HEMENWAY RD - BUILDING INSPECTION 1 I, A � The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
y j Massachusetts State Building Code, 780 CMR, 7' edition OF SALEM
i� Revised Junnurl-
Building Pennil Application To Construct, Repair, Renovate Or Demolish a I. :rRAY
One-of Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
Signature:
HuildingC missioned Inspector of Buildings Data 7
SECTION 1:SITE INFORMATION
I.I Property Address: 1 1.2 Assessors Map do Parcel Numbers
Ofo&-Aful±!� CDAU
I.la Is this an acc4pted street?yes no Map Number Parcel Number
IJ Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Are=(sq It) Frontage(11)
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 Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public O Private O Check if es0 Municipal O On site disposal system O
SECTION2: PROPERTYOWNERSHIPt
2.1 Ownerr 13tec rd
�i�c C_ S4WptI"( 6SSooa'
Name( M) Address for Service:
t
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied O Repairs(s) O Alteration(s) ❑ Addition O
Demolition O Accessory Bldg.O Number of Unit_ Other 0 Specify:
Brief Description of Proposed Work': - a a. Z O Y 3 U Te w'{ G3 vU
in& wkpve r)A- n e VY+-°-f_
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllelal Use Only
Labor and Materials
I. Building S 1. Building Permit Fee:S Indicate how fee is determined:
O Standard City/Town Application Fee
?. Electrical S p Total Project Cost(Item 6)x multiplier x
). Plumbing S 2. Other Fen: S
. Mechanical (IIVAC) S
a List:
S. Mechanical (Fire S
Suppression) Total All Fees: S
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S N � 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor ICSL)
A24W 0 License Number Expiration Date
Name art C'SL• I folder 2 / Q/� List C'SL type(see below)
Z
11,'��� -F� o r I Descri ion
613nti U I unrestricted u to 35.000 Cu. Ft.
r R Restricted Id2 FamilyDwellin
"itt
-f'7S RC Residential Roofing Covering
Telephone Iws I Residential Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
F
egistered Home Improvement Contractor(HIC)
ompany Name or IIIC Registrant Name Registration Number
s Expiration Date
ure Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.1 25C(6))
Workers Compensation insurance affidavil 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 ..........O No...........O
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 to act on my behalf,in all matters
relative to work aut onzed by this building permit application.
sigwomorOwner Date
SECTION 71b:OWNEW OR AUTHORIZED AGENT DECLARATION
rbehalf. .
as Owner or Authorized Agent hereby declare
d information on the foregoing application arc We and accurate,to the best of my knowledge and
Signature of Owner or Authorized Agent Date
70wner
the ains and penalties ofperjury)
NOTES:
er who obtains a building permit to Jo his/her own work,or an owner who hires an unregistered contractor
stered in the Home Improvement Contractor(HIC)Program), will W have access to the arbitration
or guaranty fund under M.G.L.c. Id2A.Other important information on the HIC Program and
tion Supervisor Licensing(CSL)can be found in 790 CMR Regulations 1 IO.R6 and I IO.RS, respectively.
2. bstantial work is planned,provide the information below:
ea(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 half7baths
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Tolal Project Cost"
'PPpd-r3p '° mJ9mQ9KJm9� IMPOFTANT DOCUMENTpPr PLpr
5
5 Certif ica W of Flan-N lResist pee
5 REGISTRATION ISSUED BY
5 o CN R Date of Shipment
APPLICATION
5 NUMBER o ss NOUSTRIE�INC.® 4/212COT
5 EVANSVILLE, INDIANA 47725 Tent Identification
5 '
5 r22aoz MANUFACTURERS OF THE FINISHED 1144�47�7
z TENT PRODUCTS DESCRIBED HEREIN
5 This is to certify that the materials described have been flame-retardant treated
r5 (or are inherently noninflammable) and were supplied to:
s 76466
r7 CANOPIES BY MICHAEL
51 WARREN ST
5
55 MEDFORD MA 2155
5
I 5
5
5
55
Certification is herebymade that:
5 Pp The articles described on this Certificate have been treated with a flame-retardant approved d
00 chemical and that the application of said chemical wa
5
pp s done in conformance with California
Fire Marshal Code. All fabric
a c has been tested and asses NFPA 701-99 CPAI 84 ULC 109.
P ,
5 Serial # 800i417C(2)
5
5
5 Description of item certified: Gi_Nii 1111, FOP 20\\N30 mPll IE
5 BRUIN VINN W/CUR7 HN
5 Flame Retardant Process Used Will Not Be Removed By
5 Washing And Is Effective For The Life Of The Fabrics
5 BKt11N PL:\S I ICS.GLBNDALF. RI 9
Si ned: 11
rj Name of Applicator of Flame Resistant Finish ANCHOR INDUSTRIES INC.
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