322 JEFFERSON AVE - BUILDING INSPECTION / 7 I'lie Cbmm�onweahh of Massachusells
(}} y; '� , hoard of Iuiding Regulations and Standards Cl VY OF
Slassachtuctts State Building Code. 780 C NIR tiALF\I
Building Permit Application TO Construct. Repair. Renovate Or Demolish a
One-or r'vO4'opi1 Dn elthi.V
This Section For Olflcial Us'Onl
Building Permit Number: —_ Date A plied:
Iluddiny URiciol(Print N,unc) S tmurc Dole
SECTION I:SITE INFORMATION
I.1 p t rass: LS Asaesfors Map& Parcel Numbers
I.la b I of an acre treet7 e n" o - \lap Nwnh r
Eared Number
LJ Zoning Information: 1.4 Property Dimenflons:
Laming District I'n,poxud Use Lot Arco(sq 1!1 Fronwy¢(I!)
LJ Building Setbacks(it)
Frunt Yard Sidc Yams Rear Yard
Required Provided Required Provided Required I vided
1.6 Water Supply:(M.G.I.c.Jo.§14) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Po,blic❑ Privme❑ Zone: _ Outside Flood Z4-ne7
Check ifef❑ Municipd O On site disposal s)slem ❑
SECTIONS: ROPERTYOWNERSHIPt
S.1 Ownerto Reco
i�cr�Ja�9-7a
Mane(Prin 1� (ily.Staia,L.I P
31L �u xdr 33r- 2sq�
a No. ,d Street fAephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Osvner•Occupied Repoirs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ accessory Bldg.❑ Number of Unib_ Other ❑ Sp¢cttL.
Brief Description of Proposed Work%
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estinsated Costs:
ILabor and Materials) Official Use Only
I. building S 1. Building Permit Fee: S Indicate how fee is determined:
'. Flecirical S ❑Standard City!Tussn Application Fee
I'lumhiitg S ❑Tuml Project C•ostr(hem 6)x mulliplier _�. x
. Giher Fees: S-
J. \lech.mieal ill\ \C) S List:._
S \Iechaniad (Fire — —•--- - — -
-- —
`igy,rcs.ionl S (oral .UI Fees: S — - -
n I'utai Project CoNI: i DOCK Check No. _. _('heck Amount . _....._ C.i,h \n tunic
O P.,id in Full ❑l)mslanding Ilal.mce Due:
c i
Mad A Obrild(o oC
SFAA ION 5: ONSI-RUcrioN SF.R%'I('F.';
5.1konstruc I oil Su lervisur license S L) /V z2T 5
I icctim:Ntankr
i)cj,;riViion
Is PC
R Re'tricted I& I anvil�
asoll
CigiI'oa11—swic.—/I 'RC Rodin L'o%crin
S�VA willdow.uld SidM
SF solid Fuel llurnills Appliances
addrvm 2
11 losolation
l'elc boon
0 Dem
olition
� � /(
.4.2 Registered Ilumor Improvement Contractor(HIC)
111C liciiii1ralion Nionvur Ift,inlon Date
(�Om
Coill 111 MO N or MOD Aipt,
a Je,� Email address
No. and Stri:91 Y 7
rcie one
City/Town,State,ZIP ON INSURANCE AFFIDAVIT(M.G.L.c. 132.1 25C(6))
SECTION 6:WORKERS'COMPENSATI d submitted with this application. Failure to Provide
Workers Compensation Insurance affidavit must be completed an
this affidavit will result in the denial of the issuance or the building permit.
Signed Affidavit Attached? Yes..........Cl No........... 13
SECTION ',, ',,,,,-.AUTHORIZATION TO13E COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I.as Owner of the subject property,hereby Outhorize—/?-1-4 1. �4,
to act on my behalf,in all matters relative to work authorized by this building permit application.
