52 JEFFERSON AVE - BUILDING INSPECTION (2) 5 r� tL,� 5 1 [b.
�
The Commo nvcalth of Massachusetts71
CITY OF
1 Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 730 CMR Revised Shrr 2911
D Building Permit Application To Construct, Repair, Renovate Or Demolish a v
One-or Two-Fmnily Divelling �
This Section For Official Use Only —+ rT
/ n t '
V I Building Permit Number. Date Applied.'
r1
- me). Si alure Date
B uilding Oltictal(Print Na _. bn _
SECTION I:SITE INFORtNIATION
1.1 Proper A d ess: five,V� L2 Assessors hlnp&Parcel Numbers
t
� tvn
I.In Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 ' ling Information: 1.4 Property Dimensions:
`Coning District Proposed Use Lot Area(sy It) Frontage(it)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wnte Supply:(M.G.L c.d0,§5d) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Public 7 Private❑ Check if es❑
SECTION2: PROPERTYOWNERSHWP
2.1
0 n City,Stole,ZIP
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORKS(check all that apply),
New Construction❑ I Existing Building Owner-Occupied ❑ Repairs(s) WAlterition(s) Addition ❑Demol
ition ❑ Accessory Bldg.❑ Number of units Other ❑Brief escri tionofP oposed\Vork-:
41�C
/r
SECTION 4: ESTUNIATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
I. Building $ �(�(� 1. Building Permit Fee:$ Indicate how fee is determined:
/ ❑Standard City/Town Application Fee
2. Electrical $ �I/ ❑Totai Project Cosh(Item 6)x multiplier x
3. Plumbing S 2.s Qther Fees: S
a. Mcchanical (11VAC) S A(A
List: 95'Cz�
5. \lechanical (Fire S
Suppression) Total All Fees:$
�- Check No._Check Amount: Cash Amount:_
6.Total Project Cost: .S S 000 ❑Paid in Full ❑Outstanding Balance Due:
SECTION5: CONSTRUCTION SERVICES
5.1 Cmrstruction Supervisor License(CSL) 5 Y ' f_ ��_ 1-6
&1- t rluy llP License Number Expiration Date
i7anie of CSL Holder 0
List CSL'fype(see below)
A dwel S�IF� _ .rypo Description
No.and Street - .
(p LL ,�^ A �Z�� I U Unrestricted 2 Farm a -elling 00 on. ft.)
AT.MC¢ �/1 !r"' R Restricted l&2 Family Dwelling
Cityfrown,Stale,"LIP M Masonry
RC Rooting Coverin
WS Window and Siding
SF Solid Fuel Burning Appliances
�id(� C/Y7'17�(S PSr✓� I�av>� 1-0 "e`- 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) )4 6 3 NO t-/3-/mob
n
( l t/ Wes.(4 t. HIC Registration Number Expiration Date
HIS om any Npm}or HIC egislnrnLDl:xne
No.and Sir
C Mfn 5p�'-�/r/-(�l(r� Email address
w it /town.State ZIP Telephone
SECTION 6:WORKERS'.COMPENSATION INSURANCE AFFIDAVIT(M.G.L:c.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 of the building permit.
Signed Affidavit Attached? Yes ..........e No........... ❑
SECTION 7a:OWNER AUTHORIZATION TO BE.COMPLETED WHEN.'
OWNER'S AGENT ORCONTrIAC 61ILAPPOES FOR BUILDINGPERMIT
I,as Owner of the subject property,hereby authorize l" d/- 1 "I-,
tj act on in behalf,in all matters r(elative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale .
SECTION 7b.OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hcr#Cy attest under the pains and penalties of perjury that all of the information
leeattic r is npp4 01te and accurate to the best of my knowledge and understanding.
Print Owner's r AutNorizcd'Agent's Name(Electronic Signature) Date
% NOTES:
1. An Owner who obtains a building permit to Jo 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
program or guaranty fund under II.G.L.a I42A.Other important information on the HIC Program can be found at
tvvaw mass ,o,Woca Information on the Construction Supervisor License can be found at www.mas�
2. When substantial work is planned,provide the information below:
'total floor area(sq. ft.) '� (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room coma
Number of fireplaces
Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'rypeofcoolingsystem Enclosed- Open
7. Total Project Square Footage"may be substituted I'or"Total Project Cost"
•1�t Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
iunsvucium oupcn r..:r
License: CS-086600Is V
CARL S WALKE)3 --
8 WILDER ST
BROCKTON MA mm
Expiration
,��,F
x
Commissioner 01/13/2016
+� 1
- Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(991m;) of
enclosed space. (,
I
Failure to possess a current edition of the Massachusetts t
't( State Building Code is cause for revocation of this license. '
For DPS Licensing information visit: www.Mass.Gov/oP5
• a
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 146306
m ".. r +ir" � Type• Individual
isS _-ir sf 1-w Expiration: 4/12/2017 Tr# 262968
CARL S. WALKER III !1 — �
CARL WALKER f
8 WILDER STi
BROCKTON, MA 02301
i.��'c --':'a✓* Update Address and return card.Mark reason for change.
sCA 1 G 20M-osm Address E] Renewal E] Employment Lost Card
C-qX-s ...."" -. ._...,_-
:X Office of Consumer Affairs&Business Regulation License or registration valid for individul use only -
OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
egistrauon 146306 Type: Office of Consumer Affairs and Business Regulation
xpi ration: 4/12/2017i Individual 10 Park Plaza-Suite 5t70
Boston,MA 02116
CARL S.WALKER III'� Cyst
CARL WALKER
8 WILDER ST
BROCKTON,MA 02301 Unarrsccrctary� Not valid without signature