6 GLOVER ST - BUILDING INSPECTION I'he Conmmonwealth of Massachusetts -- -
J' Board of Building Regulations and Standards CITY OF
J'
Massachusetts State Building Code, 780 CNIR SALEM
Rrrrsed.1 Gv_'Ill l
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-FunrUe DweHb{K
Phis Section For Official Use Onl
Building Permit Number: Da .Applied: _
Building Official(Print Nurne) Ll Signature tale
ale
SECTION l: SITE INFORMATION
1.1 Prop rty Address.. 1.2 Assessors Map d Parcel Numbers
I.I a Is this an accepted street?yes_ no Map Nu nher Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.§54) 1.7-Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
Check if ycs❑
SECTION2: PROPERTY OWNERSHIP'
`sl Ownert of Record: �k� 0, 1 70
.pAl yYz� �rLk7'�i vim.
Name IP in ) City.Stat�Llp
No.and Street elephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item MEstinid Official Use Only
y
I. Building I. BuildingPermit Fee: E Indicate how fee is determined:'. F.Icctrical ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier ___xi. Plumbing 2. Other Fees: S
a. ,Mechanical ((11�'ACList:5. .Mechanical (Firetiu rssion) TotalAll Fees:SCheck No. ('heck Amount: Cush :\mount:
t;. Totrl Project Cos ❑ Paid in Full ❑Outstanding Balance Due: - -- --
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(C'SL)
License Number PSpvatiou Date
NII111C 1 CSI. Holder
�1 List CSI,1)PC(see helulvl
Sa� rtct., 1cdrC�- -- --
No u1J Street T)pe Description
(I Unrestricted(Iluildin gs uo h)35,000 ea. It.)
R Restricted 1&2 Family Dwellin
Cityll\mn,State.ZIP M M1lawnr
RC Roolin g Covering
._ WS Window and Siding
SF Solid Fuel Burning Apphallces
"A`V-7 �i ` cSQ�Wrcrierxl, I I Insulation
cic hone limai1 address D I Demolition
5.2 Registcret/� tome Improvement Contractor(HIC) tK1 7 I q l7
K-r IIIC Registration NumberFi piratiun Date
on pap Na QIr I II ' itegist n u
Al
No.:uu(, Ott(Z� �q h ca►7' 9�`a �-9 9 2 9--� Email address City/Town. State,ZIP 1 `I 'rele hone
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 .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,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.
Print Owner's Name(Electronic - ature) Date
%CCTION 7b: OW ERt OR AUTHORIZED AGENT DECLARATION
By entering my nal belo , e y attest under the pains and�penalties of perjury that all of the information
contained in this ap tion is rue and accurate to the best of my knowledge and understanding.
Print Owner'.or Authorized Agent's Name(Flectrunic Signature)
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 Hume Improvement Contractor(HIC) Program), will not have access to the arbitration
program or guaranty fund under.M.&L. c. 142A.Other important information on the HIC Program can be found at
%f%11%.ma.,. ;o1 o .( Information on the Construction Supervisor License can be found at dq,
2. When substantial work is planned, provide the information below:
T)(al Iloor area 1 sy. R.1 (including garage, finished basement'altics,decks or porch 1
Gross living area I sy. 11.) - _ Habitable room count
Number of fireplaces _ Numberolbedroonls
Number of bathrooms Number ofllalf'balhs
I)pe of(felting system .. - -.- — Number ordecks, porches ..
I\pc of Cooli11g Svste1n -_ (inclosed ---Open
3. "Iblal Project Square footage"ma) be substituted for"folal Project Cost-
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1 Y'1xIN.q I
\l 111 M
I'r.t./7ll•;'S•13Y3 •f I,r ,MK�\.u.l n a I I,JI'�/:
Workers' Cumpenfation Insurance 1f0dnrit: UuitderyCuntractur3/Ele tricianf/Plumbers
\ ) )Iltunt In nnnaflo
V;1111011h1vIK,ail7raanuJlinrvindlruluull:
(.sire sl:tlC �'�8� �1�� �G1 �-3?�
M� i/:
.t ry)uu a n vulployer:'Check the:ylpropr Phunr late box; .
