1 HAMILTON ST - BPA-14-1619 . , T� - � �, - � � � � � �P3 � � � �i ���
1 �- �-�� � � RECEIVE .
- ../ l�s� � « � �
� "fhe Commonwealth oFblassachusetts �� eiTv oERVIC S
+ Board of Duilding Regulations and Stnndards
��� � ��i� blassachusetts State Building Code, 780 CbIR t��� �e�.��'������ 3
Building Pumit Application To Construct, Repair, Renovate Or Demolish 3
���,�� One-ar Ttivo-Fnmily Divellin,g
This Section For OtTicial Use Only . '
E3uilJing Permit Number. Dnt pPliedf
?,ty,,,� , ,� /3— (
OuilJing Otlicial(Print N:une). �� . Signalure- �. � Dute �
SECTION L•SITE(NFOR�IATIOIV'
� t.l Property Ad�ress: 1.2 Assesson iNnp&Pnrcel Numben
I Elu�, '1 i�� S 1'-
I.I a Is this an accepted street� no hlap Nwnber Parcel Number
Ii.3 "Loning iuFormstiun: !.� P:roperty Dlmensions:
"Luning Dislrict ProposeJ Use Lot Arca(sy It) Frontage pt)
I.5 BuildingSet6acks(R)
Front Yord Side Yardv Rear Y�vd
ReyuireJ � ProvideJ Reyuired ProviJed Required ProviJed
I.6�Vnter Supply:(M.G.L c.d0,§Sd) 1.7 Flood Zone Informntion: I.8 Sewage Disposnl System:
Zone: Outside Flood Zone7 Municipnl O On site disposul syslem ❑
Public❑ Private❑ Check if C9O �
SECT[ON1: PROPERTYOWNERSHIP!`
2.l Owner�of Record:
(„ CCCV�r�� 1��`�P SGjP✓Y� .M/� !'i1CG '7�
X t��hme(Print) Ciry,Stute.21P
\ I fF4�, •1 1u., s I- C d r 1..� ue�i¢.an ive.f
Nu.nnJ Street Telephane Email AdJress
SECTION 3:DESCRIPTIOIV OF PROPOSED WORK'(check nU that npply)
New Construction❑ E3isting Building O Owner-Occupied O Repairs(s) Alreration(s) ❑ Addition ❑
Demolitiun ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
�rief Description of Proposed 1Vork: f= ` �
a
' \ SECTION�: ESTIbIATED CONSTRUCTIO�COSTS
Itcin Estimated Costs: p�'�ci•rl Use Only
Labur and hluterials)
I. 6uil�ing S I. Building Permit Fee:$ Indicate ho�v fee is determined:
❑Slandard CitylTo�vn Appl(cation Fee
2. Electrir,d � ❑Total Project Cost'(Item 6)s multiplier x
3. Plumbing S ���her Fe�s: S . �(���
d. �Icch;mic�l (FIV;1C) S LisC �
5.\kehanic:il (Firz ,� �utal�UI Ecas:3
Su rcssiun)
` „ a� Cl�eck Na_Check Antount: Cash Amuunt:_
Y6. Total Project Cost: .'S � �a(o . ❑p;�id in Full ❑OwstanJing D�lance Due:
C P�l,�. w�11� �o N�,
C.�aw�D 11'i 5
�- ` secT�ov s: co��s•raucr�o��sEav►cEs �
'j,l Cunstructiun Sopervisur Liccnse(CSL) ������ ,a - y - aar s
`� S�d71' �k�.��B� ,�1
License Numbcr E.rpiratiun Uale�
N;mie of CSL Ffolder I,ist CSL'fype(sce below) /'G
o�t1 ��^A[Ji�.rr�S'� Type� � �� " � � � Description
� No. ;md Streee _. .. .
q �� U Unmslricled Ouildin s u �to 35,000 cu. R.
S(/.�'�°✓✓1 ��✓7 G(y "�� R ResUictedl&2F;unil D�vellin
City/Pown,State,"LIP ibl �lason
RC Roolin Cuvcrin
WS WinJo�vandSidin
SI3�Ci�/1�W�U'������ SF SuliSFuelDumingAppliances I
q�� 7yy -a�7 S �' ''Ne �'" I Insulation
Tcle hana Email adJrcsy D Demolilion
5.2 I2egistereJtlomelmprovementConVactor(HIC) ��(lo� S 5`�7"a°�
S� /��C�qa�- ��•��G fi1C RegisUation Number F.xpirotion Date
fIIC Cump;my Name HIC Re�istr�nt Namu
L!/ o S haK tt e 5 f� x"B�C��(�.�v /� vGr t`za� - .Ue i-
Nu.�aLP+Yt � .�1�- a14Y0 97�-�yv-a�?S Emailu�Jrese
Cit /Town,State ZIP Tele hone
SECTIOK 6:WORKER$'COhIPENSAT[ON lNSURANCE AFFIDAVIT(M.G.L:c.i52.§ 25C(�).
