77 HATHORNE ST - BUILDING INSPECTION l �
2_ q3 - i `-I2�
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY q(f M Massachusetts State Building Code, 730 CMR SALE
Revised,Llar 201
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Drivelling
This Section For Official)2sb Only
Building-Permit Number: Date, pplied:
S / 2
Building Official(Print Name). Signature Date
SECTION I:SITE INFORMATION
1.1 Propertydr Ad ss: 1.2 Assessors Map&Parcel Numbers
7� �a'f'ti or,v t 5>
I.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq tt) Frontage(It)
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: 1.8 Sewage Disposal System:
/ Zone: _ Outside Flood Zone?
Public tad' Private❑ Check ifyes❑ Municipal On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner of Record-
M��,� y� r��Sk- ," SRLcrn H9i4 0/q�0
me(Print) ,,// City,Slate,ZIP
:77 37p 519T
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply) .
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of units_ Other ❑ Specify: 7 m
Brief Description of Proposed Work':
,� b/ /f n i, �
SECTION 4: EST►MATED.CONSTRUCTION COSTS
Item
Estimated Costs:Labor and Materials) Official Use O nly
I. Building S I. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑-Standard City/Town Application.Fee
❑Total Project Cost'(Item 6)x multiplier. x
3. Plumbing S 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Nfechanical (Fire S
Total All Fees: S
Suppression)
i� Check No. Check Amount: Cash Amount:
6. Total Project Cost: S Q7 ❑Paid in Full ❑Outstanding Balance Due:
To 0 1==.
SECTIONS: CONSTRUCTION SERVICES ' I 5.1 Construction Supervisor License(CSL) p `
1JOt..t-4�Z C�_�t� i nse Number Expiration Date
Name of CSL Holder u
List CSL type(see below)
a<< M.~nOrwT 2�
No. and Street Type -Description. ..
1 \ U Unrestricted(Buildings up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
City/l'own,State,ZIP M Masonry
RC Roofing Covering
q WS Window and Siding
00 �30 L) Ar 4dO•(d I Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registte/ered dome Improvement Contractor(HIC)
Z5SCr-'�( rGVnJT� M.a�W"i-2�✓G{.l "— HIC Registration Number Expiration Date
IIIC Company Name or HIC Registrant Name
?u tM G.l a etti�T 2()
No.and Street ` Email address
nA n( 978-31 N ��G 6
City/Town,State,ZIP IP Telephone
SECTION 6 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.g 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
1, as Owner of the subject property,hereby authorize
t4 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Nine(Electronic Signature) Date
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
contained in this application is true and accurate to the best of my knowledge and understanding.
Print Owner'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 M.G.L.c. I42A.Other important information on the HIC Program can be found at
www.mass.cov;'oca Information on the Construction Supervisor License can be found at w%v%v.mass.->ov'dns
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) 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
3. `Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.VLENf
PUBLIC PROPERTY
DEPARTMENT
u�u.aur o.e�Yy
wove
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HOMEOWNER LICENSE E.XX.MpTIO,V
Pt@w lrlat
Date
job rogation
Roma Owner Address
ifams Owssr Telopboao
Resort Ma Ung Addrew
no current exemption of"Homeowner"was extended to include owner%oeeWied
dweUingl Of""Unit#Of few and to allow arch homeowners to eagags as Individual for
hire who don rat poa$eas a UeensM provided that the owner acts so auparviscr.
DEFINMON Old HOWOWNER
Parson($) wbe owns a par ad of Lad as which Wshe resides or intends to reside6 on
which there ist, or is intended to bS a one or two limily dwelUn& attached or detached
structures accessory to.such us@ and/or lire stn.cttuV& A person who constructs Mons
than one home in a two year period shall not be considered a homeowner. Sucb
"hameowna"1W submit to the Building OQfeial,an a form acceptable to the Building
Official, that helshe be responsible for all such work performed under the Building
Pamir
The underaigred "ftarneownes""some@ responsibility for compliance with the State
Building Code and other applicable bylaws and rejuladonL
The undeniSned "homeowner certifies that WAS undentands the City of Salem
0WIdint Department minimum irupection procedures and requirements and that heshe
.vill comply with said procedures and requirement$,
HOMEOWNERS S(GYATLRB
kPPROVAL OF 9UILD NG iNSPECTOR
See atha tide for state coda
CITY OF S.UI E-M, INIaSSACHUSETTS
BUILDC\G DEPARTMENT
N• 120 WASHINGTON STREET, 3" FLOOR
TEL (978) 745-9595
FAxe(978) 740-9846
KIN{gFRT FF-Y DRISCOLL
MAYOR YOR THOMAS ST.PIERRH
DIRECTOR OF PUBLIC PROPERTY/BUILDIING COJLUISSIONER
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 111.5
Debris, and the provisions of MGL c 40, 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 disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
•_: OvtaR S I&w�e/d
(name of hauler)
The debris will be disposed of in :
----- t((0 S —
(name of facility)
—(Iddress of facility).
