15 HAWTHORNE BLVD - BUILDING INSPECTION (002)r
c
I he Coninionv%o tlth Ili Mass.lehuu.•us
t IIUJId 01 Building Regulallons ,lld St.wd-11dN R
%it Nit III \1 iI1
- ss State littildi ('adr.
LL . J�huscns n '�
Building Per nlil Applica11011 ru construct. Repair. Itcm ,Ide Or I>enn ll,h u
h-unrlr lh;rll e — ----
I his n Sen -or I'
fetal ,r lhdy
j Buildmt Permit Nun cr.. _ 1 r :\ppbrJ
BuIIJ;uf C;nnlnn.n ni l/ a .eilut.q Bw ui�, Ualc
-- SEC"PION 1: .SI I'F: INFOR.MA HON
1.1 Propcfls ddress:— �� �J/� — i 1.2 li+se+surs flap & Parcel Number+ -- _
I la 61h s .ln al,,q)wd slice[ �cs l/ no_ — \lap Isumhcr
1.3 Zoning Information: 11 1.4 Properly Dimensions:
Zinmy. Dn;ni; Pngw,rJ 1'u• � i.o! :1 rcu � (o '-;,... _ . , I
1.5 Building Setbacks (ft)
Fr,,nr tiard Side Yards Rcar Y:ud
'~ Reyuue 4usIJoJ __. Kcyw;cd Prue;drd Kayun;d PI d, I —�
1.6 'A'o[er Supply: L\,1(; L c. 10. §511 1.7 Flood Zone Information: 1.8 Sewage Disposal System: �
Zone Outside Fluid Zone! .Mun;a a lxwal ,,,I
Public ❑ Private❑ — p I ❑ On ,Itc dI, C In ❑
Check It ye,❑
I SECTION 2: PROPERTY OWNERSHIP' �
� _.I Owner rd:
.� L�c/ SCR/G l O.L�c����� L`%i y.PC�� d.G i7c��U✓T o1d(/�
N ur. �Print, Address for Service: �
Sienrttirc -clephune
- SECTION 3: DESCRIPTION OF PRO—POSED WORK' (check all that apply) _
Nc:v Cr,r,stnrction ❑ Existing Building Owner-Occupied ❑ Rap.rn:,l sl ❑ :Uteruiun(s) ❑ Wdiln n ❑�
I
(1 m 0 4:crwr\ Bldg, ❑ INumberof Units-__. Other ❑ Specit} ___�
I
SECriON a: EST ISIATED CONSTRUCTION COST'S j
E,umated Cnets:
Item Official Use Only
1 Luhur .;nJ Ylatrnalsl
I BuildingS I Building Permit Fee: S _ Indicate hr;w Ice I, Jcic;Inined
-' andard City/I"own Appllcauon Fee
�11
{leemeal ❑"to(al Project Gl+l' t Item 6) s multiplierlunhmng S 1 _, Other Fees: 5
4 Mechanical Ilf\ .Ac) S � 1_bl' -
I'i Plumbing
!Fire p
1u l ne„unl S r"rtul All Fee,
— �
(heck No .\nl,,unr l'.nh \;n,unl
0 rotal Project Cost - ----
___ Cl P.ud In Full _❑ Oul>t_rndilliu, L;n.e Ihie_
SECI•ION 5: CONSTRU TION SER% l ES ---- — — —
I e unstrucUmt . open tit .)
f`{ni.uion 1).tli
\ )JR
R Ri,to ix' Famih IAA Ilul _
Rl Ri.IJ:_nnal ! "Ime( u,iinie
fi li phone R.•aJ;
Solid iil liuiniu`
.? Registered flume Improvement Contractor I IIIC)
HII ( omp.ms .\'an)r Ur 111C Registrant Ninit: Kell]IraW�n \unlhir
\JJres, -
Fi yniawm U:ne
1itnaturr relephune
SECTION 6: WORKERS' CONIPENSATION INSURANCE AFFIDAVIT (b1:G.L. c. 152. § 25C(6))
Workers Compensation Insurance affidavit must be completed-and ,ubmitted with this application. F.olure ro pros lde
this affidavit will result in the denial of the Issuance of the budding permit. t
Signed Affidavit Attached? Yes .......... ❑ No ❑ - - .. ..
