38 IRVING ST - BUILDING INSPECTION �( 2 v F 3
The Commonwealth of Massachusetts
~ i Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CIVIR SALEM
Revised.tlur 011
Building Permit Application'ro Construct, Repair, Renovate Or Demolish a
Otte-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: Date A lied:
Building Official(Print Name). Signature pit
SECTION 1:SITE INFORMATION
I.I Property A 1.2 Assessors Map&Parcel Numbers
L I a 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(sy 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Reyuircd Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check it' es❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of,
l�thme(ant) City,State,ZIP U
No.nuJ Strect Telephone p Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check. that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units th ❑ Speify:
Brief Description of Proposed\York':
J<.r
SECTION 4: ESTUMTED CONSTRUCTION COSTS
item
Ofci e Onlytbsa
as
Labor ndlatcria a
I. 13uildho,
_ I. Building Permit Fee:$(Z .Indicate how fee is determined:
2. Electrical S ❑Standard City/'rotvn Application Fee-
❑Total Project Cost"(Item 6)x multiplier x
3. Plumbing .S 2. Other Fees: S
I. Mcchanical (IIVAC) S List:
.i. Mechanical (Fire _
Su""ression) S rotal All Fees:3
Check No. Check Amount: Cash \mount:_
6. Tntal Project cost: S _ 0 Paid in Full 0 Outstanding Uatance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Consh u n Supervisor case(CSL) CH
License— umber F.epira on ate
Nentn or CSL 110 ,r tttJJJCCC L see below
List CSL'rype( )
rype Description
No.and Street
U Unrestricted(Buildings u to 35,OW cu. ft.)
��I(>�I R Restricted 1&2 Family Dwelling
Cityll'own,State,ZIP M Nfnson
RC Roofin Coverin
WS Window and Siding
' SF Solid Fuel Burning Appliances
I Insulation
'I'elc tone
' Email address U Demolition
5.2 Registered Home►m men Contr r(1HL
HIC Registration Wir, Uute
I u nte' r Name
No and Sty ! Email address
l y �33
City/Town, State,ZIP 'role hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(VI'.G.L c. 152.§ 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 IsSuanc of the building permit.
Signed Affidavit Attached? Yes .....:.... No...........❑
. SECTION 7a:OWNER AUTHORIZATION:TO BE COMPLETED W HEN;
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING
PEMIIT
1,as Owner of the subject property,hereby authorize ` ' /a��
t9 act
on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Nane(Electronic Signature) Date
SECTION 71:OWNERt O AUTHORIZED AGENT DECLARATION
By y name below, (hereby attest u er the pa' sand Wallies of perjury that all of the information
con wined in its ap true and accur to to the a of k vledge and understanding.
4462
Print( vne 'sorAuthorizedAgent'sNatte( 'Iccuonic. tgn,lure Wile
VOTES:
I. .An Owner who obtains a building permit to o 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
pro,ram or guaranty fund under NI.G.L.c. I42A.Other important information on the HIC Program can be found at
w%M.mass."'ov'oca Information on the Construction Supervisor License can be found at t"y%v mass. ,ov:!din
? When substantial work is planned,provide the information below:
Total floor area(sq. R.) (including garage, finished basement/attics,flecks or porch)
Gross living area(sq. It.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
rYF .
e of hcatin S system Number of decks/porches
rypeorcoolingSystem Enclosed Open
3. "Total Project Square Footage"may be substituted for"'total Project Cost"
Sold.Furnished and Insl:dlcd hy:
l If At-Ilona Scrc ices. Inc.
,H)it the I Ionic Depot AI-I Ionic Saw ices
9nS Bosom Turnpike 1, nit I,Shraysburr.NI A li4i
Branch Name Boston .ADrib Uate:9'i9;2(11. .. Tull Free S',yut3-frrhuc NP0QtgA6l0
111:Lie k C 0_3;9 RI( ,lit. Lien 164-
CT Lie a'1IIC.Oi6i,'- MA (tome linprnycmcnt
Branch No: ....
Conti-aclor Rcg. 1_'hy93 Federal ID r
._--'_698460
Installation Address: IS hying St Unit A Salem MA 01970
— GIN, State _ Zip ,, Y
Purchaser(s): \A'ork Phone: Home Phone: Cell Plume:
I
MIM Jillian Sarro - �1 19751 3,3�-471j
1
Home.Address: �S hA in,_Sf Unit A Salem NIA01970
(If dillcrenl tiom Installation AddresS) City Slate Zip
E-mail Address Ito receive project communications and Bone Depot updates): ifs;n'ruio_'mail.cont .
N9;rkeling entails trill not he sent tiont'Ihe Hume Depul.
