251-253 JEFFERSON AVE - BUILDING INSPECTION 1
The Commonwealth of Massachusetts
I'} Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR I1e11 SA EM,prr
LbW
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-FwndY Drelling
This Section For racial Use Only
Building Permit Number: ate Applied;, y_
U
Building 011icial(Print Name) Signat Date
SECTION 1:SITE INFORMATION
1.1 Property AJJress: 1.2 Assessors Map.4r Parcel Numbers
2SJ -2S3 )t>Ft ow �e
I.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 It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood"Zone?
Public�- Private❑ Check if ycs❑ Municipal On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerm of Record:
Ll7tw) Lc a�. se,f-cel, /yA O[f'2d
N;une(Print) City.State,ZIP
Z3 i �S r j�cor./ AIJF q7a 376 3fo64
No.and Street 'relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
FDe,no
wConstruction❑ Existing Building�, Owner-Occupied ❑ Repairs(s) Alterations) ❑ Addition ❑
lition ALI Accessory Bldg.a9. Number of Units Other ❑ Specify:
Brief Description of Proposed Wor
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)s multiplier .e
. Plumbing $ 2, Other Fees: $
4
. Mechanical (li\':1C) S List:_ /� c
5. Mechanical (Fire S Suppression) Total All Fees: S
Check No. Check Amount Cash
6. Total Project Cost: S 5 t Qu/ ❑Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �_1J
_�n G'` ���--- License umber Expiration Date J
Nm»o of CSL I lulder
B0.y C� .�'U�i List CSL Type(see below) U
No.and Street Description
70 U IlnnslrieteJ(Buildings ti to 35,000 cu. R.1
L Restricted 1&2 Family Dwelling
Cilyllben.State,M M Masonry
RC Rooting Covering
W'S Window and Siding
SF Solid Fuel Burning Appliances
�J` �7376 d�C-L✓�l.t��� yiQ., L I Insulation
"felt hone [:mail address a Coat D Demolition
5.2 Registered Home Improvement Contractor(HIC)
I IIC Registration Number Expiration Date
I IIC'Company Name or I IIC Registrant Name
No. and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.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...........
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
A
1,as Owner of the subject property,hereby authorize d 'l C 00-5S U—Q-
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Naine(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
L J�jn' 09 S S
Print Oii ner's or \uthurized Agent's Name(Electronic Signature) Dale
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 Hume Improvement Contractor(HIC) Program),will tint have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important infornmtion on the HIC Program can be found at
Information on the Construction Supervisor License can be found at g\y_w, im's.,_o� 'Jp,
2. When substantial work is planned,provide the information below:
Total fluor area(sq. ft.) _(including garage, finished basement'attics,decks or porch)
Gross living area(sq. fl.) _-_ Habitable room count _
Number of fireplaces_ Number of bedrooms
Number of bathrooms Number of half baths
1. pc of heating system ---- Number of decks porches
-------------- -- - ------------
7)pe ol'axtling system _ Enclosed ----Open ---
1, "folol Projeel Syuare Footage"may be substituted litr"total Project Cost"
".�, iN leadchutLCt� Dcp utrrtenfi ui Publie S itch �`
Boanl-ot 6udrhn�� R� ul.ninur and stand a d, �.
Construction SpgrviSoe License
License: CS '98313 �
RANA ROSS.JR 'r
75 COLUMBUS AVE APT 3 y�sa'.
SALEM MFl 01970..' ;
,. !�. . Expiration 5/4/2013
{t ( Horn ;r nicr - Tr#.. 14836
f
CITY OF Slut &Avt, , L1SS.kCHL'SETTS
BLtWNG DEPARTMENT
110 WmMLYGTON STREET, 3"FLOOA
T L (978) 745-9595
FAX(978) 740.98"
Kl.%®ERLEY DRISCOLL
MAYOR THows ST.PtERRs
DmECTOI OF PLBLIC PROPERTY/BLUDLNG COMIISS10-1ER
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 a 40, S 54;
Building Permit Al is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defincd by MGL c
l 11, S 150A.
The debris will be transported by:
'5J0
(name of hauler)
The debris will be disposed of in
1
(name of facility) n /
S a )Pfv,, 0l/EY
(address of facility)
A-'sIgAniturcopermit applicant
date
' 'a bnvlr Lw