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN,
OWNER'S AGENT OR-CONTRACTOR APPLIES FOR BUILDING PERMIT
l as Owner of the subject property hereby
i ❑wWmzr - to act on my behalf. In all io irlei:+o
_
relative to wink authorized by this building permit application.
I
Si¢nature of Owner --- -- Date
SECTION 7b: OWNER( OR AUTHORIZED AGENT DECLARATION
I.
, as Owner or Authorized Agent hereby Jackne
that the statements and infitrmatiun on the foregoing application are true and accurate. to the best of my knowledge .Ind
behalf.
Print Name
Sienuturt of Owner or Authun red Agent Date --- j
t.tit med under the arcs and penalties of (u ) -
VOTES: _{
I. An Owner who oblams a budding permit to do his/her own work, or an owner who hires :tit unregntetcd aaura, for
(nut registered in the Home Improvement Contractor (1110 Program). will nitif hasr acces, to me athitiauon j
program or guaranty fund under ,vI.G.L. c. 112A. Other Important inhumation tin the III( Pr„gr:un .ind
Construction Supervisor Licensing I(�SLi :.m he hound in 780 CMR Regulations 1 10.R6 .utd 1 It) 10. re,peeu,cl
When substantial work is planned. provide the mlurmation below:
Total floors area iSy. Ft.l (including garage. fini,hed ha,en)ent/auics. decks or porh,
(lro,s Irvin_ area i Sy. Ft.) Habitable room count . .
Number of nirplaccs __ Numhet o f hedroI an, _
Number.it h.uhtoom, _ Nunihei of h.ilt/h.iths
I
' fspe of .00llne ,r,lem 1]i.bi,iJ Open - �.
3_ "Loral Pnyect Square Footage" ntav he ,ub,tituled for "fol.il Prolect
�TF/T
Ij
City of Salem, Massachusetts
Fire Department
48 Lafayette Street
�a6en roV 7uryq r SaCem,9K=dtAusetts 01970-3695 Tire 4Yevendoll
Chief 'rer.978-744-7235 !Bureau
FaX 976-745--4646
.978.745-7777
APPLICATION/PERMIT TO ERECT TENTAGE OVER 120 SQUARE FEET IN THE
CITY OF SALEM ACCORDING TO THE MASSACHUSETTS FIRE PREVENTION
REGULATION 527-CMR 19.00, AND THE SALEM FIRE CODE, ART. 0 20
FEE $30.00
/J CHECK #
APPLICANT_ i�lyftpCr.Zµ9,�✓�' (j S*DDRESS: / p
CITY: �igC{+yy�ryry�� _ STATE: /�- rovf ZIP: 'j O/ PHONE:�L�,
LOCATION OF TENTAGE:_ P
OWNER OF PROPERTY g� A.ADDRESS; �S �7l�.tlAp
CIT1 ;_�^yya�cy�� STATE: AyC7 ZIP: 4'/g'7d PHONE:
INSTALLER/RENTAL CO. OF TENTAGE: e .ta'�ryJp m�s�v�e-� PHONE 922 - 1�,Z60
Al7URESS 12P SZ CITY: SgnL, STATE; /�/�j - ZIP:
INOTC•ATE WITH REFERENCE TO YROPERTY LINXS AND OTHER BUILDINGS THE LOCATION OF
THE TENTAGE ON THE BACK OF THIS FORM:
MATERIAL USED: el &A-
MAxueacTuxEa: A44CA&k-- -.
SIZE OF TENTAGE: — X
NAME OF TESTING AGENCY:
AGENCY APPROVAL NUMBER:- CERTIFICATE OF FLAME RESISTANCE; SEE �Ciff•*+r.�'f�
CONDITIONS OF APPROVAL OTHER TRAM AS PER FIRE PREVENTION REGULATION: zyo
SALEM BUILDING DEPARTMENT PERMIT NUMBER: .291'-a(?
DATE OF IS5UE, -7—/v —e09'SITE INSPECTION DATE: Sl os EXPIRATION DATE:
APPROVED BR: TITLE; j^fz,G
FORM e(VD Rev. 8/,)9)
80B
T'd 96860b1J8L6:01 :woJj ££:LO 8002-TT--inf