0028 1/2 GROVE ST - BPA-9-540, ADD 2ND EGRESS FOR 3RD FL UNIT 01/09/2009 11:40 9787409846 CITYOF SALEM PAGE 01/04
4 The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
..4 Massachusetts State Building Code.780 CMR. 7'v edition immomw
Building Dept
Building Permit Application To Construct.Repair. Renovate Or Demolish a lbOBMglR
One-or Two-Family Dsvel ing dun&
This Section For Orlicial Use Onl
Building Permit Number: Date Applied:
Signature: b/L -
(�V,1 1 Buiidirtg Commissi M lnspmtor of Buildings Vote
SECTION 1:SITE INFORMATION
1.1_Prope Address;
r✓ V t 13 Assessors Map di Parcel Numbers
Lv
1.I a Is this an accYpled street?yp �( no Map Number Parcel Number
IJ zp, Y_nfermetlon: IA pro city_ fmtns g
Zoning Dissdd Proposed Use Lor Arcs(sq R) Prmi age(tt)
1.3 Building Setbacks(R)
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 Intermission: 1•s Sewa;e Dl�pasal-System:
Public IR Private 0 Zone _ Outside Flood Zone?
Cheek if et® Municipol¢'On site disposal system 0
SECTIONS: PROPERTYOWNERSRIP
2.1 owner of RetOr�
Name(Pei ( r� Address for Service:
7 'Q
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKS(eheek all that apply)
New Constmction❑ Existing Building 0 Owner-Occupied Repairs(s) 0 Alteralion(s) O Addition 0
Demolition 0 Accessary Bldg,0 Number of Units Other aB Spa iy: t/
Brief Description 0Proposed. ork':
� 2rr
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Ofllelal Use Only
I, Building S '��� l7 1. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S 0 Standard Citylrown Application Fee
3. Plumbing
Cl Total Project Costs(Item 6)is multiplier is
� S
2. Other Fees: S
4. Mechanical (HYAC) S List:
5. Mechanical (Fire
Su ession S Total All Fees: L
6.Total Project Cost: S Check No.,Cheek Amount: Cash Amount:`
0V U 0 Paid in Full ❑Outstanding Balance Due:
e aV-e�
01/09/2009 11:40 9787409846 CITYDF SALEM PAGE 03/04
s CITY OF SALEM
3h PUBLIC PROPRERTY
DEPARTMENT
m kil;;k:I'Y 1)NISt:ul,l.
Man m 12C WAsraNG I ON 5'Ir UT a SALEM,WASSACI n v:i'a s 01970
Thu 976.7459593 a rnx:979-74,-.W46
Wurkers' Compensation insurance Affidavit: Builders/Contractors/Electri Cis ns/Plumbers
AvIllicant Infitrmalion Please Print Le ibly
?1.1fDc Ialninessl(hganirorinNinJivlJuuil: nl � r'f r t G
7 A `
Address: �t� /I ( A �P-, A-loc
City;5tatci%ip:_ Q k W" V 11hont:01:
Are you an vmployer?Check the appropriate box: [7.
ype of project(required):
1.❑ 1 am a employer with' A. ❑ I ail a Sencral corttmetor and 1 . New Construclion.-
tpluycat(full andfur part-lime),- have hired the.uh-contractors
2. 1 ant a sole proprieusr or partner- listed an the attachal sheet. ❑ Remodelingship and have no cattployces These subconvacton have . ❑ I nsolition
working for me in any capacity. workers'comp. insumrlm ❑pudding addition
fNa workers'Gump, insurance 5. ❑ we ate a corpatytion and ittrequired.) officers have exercised their 0.❑Electrical repairs or additions
7.❑ 1 um a homwwner doing all work right of exemption per MC'L I1.0 Plumbing repairs or additions
myself.(No w;orkcrs'comp. C. 152,§1(4),and we have no 12.0 Roof a-pairs
insure ike required.)t cmpluycL:, [No workers' 17.❑Other
camp. inwtam:c tequind.J
;Any:gqklica t Char checks box Pl man also fill wl the ue¢Ii,m hcluw showing their wudre'rumpenrnilek Pulicy infllgkullun
I lomellwacn odor auhma This amdaeit indicating Ihry am doing la)work ilea ohm him aawc llnlrnLYOrf innoo mhonia a nM alYJnv111nJ1Ulina NIcM1.