II.0 1 :un a empluyur with 0, un a yunudi toulrxtor and 1 l yM"rt ro)uct(required);
2•Ovnlploycux(full JnWur parwime).• huvo hired the suh•uunlraeturs �' 0 new colutruetiun
I.un a sold prnpriulm or partner• listed on the attueheli.,hcet t
ship and have no mnpiuyvds Throe sufseonrdetors have y' Relnotleling
working file me in any capacity, worker a'coln ens e' ❑ nemolition
I NO workurs'cutup, iusurauclt J. warp. 9, OuiWing addititat
rcyuircd.J 0 wean a corporxtitm and its
[]
3.0 1 :Jill J halm uwnvr diling all work light of vallli`tion er their I0.0 Elecrrieal reptiles Or additionf
myself. Ino wnrkars'cutup• c. 131,ti I(t1.and w�Anw no
11.0 Plumbing repairs or additions inrurancn rcyuired.J / cmpluycus. (NO%vorked' 1=•0 Rutlfnpuirs
clunp incudncyt nyuind.J l GQ-tl rs
IJ• Odle►
•Anr•ylpxca111 IhW al:ucxa aea al mua alw IIII uw 1M vivuun uvluw dwwm r
'tl,.r,yurrwrr rile.IJw1it lxir dllldxrll indkJrina thin+1e Jucnf WI wurY aN l wwllxi cane
f�.nlrwue.Ihxl aMwk 1111r ban nluN nlaxef Ie adalli hw llW uxKib euwr� ll"lirr lnrwnwliun
uyl.IKeI Ju.ina 1M na1,y a4v"Side
num Inwl.uIw1Y a nele a1RJxra inJlayin f u1w�,
/IIrN 4/I elllp/aye//AW if yrYr/d/ryX IVW.�I/J'rd/n�Ia1tN/all IILfYrIIry{'e�W ray p V aM r11rM wylrpne'.p,11�•�„IKy II11t,r111so
iu�o/,nu/!r/A /r/J er.R Bi/wr is/AI Wallyu/IJ/a1 airy
Invuranee C'unlpaoy .Valne:�
,��e
1ldicy a-Jr SvlGins. Lit.n;_
lab Slid Athlre..r:�7— ,y Expirutlon DaM:�_
NtacA it enyy of the lrerkars' � C•IIY'SWterLlp: � —_
pvnut ,a pulley Jvclarativa page(showing the policy numbv►and erplrstlua dote),
PJl lulu to wcuro cut nuye required 10 •r Seeker 251%v1'.�IGL c. 132 eau lead ro the impofition oreriminal pensllief of a
Rna up nl.l'I Sn0,r4"1" r uue•year i pri.nlwncnt, JY 1Ycil J,civd pcnahlw in the farm alb 5TUP 1VDRK ORDER and a floe
0/up rn i?J0.g0.1 JJy I ills'Ill*v' IJlne. lic advl.rvd(hut a e11
In1 i,11�Jllnna ul :Ile III,\ r nnl .usu.l;vcrJ;r'lcritiuuun, PY uflhlx,lmv,neiii may be iurwJrJcJ to the oilicdvF
/,lu/rrn•hy I crri/�all, the line�nld erred/ire u
l lYrr/ury rho/die ia/unau//oa prvride�ubgva is/ru ear/correelt
in•.� nll COJ
114/"lire is d�1r urea, ru Ae rurny/vrrd Ay airy of/oleo o//liivL
f„uiny .luthuril —� Pcnnifrl.itcnrv�
y (rirdo nnc);
I.G I0
t1I11V err IIrJfl li !. Iludlhn j Iklrt t11.'Ion11 C'leek J. Electrical hlspec/ur :,
� t'��n.1et IOrwu:
i
and Instructions
Information p P
\LUs.1.hU:eus l,cncrJl Laws c aV ve t+on in the service of another unkler.tnY wmract of hire.
h ter 1 i2 tcywra all anployars to provide workers coin an+roan Iy their ct hi
I`ur.u.uu to[Writ )tJtute, an rtmplgs'e+to JetineJ Js". .a ry l"
:vpreas or unplicd, oral nr wnitan•" oration or other Icgal cntiry,or any two or more
uMenhto..tssutrauua,carp yr or the
�n employer[s Joined as"an individual.p ton vm loycas. However the
N the taceewng engaged m a lo,m enterprise. and tnclallod the!heal rgalgnat attvas IQ a deceased emp uY of
, I In%: Ir dw
Jr trustee of.art iudivtdttal,parmenh[p, ssoetamaa or other legal annry.amp Y { ' P
ng house
owner of a dwelling house having not more than three Jpattlnents and who resides thercus,or the occupant
Owner
Iwusa of another who employs persons w Jo 110,because of such employment be deemed to b""ruclion Of jfpgig work On ughe in employer-"
r ,,n the grounds Jr building appurtenant thereto shall nor because
vSC 6 also $tate+ that"even slate or local licsnsl+{agency Shan witkhuld'tha bsfor la or
�tGL chapter 152. y_ O ulnd.'
