2-4 HOWARD ST - BUILDING INSPECTION 5 �
AQ, The Commonwealth of Massachusetts
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'"edition
�t� BuildingDept
Building Permit Application To Construct, Repair, Renovate Or Demolisja :*#kmosodwa
One- or Tyco-Fumih Du elling
This Section For Ofrtcial Use Only
Building Permit N mbbeer: Date Applied: / /l
r Signature s J I �OT
Building Commissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
V 1.IMy j j � � 1.2 Assessors Map& Parcel Numbers
L la 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 6) Frontage(A)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
Fptwer
.G.L c.40.154) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if esO
SECTION 2: PROPERTY OWNERSHIP'
� �.v� e 3T
A ss or "I.0 :telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alleration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': ti � -
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Budding S ®0V I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical f �> ❑Standard City/Town Application Fee
❑Total Project Cost,
ost (Item 6)x multiplier x
J Plumbing $ 2. Other Fees: S
4. .Mechanical (HVAC) S l+ List:
5 .Mechanical (Fire
Su ression Total All Fees: S
' r Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: S fnT m ❑ Paid in Full 0 Outstanding Balance Due:
r ,
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
sL �q6 11
/'per_ License Number Expiration Dare
NX=o Y'SL- Helder Cam[ Lot CSL Type bec below) '
�'� T Description
AJJrcs ����
U Unrestncredi uo to 35,000 Cu. Ft.)
R Restricted I&2 Family Dwdlin
Signatur" v1 %talon Only
/� RC Residential Roofing Covering
Tdeph ne q O n�0 ^ q/ WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered omit Im rovem tit C ntractor(HIC)
HIC C�pan Name ar C e istrant Name Re is ration Number
�r 0
Addresf PIWOW�
I
Expiration Date
Signature Telep on,
S CTION 6: WORKERS'COMPENSATION INSURAN E AFFIDAVIT(M.G.L.e. 152.; 2SC(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 o building permit.
Signed AlTidavit Attached? Yes.......... No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1. �Q as Owner of the subject property hereby
ry��/h..
awho ' e`�oc_,./!P A4 dj�7C V� to act on my behalf,in all matters
relative to work authorized by this building permit application.
—(6
Si rc of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
as(i*=Yt;or Authorized Agent hereby declare
that the s#ments and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf
Print N
7�1 �j—OCI
Signature ner Authorized Alien Date
Signed un r the Rains and natiies of r u
NOTES:
1. 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 dd have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and 110.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floor
s 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 halfbaths
Type of heating system Number of decks/ porches
Ts pit of cooling system Enclosed Open
1. "Total Project Square Footage"may he suhstitu(cd for 'Total Pro)cct Cost"
CITY OF SALEM
1 �
Is ,j5 PUBLIC PROPRERTY
DEPAR�I'L1ENT
',I 1.lII1 • \1I1 \I. \I I'� -
Construction Debris Disposal Aftid:nit
(required lbr all demolition and renov:uion work)
In accordance \\ith life sixth edition of the State Building Code, 780 C'hlR section 1 1 1.5
Debris, and the provisions of'Iv1GL c 40, S 54;
Building Permit /t is issued with the condition that the debris resulting from
(his work shall he disposed of in a properly licensed waste disposal facility as defined by tMGL c
l 11. S 150A.
The debris will be transported by:
I name of ltaul,r)
I he debris will be disposed ofin
I LD �d�►
(mine ul lau Ity)
.-�rl-G � r� f/e w' I�u Kb t? �6'Lj lA
IJJre.� ul 1]cilnvl
aci dlwt ul p:nnrt .y+plicunl
i at CITY OF S.1I.E%[, .L\L-�SSACHUSETTS
BUILDING DEPAIMLEVT
120 WASHINGTON STREET, 3aa FLOOR
TEL (978) 745-9595
f.+x(978) 740-99"
Kj,IBFRi FY DRISCOLL
MAYOR THON(AS ST.P[EM
DIRECTOR OF PL BLIC PROPERTY/BCQDLNG COSMUSSIONEI
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriclans/Plumbers
Al1D11e2nt Information Please Print Legibly
Name lBusi wn 0rpmzaiorv1nlhv1duall:�fl
Address:
city/statc/zip: >%PI Phone#: g74���a7 6D(3
Are you an employer?Cheek the appropriate boa• Type of project(required):
1.❑ I am a employer with 4. am a Cnzl contractor and 1
employees(full and/or part-time)." have hired the sub-cmaractors 7. ❑New debt construction
2.El am a sole proprietor or partner- listed on the attached sheet : • ❑ Remodeling
ship and have ma employees These subcontractors have S. ❑ Demolition
working for me in any capacity. workers'comp.instannim 9. ❑ Building addition
[No workeri comp. insurance 5. ❑ We are a corporation and its
required.)
officers have exercised their 10.0 Electrical repairs cr additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself. [No workers'comp. C. 152,§I(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. INo workers' 13.0 Other
comp. insurance required.)
-Any applicant 1hrr chocks elm A meal also fill aul the secsim below showing their wmkm'cornpmsa&m policy infunnadom -
't l.,meowtan who su6rnl this aflldavit indicating Ihry an doing all work and tho hiss atasside eerracsas srdul suhmil a new allidavN indiotip suck
:r-,ntmion that shack this base mud attached an aaditi,n a slues showing the name of sir auk consncfan and their workm•comp,Policy infmroam.
I one as employer that Is providing workers'compensation Insurance for my ensplayeez Below/s the poNey and fob site
injarmmlon.
Insurance Company Name:
Policy N or Self-ins. Lie. N: Expiration Date:
Job Site Address: City/state/zip:
,\teach a copy of the workers'compensation policy declgntion page(showing the popery number and expiration date).
Failure to secure coverage as required under section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51.500-00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S250.00 a day against the violator. lie advited that a copy of this statement maybe forwarded to the Office of
Invcsngatiom ol'the DIA for insurance coverage verification
I do hereby crrt'y under the pa• rand pmdI/ ojperJuly that the informasion provided above is true and t:arreea
inn t it
Phone 4: r 12_. o y
iOfciai au only. Do not write in this area, to be:ampleted by city or raven offtridL
City or town: _- Permit/License
Asuing.\ulhurily (circle one): -_- —� - --
1. Ituard of Ilrallh 2. fluildlnL Department 3. Cityfrown Clerk a. Electrical Inspector 5. Plumbing Inspector
6. Other
L"Illact Person: Phone N:.
: 1
Nlassachu�ctts - Dopaitmcnt of Public Sai'vi;;.
Board of Building Re
ttlations and Startdardf
Construction Supervisor Sptxialty L1ceb8e
License: CS SL 99685 s
: .Restricted to: RF
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•I.QMDCN DERRY„NH 03053
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Expiration:'`t?J1'
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Board of Building Regulations and Standards
HOME IMPROVEMENT CONTRACTOR'
Regis"tign, 122385
ExpnationGB126/2010 Tr# 274007:
I . TiTy¢pe SBA .
_ J& DiNEATHERSF�§t_,,
JAMES DEBRECENF— 3 -
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