I
e7l
Print Ooocr'li
SECTION 7b: OWNEWOR ZED AGENT DECLARATION
By entering my name below. I hereby attest under the pains and penalties Of Perjury that all of the information
contained in this 3PPIic2I\iOn is true and accurate to them of my knowledge and understanding.
njtg
NOTES:
I. %v er\vno hi 1 uEnregistered contractor
ZT do hither own work,or an hires an "'o'
Tu;iT—ngpflInI 0
lin 0\ttier\Nho obtains 3 ill da) have access to the arbitration
0 ra arc
an
out registered in the Home actor I HIC) Program),Nv nican bit round at
to!lIlprovellient Contractor
program or guanial) Nod der.m.G.L.%:. 142A. other important information on the HIC Program
Information on the Construction Supervisor License can be round at
rurination below:
2. \k lien substantial\turk is planned• provide the tit 1 licluding garage. finished basement.attics.Jerks klf romll)
rota) flour area(iti. 111 Mittilable rou'll cWflll
L;r,iis ii,tiog area lit.I. It I Noolher tit bedrooms
Nuoibcrolhall'boill"
Nimilicrol bathrounis Nunlbcrolior%.ho
Y\I)%:kit livating is iteill 1'11%:IoNt:d .01wil
I's ilt:ol'01011114 's'leill
% he j1hww,:d l'otal Proica Felt"
m.il �kluarc Fool-luc 1113.
CITY OF SALEM, 2AXSSACHL'SETTS
BLILDIING DEPARTMEINT
Ito 120 WASHIINGTON STREET, 3"FLOOR
TEL (978)745-9595
FAX(978) 740-9846
KIN
IBERLEY DRISCOLL T HONW ST.PtERRB
MAYOR
DIRECTOR OF PUBLIC PROPERTY/HC)LDLNG COSaIISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A f llicant Information Please Print Legibly
Name(Busincss;Organizatio(vindividuai):
Address:Citylstate/Zip: S/� /2� Phone If: f ldfy
- 7t//— 3 q If
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These subcontractors have R. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9, ❑ Building addition
(No workers comp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their ME]Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL ME] Plumbing repairs or additions
myself. (No workers'comp. C. 152,§1(4),and we have no 12.❑ Roof repairs
insurance required.]i employees.LNo workers' 13.0 Other
comp.insurance required.]
Any applicant oat chucks box 91 must also fill out tho setttion below showing theuworkers'compensation policy information.
I fe"cowners who submit this affidavit indicating they are doing all work and then hire outside contractors most submit a new affidavit indicating such.
:Conirxton that chuck this box must attached an additional sheet showing the name of the si bconlractom and their workers'wrap.policy information.
l am as employer that is praviding workers'compensation insurancejor my employees. Below is the policy and fob slte
injonaathim
Insurance Company Name:
Policy 4 or Self-ins.Lie. 4: � L �6/��U�( Expiration Date:
Job Site Address: 32 Z �ICPWSO 0 4-V C/ City/State/Zip:
mtach a copy of the workers'compensation policy declaration page.(showing the policy number and expiration data}.
Failure to secure coverage as required under Suction 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the Corm of a STOP WORK ORDER and a fine
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do hereby re t'y«nd and/lenalrles ojperjury that the hr/oratuton
� provided a�bo�ve istr a and correct
Si�,ruurci 1Z7
Phone d: -7 4V
Ojjicial use only. Do not write in this arra,to be completed by city or town afliclal
City nr'1'uwn: ___ Permit/License
Issuing Authority(circle one):
I. Board of health 2. Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6,Other.__ --_-----
Contact Person: ._._....___..___ Phone#:
- CITY OF SjU�E-M, iNLAsSACHL'SETTS
• BUILDNG DEPAR-MEINT
1r 130 WASHLNGTON STREET, 3° FLoo&
T EL- (978) 745-9595
F.ax(978) 740-9846
(CI-,tBERLF-V DRISCOLL
MAYORTHO�tAS ST.PtERRS
DIRECTOR OF PUBLIC PROPERTY/BI;HMNG COSLNIISSIONER
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# 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 I50A.
The debris will be transported by: ^ /
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
late
a��is�ttd«