3 HORTON CT - BUILDING INSPECTION r.
The CummomNealth of Massachusetts
Board of Building RegulationsIl Nl( IY
M
and Standards tR
4 y 5 !\ 'll'.\I.I
1 i t, ri Massachusetts State Building Code, 731) CMR, 7"' edition I lSl. I
Building Permit Application T nstru . Repair. Renovate Or Demolish a Rci o,fa.Auui,n%
\ On , or Tn o-Farm v Du ellin,t; 1, 'tent
This Section Fur vial Use Only _
ate Applied:
' C7
Building Permit Number. PP // --
Building Coi mi isioued Inspector of i 1 mgs Date
—�
SECTION 1: SITE INFORMATION
1.1 Properyy Address: 1.2 Assessors Map & Parcel Numbers
1.la Is this an accepted street? ves nu _ Map Number P:ucel N:mtbcr
1.3 Zoning Information: 1.4 Properly Dimensions:
Zoning District Proposed Use Lot Area(sy f) Fronlage il't)
1.5 Budding Setbacks (ft)
Front Yard .Side Yard, Rear Yard
! Required Provided Required Provided Required Pnrvidcd
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 Private❑ Check if yes❑ Municipal ❑ On site disposal syucin ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
1-�
�FA:.ts� MA2Zv�c � Cstt?N CT"
N Pri ul Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construrron ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Additi�rn ❑
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units_ Other ❑ Specily:_
Brief Description of Proposed Work':- _ t✓ltkan)s W i'1�( _ 171i_+�C r�C
W iYIADt�Dra_,�,-_�Nf�GWS /
SECTION 4 ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ — 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Appitcation Fee
2. Electrical $ ❑Total Project Costa (Itern 6) x multiplier x
i
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire
Su ression) Total All Fees: $
Check No. Check Amount: Cash Amount: _
j b. Total Project Cost eecos- 0 Paid in Full 0 Outstanding Balance Due:_ ___
SECTION 5r CONSTRUCTION SERVICES
5.l I�icensed Construction Supervisor (CSL)
,, M l ei"to Apr License Number I..vpu.wm Uwa
Name of C ' - Holder
List CSI_Type(see bclowl
Type Descri pion
\� ss
C Unrrstncted to m 35,000 Cu. Pt.r
R Restricted I&2 Family Dsselling
Stg u u .bi Masonrn Only
Gt1Q'�}.i�I$g10 RC Residential Rooting C o%enng
Telephone wS itesiJatbal WmdWe .md Sidtn_' -
SF Residential Solid Fuel Burning \ppinmre In..t.JLw�-u
D Residential Detnuli mi
5.?r �2e�stered Ilor Improvement Contractor(HIC)
HI;Co npm y N. tne or fIIC Registr.-µt-+N. e Registration Number
Lc. J Lt14 O L 5'
Ad r s
_ __-_----- ` ti2� -xpitatiun Date
t Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDA VIT IM.G.L. c. L5_- 3 25,C(3;)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure nt pnts'ide�
this affidavit will result in the denial of the Issuance of the building permit. I
Signed Affidavit Attached'? Yes ...... .. No __....... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED "'HEN
OWNER'S AGENT OR C4NTR4i_"OR APPLIES FOR BUILDING PERMIT
[, �' as Owner of the subject n.roperp, hereby j
authorize_ =Qsp__fu1l, c•.'t-1-R` to act on my behalf, in all matters
relative work authorized by tins building, permit application.
_1 _��___--
Signature oFOwr.er Date
SECTION 7b: OWNEW OR AUTHORIZz.D AGENT DECLARATION _
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. ame
Sigwn::_
r Dated �� --
(Si ned ern cr h sins an enalties of perjury)
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 at
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing WSL)can be found in 730 CMR Regulations I IO.R6 and 110.RS. iespec(oely.
