15 HARDY - BUILDING INSPECTION S, The Commonwealth of Massa
chusetts Town of
r1 Board of Building Regulations an
7� Slassachuselts Srrte Building Code, 780tion Building DeAIENOWpt�' Building Permit Application To Construct, RepaiOr Demolish a 1tl1�a8Y08kOne. or rvro-Fannfl DuelThis Section For O(Bcial OBuilding Permit Num Date Appd
Signature:
Bud g Commissioned Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
(Z
Ma Number Parcel Number
1.1 a Is this an accepted street?yes_ no p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sq tp Frontage III)
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.40,654) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
J Zone: _ Outside Flood Zone? Municipal site disposal system ❑
Public 1a Private❑ - Check if esM_
SECTION 2: PROPERTY OWNERSHIP'
,,A
Name(Print Address for Se ice' ( �ri\` .VA l__`
s a t Telephone
SECTION 3: D CRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) Addition ❑
Demolition Accessory Bldg.Cl Number of Units_ Other ❑ Specify:
Brief scription of P op os Work': 11N rem i
S
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building f $Sb0 p I. Building Permit fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical f ❑Total Project Cost'I(IIttc''n6)x multiplier x
3 Plumbing f 2. Other Fees: f W
4. Mechanical (HVAC) S List:
5 .Mechanicai (Fire S U Total All Fees: f
Suppression)
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: f 0 0 ❑ paid in Full O Outstanding Balance Due:
, 3s
1 3s�
4
f �
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) it) 3I 12 ZC�1 '
,• C.0\C - CtiA�C I-wensc NumRr Expiration Date
N;Imc of CSL- HplJer List CSL T
�,�• CC�SS �(' YDe(,cc below)
Address Type I Description
U I Unrestricted[up to 35.000 Cu. Ft.)
R Restricted 1&2 FamilyDwellin
Signal C/ ' N 1 MastinryOnly
RC Rcsrdcnual Roofing Covering
Telephone WS Rrsrdennal Window and Sidra
/}/C .�P_S `� SF Revdentul Solid Fuel Burning Appliance Installation
D I Residential Demolition
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.C. 152.1 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 AlTidavit Attached? Yes.......... O No........... O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, S as Owner of the subject property hereby
authorize c Ste. to act on my behalf,in all matters
relative to work authorized rmil application.
IiiA 2 ee�
wrier Date
SEC b:OWNEW OR AUTHORIZED AGENVDECLARATION
1• as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate, to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of peru
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 W have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I MRS, respectively.
2. When substamial work is planned, provide the information below:
Total floors area(Sq. FL) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) Habitable room'count
Number of firepiaces .Number of bedrooms
Number of bathrooms Number of halfbaths
Type o(heaung system Number of decks/porches
Type of cooling system Enclosed Open
1. "Total Protect Square Footage"may be substituted for 'Total Project Cost"
CITY OF S.U.Ems NVL-kSSACHUSETTS
BI:0I mG D EPA RTTIE-iT
". 120 W.iiHRVGTON STREET. 3w FLOOR
TEL (978) 745-9595
FAX(97I) 740-99"
KINBERIEY DRISCOLL
�►YOR IItOaW ST.PmRRs
DIRECTOR OF Pl:BLIC PROPERTY/RC'QDLNG CO>L\DSSIONER
Workers' Compensation Insurance AtTidavit: Builders/Contractors/Electricians/Plumbers
Annl(cant Information Please Print Legibly
Naine (I usine+s.Organmliorvindtvttlssal): RZ e Ctl 4K
1JJress:
5k
City/StatdZip: R S t Phone*21 Z%4 `f(3/0
Are you a�n employer?Cheek the appropriate boa: Type of project(required):
1.❑ 1 am a employer with emp 4. 0 I:us a general contractor and 1
6. ❑New construction
employees(full and/or part-time).* have hired the sub contractors
partner- listed on the attached sh"L : 7. [�Kemodeling
2.❑ I am a sank preprietmsal P
ship and have no employees Theme sub-contractors have V. L�molition
Working for me in any capacity.ry• workers'comp.insumnc& 9. ❑building addition
[No workers' comp. insurance S. ❑ We am a corporation and its
required.] oMcers have exercised their 10.�1ectrical repairs or additions
J.❑ 1 am a homeowner doing all work right of exemption per MGL 11. PI '6ing repair a additions
myself.[No workers'comp. c. 152,11(4),and we have no 12.®'RoOf repairs
insurance required.] t employees. LNo workers'
Il.❑Otha
comp. insurance required.)
•Any applicant Ihts choeb 11011101 mom aW rill snit the section below sh rwiag'hair workm'congsnaadnn paltry infomsadon.
' I Lvrteowtm',who stbxnit this affidavit indicating they are doing all work aid than him,Hide contracttxn mum i ulsmit a.atildnvx indicating neck
{.,nu:srn lists cis ek this boss mum anaehsd an additional dww showing the rums of the salt-eomn kept and their western'come.policy infsmnian.
/ant aw awployrr rhN b provid/n,�ItrorAen'roraprttradaa Inienwer jrr aq rtaplayrresl, Qrlow/i the po!!er rttd/ei r/se
injormruiom //'�� _
Insurance Company Name: C3,ca r,,vr_ t tns .
Policy for Self-ins. Lic.N: t,J c/607 -y'2- 257 e2 Expiration Date:- nDS I0,51/b
Job Site Address: 15 Me,( u Si" City/State/Zip: .kl U /Y(A
Attack a copy of the workers'compessatloa policy declarstba page(Showing the policy number and espintles date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
f ne up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties is the form of a STOP WORK ORDER and a fine
of up in S250.00 a Jay against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
In%csslgaliuna ol'dtc DIA for insurance coverage verification. -
l do hrreby grrdfy us rr the 'na mrd penalder 01 prela ry that the injoriesidoer provided above is trust and eorsret
, n Hurt: I)at : lif3Jis
O,idol uqr mnly Do not write in thir area, to be cumpletd by city or town ulnriet
City or ru'wn: _ _ . eermit/LlcenseN__
I%suing.%whonly (circle une):
I. Ituard of Ilealth 2. 9ueldlnU Department 1. Glyffown Clerk 4. Electrical Impactor 5. Plumbing Inapeetor
b. other I _ '
l„nlad Pcrson: _ ._ _. ... Phone N: ..._. _
" CITY OF SALEM
' 4
PUBLIC PROPRERTY
DEPARTMENT
n.V:.M t RY•'M�:A�1 L
Construction Debris Disposat affidavit
(required fix all demolition aid renovation work)
In accordance with the sixth edition of the State BuildinS Code, 780 CAiR section I I I.S
Debris, and the provisions of MtGL a 40.S K
Building Permit 0 _ is issued with the condition that the debris resulting hom
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
t 11, 3130A.
The debris will be transported by:
„�,ws�t ►erg
me debris will be disposed of in :
,:.me of iacil,ty)
-- ..Jdress al'f'xiL1;q
�....16.4