210 JEFFERSON AVE - BUILDING INSPECTION (2) s
The Commonwealth of Massachusetts CITY
` Board of Building Regulations and Standards
I` 1 Massachusetts State Building}'I Code,780 CMR, 7`s edition OF SALEM Revised January
I Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 1008
One-or Two-Family Dwelling
liis 5e pb;;(Stli-[aisle°Only
Budd„tng Permu Nutribe %`' ate ppt* d/:`I
Stgnatltre � r /f�!
=Biuldrng C9im uss�oner I c r'ofButl ' a
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
o� !U -5 G n
1.Is 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 ft) .Frontage(ft)
1.5 Building Setbacks(it)
From 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:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ the site disposal system ❑
Check if yes❑
2.1 Owner'of Re ord*
� r�
�� /' �r��� , L o1JG fe�� � l1 SGD7 /Ill
Name(Print) Address for Sere' e:
.ez_ Ll
Signature Telephone
s SECTIONS PF ("RIP [ ( PPO5E1? ,.ORr(etedk;all;thatapply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':
-GCi o i!J dui —4/A
SECTION 4: ESI_INJA� DCON$1RfJl"II4}1VUSTS .
Item Estimated Costs: '
�ffieraT IIse Only
Labor and Materials
1.Building $ 1 B>f+Idmg3�5rritFOe $ _Indicatehow fee is.determined:
2.Electrical $ �7 Stanfiard CxtylTdwn Appheatton Fee-
fal To o[Ptbdect3�str�Ote t 6�z gt4lt ter. x'
3.Plumbing $ ;OtleFes t
4.Mechanical (HVAC)
5.Mechanical (Fire
Suppression)
6.Total Project Cost: $ 4heck h]or Cheek Amount Cash Amount:
�,�� - ❑Pa1d iFull ❑Outstanding Balance Due;
SGT!( l s E ERx(CPS
5.1_Licensed Construction Supervisor(CSL) j�—
M (a 2 I° L `' �ti License Number Expiration Date
Name of CSL-Holder- List CSL Type(see below) L_/ -
ivDU
Address j n _ rTtjoe
T�i(tiCu J U Unrestricted u to 35,000 Cu.Ft.
R Restricted 1&2 Famil Dwellin
Signature / M Masonry Only
-7��- 13 - RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D I Residential Demolition
5.2 Re 'ster-A H re I (prove pent Contra gt rrIC) Al _ 5
HICCame or C Reg nt le Registration Number
el
�L4 .'' / 7g-74 P23 Expiration Date
Signature_ Telephone
SEGT,ION 6 ,WORTC>C�RSr COMPNrTliki AjII1 tAN AFFIDAY►T(iVI 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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No...........❑
SECTIbN 7a U1!ER Iti 'AF �i [ AF
OVIIYER'SAGENT:ORCQNI CTt1R 1PPIk�Si1�OR} Mi PER-iSLT "
I /7 (' C r"d!/4 It as Owner of the subject property hereby
authorize 4(Z.-5f=& to act on my behalf,in all matters
relative to work authorized by this building ermp it application.
%G /7 / /
Si nature of Owner Date
SEp( 0104
'tk" nT rECCFIO1V;
.c�i"�" p z"t 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.
L
Print Name i
Signature of Owner or Authorized Agent Date -
Si aed under the sins and penalties of a 'u
1�OTES, 77
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(HIQ Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other importantinformation on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"