2. When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) ___. (including garage, finished base ment/attics. decks or porch)
Gross living area iSq. Ft.) __ .__ Habitable room count _
Number of fireplaces Number of bedrooms _
Number of bathrooms Number of halt/bath,
Type of heating system Number of decks/ porches -- _--- -_ j
Type of cooling system Enclosed, __.--___Open _ _—_--
3. "Tood Project Square Footage" may be Substituted for "Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
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Name M t�--
Addres (�c 1.4 I�VV"Ci tc Sa
City/Satw7lp MA r714)1 D Phone a<f_ G1�F—75/�1-Zvi d
Are u c.pMrir!C1eeh the eppt+spetaq heed _.
1. �a maploysr wiflt� 4. 01 an a gedsed oonalemr and I
empkgem(ha and/or PW"ime).d have hkW do s6coaftee a 6. 0 Now amoud m
2.0 1 sm a solo peapnietoe a patmm listed as the aaaah_d sbeet,t 7. ❑Remodeling
shir and bew no ampioyess Them sub4cosescom haw 1L 0 Damontim
wotkinp be we In any capeeity. werkam'camp ingwonea. !. ®adwits addhl0�
(No w�odwe comp;.saran 3- 0 Ws_m a aarpamdest and is
l ho)mbwner of ers hew mumdud dM6 10.0 Bleaalnl mpeim or adMims
3. doing all wont right of a camptloe per MOL It.13 ihmbins mpshs or adtl om
my-04(No watkas'eomR a IA 11(4)6 and we haw no 12.0 Roof mpaW
imps ens regtiriNg t employees,Db waders, 13,0 Other
camp Worsaw required.)
�Aay rppaew erawr.ra/1 Miesrbs Imar eeestlairs. _ , I[ -- I
rtetyr.t.ed<..r or.p..slte
1100 eawtvbtonnetabaaidwe dWwdobsAll.00addinareaoattltaaaasas�.r.its .md rr roryPsis IC,.e.erwsseRttareatmastmrol.d..ddtueerAsam , ifelrawetens addwk%vde'eat,voterbrad
few aw nybye"l:pr*vAd j w.r*M'eeaPessrtiow b8srrWN1M br eqr eerPloyWM Bdkrw b rlbPoAit7'ewdi/oti eNr
Joseeearesa
Insurance company
Policy M at Semins.Lk.Ak 5-29— 9 `j Fxp"d=D"O
Job site Address-3 CST 2: ply)
Attach a copy of the workers'compaasatloa policy decLr_tlen pep(_hewing the policy amber dad&X&Mdata dSb)6
fi ft up to eeeun coverage o rerptieed under Sestina 23A of UM a 152 can lead m the imposition of criminal penal"of a
fine up 11 i 1 .00a d y aping
one-year imp isonmma'at well m civil penalties in the form of a STOP WORK ORDER and a line
of up to l230.00 a day ageitttt the violater. Be advised am a copy of this statement may be forwarded to tht Ofliu of
Investigations at the DiA f coverage venIIpdos.
do junk) rnd"AtPw" put ier/r+p tAet tArG/or_r�lloao^ov//tI above trw awetawtett
Phone M: lq(-7 h/2 1 O
o,Qleld use 0* Do not wr1N In Wir dreg,N bt eosePleNd by elly or on q eAd
City or Tows: - Permlt/tleeam M
Issuing Authority(circle one)..
1. Board of Health L Buildlnt Department 1.Ctryfrown Clerk 4. Electrical Inspector i Plumbing Inspector
6. Other
Contact Person Phoew W
%.� CITY-0
F SALEM
s
tip;i PUBLIC PROPRERTY
DEPARTMENT
ril\IIGRLF.1"! NISia?Il-
\1 120 WA51.11NGTON S"i REET •SALLM,MASSACHLSL[-I S 0197C
TE1:978-745=)595 •FA8:978.74G9846
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 tt _,.__-_ is issued with the condition that the debris resulting from
di
this work shall be sposed of in-a properly licensed waste disposal facility as defined by MGL c
S 150A.
The debris will be transported by:
(name of hauler)
Thee debris will be disposed of in
I �
(name of facility)
�N�caH �D ,��A
wLlaress off
Sit- turf o permit applicant —
%t 14
;ate
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