Pruiect Information: Under signed t"Customer').the owners of the property locoed at the aboyc installation address, agrees to
buN-and I'HD Al-Home Scryices. Inc. r 1'he Home Depot"')a^_rces to fiunish.deliver and arrmce for the install:ninn(-'Instalfiiii
ori')of all millet ials described tin the hellm and on the referenced Spec Shect(S). all of which arc incorporated into this Conuuct
by this rellereuce, along tcilh any applicable Stale Supplement atnl payment Snlllmal'N attached hereto and anc (h;urge Orders
Icolleclk etc."C'ontract"1: .
Job#:WoernA Retcr.•n.cl Products: Spec Sheet(s): Project Amount
7147701 � Windotes � 7147701 S139739
Mininnrm 25%, Deposit of Contract:\mount
due upon execution of this contract Total Contract Amount S 139 i.�9
Cusrtuner agrees Ihut, immediately upon completion( l the work forcuch Pntdtlet. (:ustutne-Will execute it C'o11111) 011
Certificate lone lilt each Product as defined by an individual Slice Sheet)and pin. :illy balance due. :As applicable. each
Customer tinder this Contract agrees to be jointly and sercrally obligated and liable hereunder.
Payment Surnmarv: the Payment Sununary?_7147701 _ . included as part of this Contract.sets IiNrih file total Conunct
amount and paymcros required loi the deposits and final payments by Product (as applicoblcl. -
GENE14AL'fERBIS AND CONDITIONS
Responsibilities:
'the Home Depot: Neill provide the Products identified above. make arr;mgenunls to hotr the Authorized SCl'ylce Provider pertirnt
the Installation services in a professional and tcorkmanlike manner.and ananec proper iusumnecs. Unless othelxy Ise expressly
provided tiff herein.Authorized Sen icc Provider trill obtain required permit,and provide permit number.
Customer:Neill identik ativ propenv lines.casements.coceuantS. underground or overhead utility lines. Prc-existing physical-or
1MW12-SA Page t d 9
NOTICL TO CUSTOl1ER
lots are entitled to a cumpleteh. filled-in cope of this Contract.signed be both con and The Hume Depot.at the time cots
sign. Do not sign a Completion Certificate before the Installation is complete.
.Al centance and authorization: C'usrtnner tierce:and undersnutds thm this Contract is the cattle uereentent Ocmeen Customer
and the Hone Depot m1h regard Io the products and installation semees and supersede,all prior discussions and agreements.
either oral m 1+riItell. rclaIing to said products and installation. phis Contract cannot be ossipsd or o III ell LIed cXeept b_c a %vruin
signed ba Customer and 'I he I-lome Dcpot.
Customer acknntrledges and agrees that Customer has read, onderstancis,voluntarily accepts the terms of and has received
a copy of this Contract. Customer acknustledges receipt of the Notice of Cancellation.and that The Home Depot has oralh
informed Customer of Customer's right to cancel. Customer's signature below constitutes Customer's acceptance and
execution of each of the applicable Contract Documents. DO NO'1 SIGN 'I'HIS CON'l RACT IF'I HERE ARE ANN'
BLANK SPACES.
You are entitled to a paper copy of this Agreement if ion choose. If}au consent to an entailed copy,your consent applies
only to this Agreement. Bp contacting sales office 11771 90,176;i ,cots mac update your email address,withdraw coal
consent,or obtain a paper copy of the Agreement at no charge. BI signing below.you confirm the follmi nw:
• You consent to receiN a onh'an entailed cope of this Agreement
• You hate access to a computer that can reeeice and open entails and PDF(Adobe Reader Version 10.1.4 or
later)formatted documents.
• four email address is correctli listed on the Hume 1 nprnvement Contract
Submitted bc:
Sales Consultant laem Beisicuel M/M Jillian Sarro (Sep 29, 2013, 11:52 AM)
License\'ante.
telephone No. 18771 903, ;765 — �
Sacks Consultant C
License No. (as applicable)
Accepted by: JB68 (Sep 29, 2013, 11:53 AM)
CANC'ELI_Al]ON: C'LS I ONiER MAY CANCEL THIS CON RAC'I \Y ITHOUT PENAL I'Y Oil OBLIGATION Bl
DELIVERING Will IT EN NO ICE '1'O THE HOME DEPO'1 B\ DIIDNIGH'I ON 'I E'LED RD BUSINESS DAY AU I LIZ
SIGNING 'I'HIS CON"I'RAC1'TO'1'HE ADDRESS LISTED 1BO\'L. THE S'IA'1'L SUPPLEMENT AI"I'ACHED
HERETO CON AINS A FORM TO USE IF ONE IS S13ECIFIC'ALI-1' PRESCRIBED BY LAN% IN CLS ONIEIVS
S %I E.
