35 FORT AVE - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Fd
� Massachusetts State Building Code, 780 CMR, T"edition Building Dept
f0 Building Permit Application To Construct, Repair, Renovate Or Demolish a 1d
One. or Ttro-Fmptili Duelling
This Section For Official Use Only
B
uildingit Numb Date Applied: t7
^
ddi Commissioner/Inspector of Bwldings Date
SECTION 1: SITE INFORMATION
Property ess: 2 ,t 1.2 Assessors Map& Parcel Numbers
/1 I Ma Number Parcel Number
accepted street?yes no D
nformation: 1.4 Property Dimensions:
Pr
Zoning Distnct opos se ed U
Lot Area(sq It)) Frontage In)
I.S Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required
Provided Required ProvidedyMunicipslbeo)n
Provided
1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Information:
stem:
Zone: _ Outside Flood Zone? system ❑Public Private❑ Check if es0A SECTION 2: PROPEERTY OWNERSH2.1 WOrd , �VI SS
Name(Print) Address for Service: �yt
If
Signature Tel phone _ J V
SECTION J: DESCRIPTION OF PROPOSED WORK-(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) O Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg. O Number of Units I Other ❑ Specify: ^�-
r
Brief Descripdon o Pro sea word
D lVr��
S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building s I. Building Permit Fee: S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Elecincal f ❑Total Project Cost(Item 6)x multiplier x
J. Plumbing f 2. Other Fees: $
4. Mechanical (HVAC) 5 List:
5 .Mechanical (Fire S Total A11 Fees. S
Suppression)
p �- Check No. _ eck Amount Cash Amoum:_
Jf1
6. Total Project Cost: f li yy j. Paid in Full O Outstanding Balance Due:
l63
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CS 2 Y 8 ZZ- r-,— 2AVIO
F gyp`( A-70e•—D (_--&U License Number Evpirauon Date
N.;lme ot'CSL HpId�0 ^ ^ ,/ N.w
'w' Lnt CSL Type lace below) G
Address �� PSFResi'deniial
Description
Victed u to)5,000 Cu. Ft.)
(�=Srgnature 7�-���- Gig G Telepho antial Window and Sidrn Solid Fuel BurningAppliance Installation
D Residential Demolition
5.2 ReglslerA Home Ins rovement Contract r(HIC)
�. Tc& �vvrz�c�9 I 13S
HIC Company..Lame or HIC Regi rant Nalye ' ' . O�w � � Registration Number
/ -G/56 Expiration Date'
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.C. 152.J 2SC(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? Yea..t...... 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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER' OR AUTHORIZED AGENT DECLARATION
I, T Q_ --U4 A)O2 � �6wnaco uthorized Agent ereby declare
that the statements and information on the foregoing application are true and accurate, tote st of my knowledge and
behalf.
� �ITCI�/ NUfZc7 = k)
Print Name
Signature Of- or Authorized Agent Date
(Sign ed under the pains and penalties of perjury
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 W 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 110 R6 and 110.RS,respectively.
2. When substamial 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 halfibaths
Type of heating system Number of decks/ porches
Tvpeof cooling system Enclosed Open
3. "Total Project Square Footage" may he substituted for 'Total Project Cost"
a CITY OF S.U-&M, ,LkSSACHUSETTS
Y BLD DLNG DEPARTMENT
_... „120-W.ASHiNGTON STREET. )'a FLOOR
TFL (978) 7i5.959S
F.+x(978) 744984
K).NBE tLEY DRISCOLL
MAYOR I?toaW ST.PO•■■■
DIRECTOR OFPL{LICPROPERTY/BU DLNGCO-NDUSSIONER
1Vurkers' Compensation Insurance Affidavit: Guilders/Contractors/Electricions/Plumbers
Anplicant Information Please Print Leaiblr
NameIBusine>WOrtarutation,Innditv y.dual T/�f� r /�V"f✓ L V
Address. / O D-Oid K
City/Statdzip: .'l J zJ-;,s/ 1.P-zo 'I/�• is Phone N: 9' 7z? — 7 6 / �6
\re on to employer!Cheek the approis t box Type of project(required):
e,18 am a employer with 2 a. am a general contractor and i
employees(full and/or pan-time).
• have hired the subcgaratmrs 6. ❑New construction
2.0 I am a soft proprietor ar partner- listed on the attached sheet. : 7. Remodeling
.:hip and have no employees These sub-contractor,have {. 0 ramolition
Workingfor arse in an capacity. workers'comp.insunax
Y P tY• 9. 0 Duildin{addition
INo workers' comp. insurance S. 0 We am a corporation and ins
required.)
officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152,1110).and we have no 12.0 Roof repairs
insurance required.) t employees.(No workers'
I S.❑Other
comp.insurance required.)
Any appliaata,ti cltoufa 1501101 marl also fill tttq tho>Rtiem halos showing their tttarkrt*'wngrnpinn pulley infut*tat{on t I I,vttetwttwa who submit this affidavit indicting they at*doing all wmtk and them hit*auniak contractors ttnar auhtnh a note atildsvir indication auah
:r-.mtt:eta a Ihm Awk this has mug attached an atldititwd Am stowing the mom•of the atth-canu wtwa and their workers'a wnst.policy ion Wtmouem.
as
I one on employer that Is provid/nji,worker'rompeasadon Inswroaee for my-eemmplayers, Below Is the pal and/oa At
infortnwiow.
In.vumnce Company Name: �7 � /`
Policy If or Self-ins. Lic..e: L-I- 01 �� 'J P n0_3 86 Expiration Date: �{�-n�• ! a
Job Site Address: } S Fw / y`^''�� Scke,,t � City/State/zip: ��"` "r g
,%ttack a copy of the workers'compensation policy declaration pap(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL e. 132 can lead to the imposition of criminal penalties of■
tine 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 fin
Of up to S250.00 a day against the violator. Ik advised[hats copy of this statement maybe forwarded to the OIYce of
Ins csl,gmiona ofthe MA for insurance coverage vcritieation.
/do hereby certi/ utt r the pains unal p dies of perfary that the beforaratlen provided above is true and correct
�� •nuure: C7 Data: t�� /Y—ci
6 ._..------_
D1rhwl use duly. Donor write in this area, to be.utnp/sied by riry or tows d/f/a'iuL
City or ruwn: eermita.Icense M _.
lssumt.whuntyfcircle(ine): - — - — - i
I. Iluard of lleaflh 2. ISuilding I)epartmcnl ).('iiy/rown Clerk !. Electrical lntpecto► 5. Plumbing Inspector
6. Other
C.,nUct Person;
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
12C\l'.%Q 9,U :..:BELT•SALI M.%t.\aMht*01::AK
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of tie State Building Code,780 CNIR section I LS
Debris,and the provisions of MGL c 40.S S4.
Building Permit 0 _ r _ 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
It1.SISOA.
The debris will be transported by:
k� SOt49
_._. oname of hauler)
The debris will be disposed of in :
inane of ia.;lllty)
�sS .
..3I.