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26 GARDNER ST - BUILDING INSPECTION < vm� C-K IOGS- -1ZS The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code, 780 CMIR Revised Mar 2011 Building Permit Application To Constnict,Repair,Renovate Or Demolish a One-or Two-Family Dwelling "This.Section I.For O.ffi.cial.Use Ory Building Permit Number Applied: ,iuiN. S Date - a SECT ION 1:SITE INFORMATION 1.1 Proper[ 1.2 Assessors Map&Parcel Numbers Q(n (_6 Address: S (I 4e —t Lla Is this an accepted street?yes-Z— no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(ft) 1.5 Building Setbacks(ft) 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 E3 Private[3 Zone, Outside Flood Zone? Municipal 0 On site disposal system 0 Check if yesO SECTIONJ:." :OWNERSHIP[1 . 'PROPERTY 2.1. Qwner'of Record: W14 MA Na— (Pr hit) City,State,ZIP at, G('CdQe( 41-7 J1 :2 C7 ktci 1) C QLA No.and Street Telephone Em dress L SECTION 3: DESCRIPTION OF PROPOSED WOW:(check:all that 4p: I apply} New Construction 0 Existing Building 11 Owner-Occupied 0 FRepairs(s) N( Alteration(s) 0 Addition ❑ Demolition 0 Accessory Bldg. El Number of Units Other 13 Specify Brief Description of Proposed Work2: SECTION:4:�ESTMATED CONSTRUCTION COSTS .. .. ...... Item Estimated Costs: 10 Use(Labor and Materials) .0 Official U Only 1. Building .g.7.-uildin I P-eftniffee-.S. Indicate.how Ice is d&effmined,:.. 2.Electrical g 0 Standard Cit y/T6wn Application Fee. ❑Total Project Costa(Item:6)k 1 multiplier 3, Plumbing $ 2::Other:Fe es... 4.Mechanical (11VAC) $ Ltst 5.Mechanical (Fire _7 T I Fees:S!TP ssion) 'Check,Na 7 Check�Atnowit-. Cash Amount: 6. Total Project Cost: $ 00 ❑Paid in Full landing ct D, ue::— kv4 SECTION 5:"CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) io ,� �_ !Mi CL. �� �, LicenseNum Exprati ate Name of CSL Holder List CSL Type(see below) cription No.and Street Type Des f /n� U Unrestricted(Buildings u to 35,000 cu.ft.) Lm nn Y,-P.A N4 A (D ► R'q Q R Restricted 1&2 Family Dwelling Gown,State,ZIP M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) � 1� M . S or HIC R-r.a^ Name HIC Registration Number Expiration ate HIC Company Name or HIC Registrant Name 0 MZ, -14 A'AlSCo S-ruc.4,ua�nc.c ,4M L No.and 5 et W� � No. rl(CA 460 0 1 g 4 O Gl K �a a (} 1 Email address Ci ITOWIl State,ZIP Telephone SECTION;6:WORKERS'COMPENSATION INSURANCE AF EDA0;( 01 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 .......... ❑ No ........... SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWR'S AGENT OR CONTRACTOR APPLIES FOR BUH.DING PERMIT NE 1,as Owner of the subject property,hereby authorize Mi rl�eL�c., to act on my behalf,in all matters relative to work authorized by this building permit application. )emu SanR:icA. ► Print Owner's MAme(Electronic Signature) Date SECTION 7b: OWNERu 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 ap ication is true an e best of my knowledge and understanding. / I t ! Print Owner's 3fAuthonzed Agent's Name-aMe7elronic ignature) 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 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 can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at wwiv.mass.gov/dps 2. When substantial work is planned,provide the information below: Total floor area(sq.ft.) (including garage,finished basement/attics,decks or porch) Gross living area(sq.fL) 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" .� ' Office on umer errs mess e a e on r 3 HOMEIMPROVEMENTCONTRACTOR Registrafion: .,773428 TYPE x ki Expiration 10,j3/�014 Corporation P +M `ONSTRUCT,IYONIi i�,;: (lllllll MICHAEL SELIG I� �� � P, 177MAINST r LYNNFIELD,MA01840 ` �'A Undersecretary . w+� r v.� �Massadhvsetts -Department of Public Safety: :'';+ Board of Building Regulations and.Stanrlards Construction Supen'iarr License: CS-106470 MICHAEL SELIG- ' 177 MAIN STREET "� = Lynnfield MA 01940 ' Ex iratioii� Commissioner 03I1912016 c �< CITY OF S.U.E1d, N-WSACHUSETtS ©UILmc;DEPARnLENT \ � 120 WASHNGTON STREET, 3AO FLOOR TF-L (978) 745-9595 RuX(978) 740-9844 KIJigERLEY DRISCOLI. NLAYOR T14oacls ST.PtEm DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONNISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section t l I.S Debris, and the provisions of MGL c 40, S 54; Building Permit 4 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: (name of hauler) The debris will be disposed of in AS12-4Aail ILC�h- (name of facility) ILGt (address of facility) signature of permit applicant d to