8 GROVE ST - BUILDING INSPECTION t i q L C2[- 14 c-i?— / 2— /U
The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards
Massachusetts State Building Code, 730 CMR SALEM
Revised.L&ir 201
Building Permit A i To Construct, Repair, Renovate Or Demolish a
One- Two-Family Dwelling
s Section For Official Use Only .
Building Permit Number: Date Applied: Z
/o% 3
❑wilding Official(Print Name). Signature- - Date
SECTION C:SITEINFORNIAT10N
I,�Pr�Spertyyv Add_rress: 1.2 Assessors Nlap& Parcel Numbers
I.I a Is this an accepted street?yes_ no Map Number I•arcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(II)
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: LS Sewage Disposal System:
Zone: _ Outside Flood Zone'?
Public❑ Private❑ Check ifyes❑ Municipal❑ On site Disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
Owncrt of R�rd- � ���+�..p S C �,Q_ O (�,U
NN me(Print City,State,ZIP
/ G� �'�. r RC/ - ? � �Gy/ AaA lejw�P�ahl, o�
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building g 1 Owner-Occupied ❑ Repairs(s) ❑ 1 Afteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Descriptiono'Proposed Work2:�i�. ,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labur and Nlaterials)
1. Building v OV O I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing .S O 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mcchanical (Fire S -
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S ` ❑ Paid in Full ❑Outstanding Balance Due:
��bd0
SECTION5: CONSTRUCTION SERVICES
5.1 Construction Sur•rvisor License(CSL) r✓S -03 Z 1 1 3 (1 /Y
�, License Number Expiration Date
Name ofICS1.rIuMicIr
List CSLrype(see below)
No.and Street 1X. ^n Type Description-
C U Unrestricted an s u to cu. It
—1 W R Restricted I&2 Family Dwelling
J
City/ru vn,State,ZIP ibl Nlasonry
RC Roofing Covering
WS Window and Siding
t SF Solid Fuel Burning Appliances
H-4S <ba 1� cuy\ Insulation
Ttic hunt --1 Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
Ii IC Company Name or HIC Registrant Name
No,and Street Email address
City/Town,State,ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION 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 Wmance 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
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
this a is true and accurate to the best of my knowledge and understanding.
Print 0w s or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under�bLG.L.c. I42A.Other important information on the HIC Program can be found at
www.ntass.uuv:'oca Information on the Construction Supervisor License can be found at www.massaeov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage, finished basementlattics,decks or porch)
Gross living area(sq. It.) 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
1. "Total Project Square Footage"may be substituted for•'Total Project cost" '.
l
r Massachusetts -Department of Public Safety
Regulations
and Standards
Board of Building 4
Construction Supervisor
License'. cS-0321Bi
Nil EL E ROSyN
23 LEBt ANC DR ,U19'
t; WEST PEABODY M
oJ.,�,,, .r1 ` n n`•.
0311712014
Commissioner m
r .
i
CITY OF SALENI, NAXSSACHUSETTS
i. l3U=D4r,DEPAR"I MNT
120 WASHNGTON STREET, 3'FLOOR
TF.L (978) 745-9595
F.mv(978) 740-9844
i<I1iBERLEY DIUSCOLL
INLVOR THomAs ST.PtERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 780 CMR section it 1.5
Debris, and the provisions of NIGL c 40, S 54;
Building"Permit it 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 NIGL c
111, S 150A.
The debris will be transported by:
mac-
(namc of hauler)
The debris will be disposed of in :
(namc of facility)
(address of facility)
Signature permit applicant
zo a 3 3
t�a0.
Id,n:-ill Ine