authorized Agent hereby Declare
1• /\
that the statement and information on the foregoing application are true and accurate. to the best of my knowledge and
behalf. ;5df ,eLIq l�E'AUl/f11 S
Print None/ _ rJ Z7 —� 6
Dant j
Slenature of Owner or:\uthonzed Agent
(signed underillic am,anJ enaiLies of -tor') NOTES:
1. An Owner who obmins a building permit to do his/her own work.ur un owner who hires an unreelstercdl ctmtra,t lr
(nut registered in the Home Improvement Contractor (HIC) Program), will nw have acces, to Inc arbilfauon
program or guaranty fund under M.G.L. c. IJ2A. Other important inhrtmation on the HIC Program :md
Construction Supervisor Licensing ICSL)can be tiiund in 730 CI\1R Regulations I IO.R6 ;md 110 RS. respecn\cly
1 When substantial work is planned, pnn'tJe the informationincluriing garage, tllit>hed base 111Cn 1/atties. deck, �n' porch,
Total flours arca lSy. Ft.t Habitable room count ---- -
I (iloss living area ISy. Ft.) Number tit hedrot ms ._-- ------
Number of tine Places _ Number of hilt/baths —__—__—_—--- —
1 Nunnber of hathfoums Number tit Jerks/ pt aches .— - -----.
Ll'�pc of heating system . Lnclo,ed —Openpe Ut cilUling s}'sltm""Total Project Syuure Footage• may be +llb,lllated tor
'"fatal Pntlecl Cost
� "'« 2 .. ✓fie Looninwmc�eaf�c �! w4e�
Board of Building Regulations and Standards
k.
Construction Supervisor License
°s 4; License: CS 95321
Birthdate: 7/13/1967
Expiration:Ex
P 7/13/2010 Tr✓R 95321
r -T Restriction: 00
I' DANIEL BEAUVAIS
10 FORT AVENUE
SALEM, MA 01970 Commissioner
CITY OF SALEM
PUBLIC PROPERTY
DEPARTMENT
KI101�!�`y tyw•ry
NAVM 130 WARdNGTON SIM•SAL84,NAssAaft.=r1301970
7ki 97&745-9S"0 FAX.976.740-984
HOMEOWNER LICENSE EXE.MMON
Please Print
Date A -0q-OW
Job Location /D /--O/ T i41/(f IU U
Home Owner Address /b FD)er A vE N u
Home Owner Telephone q-78- 7 4l/- ver 9&
Present Mailing Address /o l:o r #0e yUP. S/��,� )W aJ lig--7 U
The current exemption of"Homeowners'was extended to include owner-occupied
dwellings of two Units or less and to allow such homeowners to engage an individual for
hire who,does not possess a license,provided that the owner acts as supervisor.
DEFINITION OF HOMEOWNER
Person(s)who owns a parcel of land on which he/she resides or intends to reside, on
which there is, or is intended to be,a one or two family dwellin& attached or detached
structures accessory to such use and/or farm structures. A person who constructs more
than one home in a two year period shall not be considered a homeowner. Such
"homeowner"shall submit to the Building Official,on a form acceptable to the Building
Official, that he/she be responsible for all such work performed under the Building
Permit.
The undersigned "homeowner"assumes responsibility for compliance with the State
Building Code and other applicable by-laws and regulations.
The undersigned "homeowner"certifies that he/she understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/she
will comply with said procedures and r uirements.
HOMEOWNERS SIGNATURE d otj
APPROVAL OF BUILDING INSPECTOR
See other side for state code
T �& CITY OF SALEM
P,
PUBLIC PROPRERTY
DEPARTMENT
"I'MW KIA 't ''KNO11 I
I?OWASI]IN(;WNSI'KCET * SAI Fsl, It il I 1s)VU-,
J FI:978-743-9595 * FAX:978.740-9846
Construction Debris Disposal Affidavit
(re(JUired flur 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 4- _ . __ is issued with the condition that the debt-is resulting front
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:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address ol'facility)
_ signature of permit applicant
(late
ddhkfld,w
74 Myrtle Street
TIGER Melrose, MA 02176
RUBBISH (781) 665-7017
1-800-778-4437
1-800-77TIG ER
SOLD BY DATE
20`'C
NAME
ADDRESS r— i
CJ !r C/ ;' -4-
CITY CITY
- r
DELIVERY REMOVAL F] SWAP n RELOCATION
DESCRIPTION AMOUNT
Container price includes two weeks rental and.
C ( 10 yd up to 1.5 tons _ I
Dumpster In
15 yd up to 2 tons
Dumpster Out - — --- —"
20 yd up to 3 tons
Customer will pay additional charges for:
1. Material weighing inyq cess of stated j
tonnage @ $ u per ton. j
2. Rental in excess of two weeks.
r v -
JOB ID# - PICKUP ID#
TOTAL
No hazardous or special waste accepted.
The removal and disposal of these materials is subject to the
agreement/acknowledgment on the reverse side of this form.
Signature
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http://salem.patriotproperties.com/PictureView.asp?IMG=sketch/7000/409001.jpg 11/15/2006