�Cn lMmlri likes cheek this[ran mow attacked an aaat knol shoat slulwing like ttamo of ale subconrravom and their wurkrn'can dk nfwmaaon.P P yi
lam vor eatpleyer that fr prvsdding wo kera'romprnmrlan hrsarnncejor ney employecv. Belolvis the pulley andleb.rile
brjormarian.
Insurance Company?lame: _ .
I•olicy A or Sdf-ins.Lic. K; ___ .. .....__ F.upiralion Date;
)ab Site Address: City/Stale/zip;
.Attach a copy of The workers'compensation policy doelarafton page(shosrfng the Policy number and expiration date).
Failure to assure coverage as required under Section 23A ofNICL c. 152 can lead to file imposition of criminal penalties airs
fin:tip nt S1.500.00 and/or ores-year imprismmncnt,as Null as civil pcnultics in Abe form ara STOP WORK ORDER and a lice
of up to 5250.00 it Jay against file violator l;r advised shut a wpy of lhis slutcmLnt may be furwardcd to the oflicc of
Insvangalinns UN119IAA for inwrarce coverage terif)eatiun.
1 du fiend reify of, the i 'as asrd�tettnffixs ojperjary that the injormafifer provided abasY is true and correct.m Si ule's ��_ �— �'s—— Cf /
E
only. Iid not write in Ntis area,to be rwnrpleled by city w town gJit fad.
n: _ Permit/Lirense p
hurily(circle ors): -- -
Ileallh Z. Mailding Department 3.City/fors a Clerk 4.Electrird Inspector S. Plumbing Inspector
nont Phone p;
01/09/2009 11:40 9787409846 CITYOF SALEM PAGE 02/04
SECTIONS: CONSTRUCTION SERVICES
5.1 yL�lcensed Construction Supervisor(CSL) Oki? q_5 --T-� '
T e �../,�,r f-I Gin License Number E.pintiop Oate
Name of CS
ZS :9"L- y*1 r ./�
y^y'� . y Lim CSL Type(sm below)
A r I lype DescrTtion
\, U Unrestricted li ro 35,000 Cu.Ft.
Signature e-' R Restricted 1&2 Famil Dwellin
I M I Mason Only
RC Residemial Routine Covering
Telephone WS i Residential Window andSidn'
— ) D — 't ) 4.e SF Residential Solid Fuel Bumin Appliance Installation
T l O Residential Derrolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date
Signature, Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e.152.4 25C(Q)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan a of the building,pertniL,
Signed AlLdavit Attached? Yes .......... 0 No..._......
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING:PERMIT
t, u- C' .l r as Owner of the subject property hereby
authorize UNn `!f, CC t1 to act on my behalf•in all matters
relativ work authorized by this building permit application.
Si hare of Owner DaOe
SECTION 7b:OWNERt OR AUTHORIZED AGENT DECLARATION
Ue,f t�C. c, � as Owner or Authorized Agent hereby declare
that the statements and information on the folrigoing application are true and accurate,to the best of my knowledge and. ,
behalf t
4( r G✓1
Print Pl q
Signature of rier Authori ed Agent Date
(Signed under the pains and penalties of
NOTES:
I. An Owner who obtaire 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 M 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 790 CMR Regulations I I O.R6 and 110.11115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq_ FL) (including garage,finished basementfattics,decks or porch) -
Gross living area(Sq.Ft.) Habitable room count
Number of fimpiaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of hating system Number of decks/port hcs
Type of cooling syslem Enclosed Open
3. '-Total Pmjeci Square Footage"maybe substituted for"Total Project Cast"
01/09/2009 11:40 9787409846 CITYOF SALEM PAGE 04/04
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
III v'.Y.•J i.•1:45 �1'�x:'i'Y 'J=o,�J„
Construction Debris UiSP05al Affidavit
(required Ii)rall danwlition and renovaliun work)
In aecurd-rncc .a if the sixth edition ol'the State Building Code, 780 CA1R section 1 1 1.5
Debris, and the provisiuns of MGL c 40, S 54:
Building Permit R is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I I I. S I50A,
The debris will Ile transported by:
I name of hader)
'I lie debris will be disposed of in
(narne ul Iacillly)
(:NhlrcxC of IJrdil�l
�Iguarurc of lq•rmil applicant
dale
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