signature of permit applicant
9-/G - / 3
date
Jcbri>aif dux
•i
CITY OF siu.&AV12 NI Lks& CHUSETTS
BI:ILDLNG DEPARTMENT
120 WASHINGTON STREET, 3sR FLOOR
T EL (978)745-9595
F.te(978) 740-9846
KI.%fBF RLEY D RISCOLL THOMAS ST.PIERRB
MAYO&
DIRECTOR OP PUBLIC PROPEM/BURDLNG COSLIIISSIO:iER
Workers' Compensatlon Insurance Affidavit: Duilders/ContractorliEleetrician3/Piumbers
Applicant Information Please Print Lep_ibly
Name(Busiix�, , )rganizatiorvindividual): 7�ow114S I�DUGt��i� �S�X �CaJ��T V'�A.t✓TeNk•'r CL
Address: , a o Au T iz-n
0
City/State/Zip: 0 94 ( Phone N: q V 6?041,
Are you in employer?Check the appropriate box: Type of project(required):
I. am a employer with %J 4• ❑ I am a general contractor and 1 6. ❑Now construction
employees(full and/or part-time).• have hired the sub-contractors
2.ElI con a sole proprietor or prutner-
listed on the attached sheet t �• ❑Remodeling
Alp and have no employees These subcontractors have a. ❑ Demolition
working.for me in any capacity• workers'comp.insurance. 9• Building addition
(No workcrs'comp.insurance 5.'(] We are a corporation and its
required.) officers have exercised their ME]Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I1.❑Plumbing repairs or additions
myself.[No workers'cump• c. 152,¢I(4),and we have no 12.ORoofrcpairs
13.Q Other s insurance required.]t employees.[No workers' �Rte
comp:insurance required.] >P
•Any applicum char chcslts box el mutt also rill out Iha sactian below showing Ihak warkms'cempanwlon paltry infmmoila►
Lvnanctt'I uw who1=ihb affidavit indlnling they an doing oil work and then him ouisidecentmceps minl submit a new affidavit tndiedng suck
!Coninctort that chctk this box must alachud an additional shot showing the name of ike submontracton and Chair warkan'comp.policy information.
l urn an employer that is pravfding workers'compensation Ltsuroncefor my employees: Below is the policy and Job sit#
injorarmiam
Insurance Company Name, f;�r^ rj—Cer+, .11.
Policy 4 or Self-ire.Lic. N: // y,/ Expiration Date: /.
Job Site Address: 7 1 q I '"1 OrAlt ST City/Statezip: 54wAt WK O/V
70
.titacb a eopy of the workers'compensation Polley declaration page(showing the policy number and explradon date).
Failure to secure coverage as required under Section 25A of,*VIGL c. 152 can lead to the imposition of criminal penalties of a
line up to S1.500.00 and/or one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to 5230.00 a day against the violator. lie advised that a copy of this statement may be rurwarded to the Office of
Invastigudons of the DMA for insurance coveraga vcriticaliun.
i do hereby certify under re /us and peuaities ojperfury t of the hifurntation provided ubuve is true and earreeb
S'✓noturc• DaN:
Phone 1,
official use only. Oa not write in this area,to be completed by city or town official
I
I
City or rown: ____Permiu7.1cende.4
L�sui ng,%uthurily(circle one):
1. iluurd of health I. lluildinq department 3.Cilyi town Clerk J. Electrical Inspector 5. Plumbing Impeetor
6.Other _-- ------
Contact Person: . .._.. ... Phonalh
i