IIW1225A Pano 8 of n
CITY OF S.A'L.EM. NWsS CHus=s
* . BUILDNG DEPAR'R[ENT
120 WA1SHNGTON STREET, 3'DOOR
TEL (978) 745-9595
Rux(978) 740-9846
KI,xtBERLEY DRISCOLL
AViAYO:i THOSLAs ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BL'ILONG CONNI5SIONER
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 t# 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:
(name of hauler)
'fhe debris will be disposed of in
(name of Faci it )
-- address of facility)
i
4igne of permit applicant
l3
(fat
I0)i f'1'
an lglniva
P;
t rrr rlu-�Zohr rrr Spec.,
flCT
�t 1 Bown 114 G 11
T j3
VVUrE.CI s, Cot1 pn ettia trt. ott' ma, tiFiclavi
�tiU'tSC3P�IR1'l llrdt,C'Il ___ f'IC a: r lrt�t7 r f tl'
tea-t,,o ;B'_ rc _!� �,. .t..ch•..d:�. . � �. Z J __. __. —_
Citj'lStat /L'ip. '' r f 1✓i Phrn;e i <�
1 Arey .anAmployer' Checkthe proor-iat bcK � Fllpeof pro
ject(reyuued?'
i 11 'maeenra twictc
e- + ,dt i �
,. 1 ' amzenayloyer ,ft, L,Ne et .tlo^
ha e hoed be b co � rerors j � --
I ettioloyees(full and(o la rl Urn e,).-
J r -' R modeln' `
1 am a e p oYt ' . o panne! hat d on the cttedhed sheet,_ C s ' . I I I
il
slap arc havt no e.mplovera These sul net+ ants hwe S, [LDe noht >
m pleV__s an h Eve wog t.e's' I� r-, n� `
j worumg for me to an} capacity � I � , �'� " , Ian
comp-
[Nouxt rat e
workers' comp unsat iceif��r]tle t t�a1 p a s or addw as
reywred ) �S. I re- a n arperanon and its
�.[] 1 am e homeowrer doing all Work
offir r,have exer oseo thetr �]R mn nr_ �,rnv o addi[inrs r
mys It FNo 1ri N of e -ninon la NIGL
t c li=..blt andw hEae
- nc I
j insu ar - reaufred j r` i i 13. n. ,
cmmp. rncarance ieyuired.l I
Ary appiceh Ih0l,eltc1.eh0:k l ruaos fi m the.'eltntel'w'howl" let.s•rr rnp sntnn pol infoll n
s.
i Hm,nwners who cuemn th, toe, a.e Jn',n_a!i a i�,i'.are iter, ire.nu,a.e nn.r.nn n s eu!nrt n t i ew1, n�. ;u 11 I
'Cnn:.raunra nu auk Mahnx must attached a,,a9duinm,.sleet shnu-inc:he name.ill the.uh-cnn;rnc••or.,and;:aye wh_.h_:o nW loose nr ' h„vr
en!pleree, if the rio-catiancTors have uplove:es.t!:ev ru..r•provide flnir ecm:it.noiic;:tn;mhe:.
I utao an entplrrver than.a providutg.woricers'compell,=ots irzsu.r¢n.c_s for nn•crrrp(nveei, Bchnr is the pottcp and juh sire -
i.n.r"Or11t¢¢Ott. j
lnsurance Company Name: .� i 1� � -�[ t-.,r — t
i
-^'J � iy I
Poky A c' SAWS ins, L t .s� — ��7'j�!j"J�7�t=,° --- _ u P ra[or DaLt___✓��i,
— .�c�--C-' `
lath Site,�.r'd _
Attach a copy of the workers'comn:.nsatior p icy declaration page isI Ivinv the policy'number and exhi;ation date.i.
Failure to secure coverage as required under Section 25,A of MOL c 152 car,,lead to t'ne itnpositior,of cruninai Penalties of a
We up to S'_ 300.00 andtot one-year impnstmme�t a;vd 11 as cis tl r n a] ies in th form of a STOP y>vk - ORDER and a fine I
of❑p to.5"iC (1('a a c a_ rrat .olainr. B. a ',<;eo that a cupv o'thr..seatern_cr may h 1br.<erdeo r. th Ofn.:e m
invesfica. ons_ni de-° 1DI,A i4 inu once l: a an nri':ti m.
1 do herebl cerdifv undo the .in I'd Ito,6a of pequr} that the Infor-mov.or provided above is trrae and Co: ect.
PRM C
7-ro
e nnlr; Do nor xritc i.n this¢'ea. to be contpietcd by ci.rOr toterwn: Pecmuthorirp tcircle.Doer.
1.Board of HealEh 1.Buildin_Department :.. Grip/Town Clerk 4. Electrical inspector Piumbirg i7nsi
Ifi.Om ersnn:er
� ConiactP
Phnnc k:- j
i
^ I
i
? � Pilassachusetts Department of PulbljcSmetv '
' Hoard of Building Regulations and Standards
License CSSL-099699
ROBERTPOCZOBUT
172 WHdALEIVS
Salem MA 01970 �
'ks"0I:G1
C ansmssmn`r 02108/2014