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this nftidavit will result in the denial of the IsSuance of the building permit.
Signed Atliduvit Attached? Yes .......... ❑ No...........❑
SECTION7o:OWIVERAUTHO.RIZAT[ON:TOBECOMPLETEDWNEIY `
OWNER'S AGENT OR CONTRAETOR APPLIE9:FOR BUILD[NG PERINIT'
i,as Owner of the subject property,hereby authorize S� �'�n�l .Scu � ({°1'/"'y� _
t9 act on my behalf,in all matrers relative to work authorized by this�ng permit application.
��j�-°'✓ � -a� -�y
�" Print Owncr's Nmne(Electronic Signawre) ���r il
SECTION 7ti:OWNER�ORAUTEIORIZED AGENT DECI.ARATION
�y enrerin�my nnme below, I herebp ntrest under the pains and penalties of perjury that all of the information I
contained in this aQplication is true and accurate ro the best of my kno�vledge and understanding.
Print Owner's or AuthorizeJ Agcnt's Nunu(Elcctrunic Signulure) Dnte
VO"fES:
I. An Owner who obtains a building permit to do hislher own�vurk,or an o�mer who hires an unregistered contmctor
(not registered in!he Home Improvement Controctor(HIC) Progmm),will nr�l have access to the arbitmtion
program or�uaranty fund under�I.G.L.c. Id2A.Other important information on the HIC Progrem can he found at
�rw�v.mus,.gue:'oca Information on the Construction Supervisor License can be f'aund at n�rw.m:us.�:o�:!JL .
� 2. 1Vhen substantial wurk is pl;uined,proviJe the inFormation below:
fot�l tluor area(sq. R.) '� ,(including garage,finished basemenUattics,decks or purch)
Gruss' living area(sy. ft.) Habitable room count
Numbcr uf fireplacns Vumber oF 6edrooms
Numbcr uF baUirooms Number uf h:Jt%baths
Type uFhnating systzm NumberuFdecks/porches
'I'ypeufcuolingsystem CncluseJ Open_
]. "I'o�al Project Syuare Fuota�e"m:�y be.,ubstituted far"futal Projtct CusP•
, � ..� C[TY OF SALEM, MASSACHUSETTS
f<
� �{�,��,��f 4�;� BiIILDING DEPARTMENT
���,,ti, �' a�' 120 WASHINGTON STREET,3'�FLoox
��_ TEL. (978) 745-9595
FAY(978)740-9846
KIMBERLEY DRISCOLL
MAYOR TrIOMAS ST.PIERRE
DIRECI"OR OF PUBLIC PROPERTY/BUILDING CO1vIMISSIONER
Construction Debris Disposa/ Affidavit
(required for all demolition and renovation work)
: _._. .___ :. .,. . . _::, ,
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit # is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
� K;d
(name of auler)
The debris will be disposed of in:
D�.�»s�-�.-� S� �;���, ��� ..z�/e
,
(name of facility)
�{1 o5�'if�c $ i- Suf�e.+n., M/}o1�270
(address of facility)
� ' `" j�/
Signature of applicant
�� aa-ly
Date
' ,�T° CCI'Y OF S:1LE1�I, l�'L-1SS.1CH[;SETTS
' � �' F3L'ILDI�G DEP.�RT(E�T
3 � ��(��� 1?O CU.ISHL�lGTON STREET, 3�O FLOOR
� `�•"'� 'I'FL (978) �45-9595
F.ti�c(978) 740-98�t6
�7��gFRi FY DRISCOLL
��tiL'1YOR � �Il-to6NSST.PtF�RR
. DIRECTUROFPCBLICPROPEATY/BI:RDI\GCO\L�f[55fOrElt
�Ynrkers' Compensation Insur�nce Aftid•rvit: BuilderslContractors/Electrlcians/Plum6ere
:1pplicant infnrm•rtinn Pfcase Prfnt LeeiblY
V;t117ClHusinessOrganira�iom'Individual): ,., � '�-O°L�t1 � C. V . y✓✓ �-
A�Jress: U( O5�✓'✓�P S f
Cily/5tatc/Zip: s���� �. /Ul�- O�� Y� Phonelt: �17�— 7��/ � G��S
Arc an cmployer'.'Chcck Ihe•rppropriate bui: 'Pype of proJect(rcqulnd):
I. - I am o cmploye�with� � 4. Q 1 om s general cantracior anJ I 6. ❑New cunnuuceion
amployees(full and/or part-time).' � have hircd�he subcoNracwry
- L� 1 am a sole prapriaor ur p�utnen Iis�uJ on lhe attachcd ahact. � �• ❑aemodeling
.hip�nd have na cmployeer These sub-confractors havc 8. ❑ nemolition
wurking�li�r mc in:uiy capaciry. �vorkers'comp. inauranca q. ❑puilding adJitiun
(No workcri comp. insurance � 5. O We are a earporation anJ iv ,
requircJ.J ofticcn havn zzereisad�hcfr �0.0 Elccrcical rcpmrs or addiiions
J.O I am a hoincuwncr duing all�wrk right of exsmplion per MGL 1 LQ plumbing rcpuin or uJditions
myselE[\o workcrs'cump. c• 152, ¢I(4),anJ wc hnvo no �2, aof npairs
insuranco reyuircd.J t �mplayaee.�No worken' I1.0 Othor
cump. inxurancereyuin;J.j
•Any upplicml ilu�cher4�6ux/l muai alw fill uW�he aecliun hloW ahowinY their worka�mmpenamiun puli�y inWrtnaifun.