renewal of s Ilcaase or penult to operate a busin ac or to eon uYpCe with the elmu Is rone�overagefliffalregor any
tpplls+at "he has not produesd aecep
tabb evldeaet of hump of its oiitical subdivisions shall
ppilea%aditionully, �IUL chupur I53, i=3C(71 states"Neither the conunonwcaI c nor any
vtGL%ji for the parforotunce ul'putliu work until aceeptahls evidence ofcun[pli utce with the insunnea
corer into any ' re-Anted to the contracting authority,"
reyutremcnu of this chaphsr haw been p'
'applicants checking the boxes that apply to your is)OIton art4 it
compensation at7tdavit completely,by number($)slon{with their 1 er ployt+ts)Other
Plea++ till out the workers' Gump ss(+s)and Photo Partnerships(LLP)with no employees usher than the
necessary,supply so Companies
n ies(L),adding
insurance. Limited Liability Cmnpaniea(LLC)or Limited Liability
metnb+rs ar p+ut►►+r+. are not required to carry workers' eomp+rwsti bmitted to the Oepuroimant ofoln�have
employees,a policy is required. Ile advised that This affidavit may ortmant of
Also be sort w e sir end date the affidav not the it. 71e aNldevit should
nnit tx licarw is lacing requested�to olmainlu workers'
.Nccidenu for conllnna►ium of insurance u PlicAd{e the tow or if you an required
ha rctt[rted to the city or town that
have anyr4ugrt°fait rea rding tea should enter their
Industrial Accidents. Should rail the Dspu+tmens so
the number listed below. Self"groused compaa'
lie . lease c
compel policy,
» Y V
self•insurance license number on tht a ro rinse lint.
City or'rows Officials
tinted legibly. The Department has provided u spuc+at Ihu m
the applicant.,
picasc he aura that the affidavit is n the let*eve and p applicant
of the affidavit fur you to bill Jut in the event the Otllee of Investigations has to untie[you rcsardrrt{ ,
hewiens In any given year,need only auburn urea at)idavit indicating current
of the ff sari to till in the pt;rmiNicens+ nwnbar which will be used as a reference number. In addinum,an ap
Ill
use
drat must n ma tt multiple penni)and
under
�d er marked by the city or town [nay be provided to the
policy i,t ubintun 1tf'necessary) and under"Job Sit*Address' the applicant +hnulJ write"all lus:utiuns to Y
tuwnl•",%coPY of the utl9duvit[hat has been officially stamp' business or commercial v+mutt
applicant as proof that a valid affidavit is on file far nature permits or hU,related
Anew affidavit must be tilled nut mu
year. 1Yhere a hurnr owner ur citizen is obmining s license or permit not.related to any
I i.e. , dug liven o ar permit to burn leaves etc.)said person is NOT requred to complete this alfidavit. wsuons.
I he !dice kit Ioveaigatiuns would I'" to drank you in aJvance flat your cooperation and should you huts,trey y
I.Icase Ju not hesitato to efvu us a cJll.
f he U:paruncnt's addre+s, telephone The
fax number.
The Commonwealth of Mossachusett
pepamment of Industrial Accident
Office of Iavesd4adans
600 Wishiftgton Street
Boston, MA 02111
T'e1. M 617-727-4900
Cxt 02 of 1-9"-MASSAFE
Fax 0 617 7
<.] ) www.Mass.&ov/din
CITY OF S.0 E.Mj NWS.ICHUSE-M
Bt:ILJONG DEP.IRTIE.VT
120 W.kiHLYGTON STRM. JiO FLOOR
hL (978) 745-9595
F.uc(978) 740.9846
KIJ®F_RLEY DRLSCOLL
NITAYOR TiO.�NS ST.Pmx p n
DIRECTOR OF PLOLIC PROPERTY/Bt:anLYG CO\p11S5IO.NER
Construction Debris Disposal Affidavit
(required for all demolition-and renovation work) -•-
In accordance with the sixth edition of the State Building Code, 780 CMR section I 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit All 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 bIGL c
111. S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
WS
(address of facility)
5idnature orpermit applicant
f
ate
A M1nvd.bw