�I lomaownun�.•ho,.u6mii ihii aflieMvit india�iny�hry am doinN oll work ond ihcn hue oNlide coNr�cmn m�ul auhmil�ncw�fflJavit indi�viny such.
�C��mn.wn�hui ch«k ihi�bua miut ana.hwl�n aJdiiiwml.Aa1 shuwinp Ihc n:une ol lhc iubaan�nnpn onJ iheir wnrMen'�ump.pullry infumm�ian.
/unr un empfuyr�rhal ir pruviding�vorktrt'cun�pu�aadun ineurui�eejor my unpluyers. Ueluw/s d�a po/!cy m�JJub r(te
infi�rurufinn.
Inzurancc Campany Vame:�"GJ1ul�.'�V`—�°--
Pulicy i!ur SclGii�,v. LiC. tl: __.,_ Enpiration Dati: �
l�bSi�e.�di4css: I f�4dy.lH-O/1 S '� CirylState/Zip:. Su��.1� � OlCL7C�
,\u�ch•r cnpy uf lhe n�orlcen'compens�tlou pulley declar:ttlan pa�;a(showing the pullcy num6e�aad explratlon d�te).
Failure W scturc coveruge;u requireJ unJ¢t Scclion?SA uf�IGL a I52 can IcaJ ro�he impo.rition ofcriminal penn�tiea uf a '
rine up m SI,SOOAO uml/or une-ytar iinprisonmcnr,as wcll ae civil penaltics in�h�Portn uf a STOP WORI(URDEA and u lin�
of up tn 5_'�0.O0 a Jay ay�inst rha viulatnr. 13e�dvizcd�hat�cupy uf this su�ement may Iw funvardcJ�a �he O11icu of
Inrrsiig�iiuns u(�hc �L1 fur insurence cuvenge vcrilicaiiun. � .
/du/renby rrrri�y ndai p .r und peno!!/r.r u�pe�jury!/mf!!�t iufunuu(!an proviJaJ uGwu i.s�rut anJ eui�ret
;�,,,,.�„�«: ���� ��:���� � - a a- �y
�h�,�e,,: g7 �r- 7 y - o1�z5 -
.
UJ/iriuf uae anly. Du nW ivriie irc dri.c�rru,m ba cuaryle�¢J by riry or io�un n/Jleru[ �
• I
Cityn�'fu�rn: _.._ .__ Pcrmir/i.lccnecq__. �
l.�suing,\utlwrily(circicunc): �--.__. ...----. . _-- I
I. 6uurd uf Ile�lih 2. Iluildln� Oeparhnrnt .1.Ci�ylfu��u Clerk J. F.Ieetric�l luspcctur 5. Pinmbing Inapee�or I
G.O�lier
� I� (:unlacl Pcnnn:,.__..__ Phnn.;7: ,
. _---- ._.... ..-- � ------. . . . __.. __ .
--� _..__:_—____—--------�--�_-_�------�-_---—_,__�.—�---�� .
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 151123
`—' ;; Type: Private Corporation
5117/2016 Tr# 254750
Expiration:
J.B. KIDNEY & CO INC. i
SCOTT KIDNEY
41 OSBORNE STREET Ion,SALEM, MA 01970
Y7nR, �— f
�:,;�� ? �U date Address and return card.Mark reason for change.
< N P
Address 0 Renewal E Employment Lost Card
-A1 0 20M-05H1
(-Dq'xe 1po�rnmemn2iseaAlt License or registration valid for individul use only
Office of Consumer Affairs&Business Regulation
before the expiration date. If found return to:
-= ME IMPROVEMENT CONTRACTOR Type. Office of Consumer Affairs and Business Regulation .
gistration: 151123 10 Park Plaza-Suite 5170.
xpiration: _.51W12616 Private Corporation Boston,MA 02116
.B.KIDNEY&CO INC
�! .
SCOTT KIDNEY �
11 OSBORNE STREET' ��t---.6.+�
... _.. ... ,,.,.�., „_.,.._..e..e.�.� Not van without signature