326 JEFFERSON AVE - BUILDING INSPECTION a The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 C MR, T°edition OF SALEM
°sr Revised Jumiury
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 2008
One-or Two-Family Dwelling
{�J This Section For Official Use Only
Building Permit Num er: F I Date Applied:
\V Signature: ✓ �-
BuildingCommissioner/Inspector of Buildings Date
(� SECTION 1:SITE INFORMATION
!c 1-1 Property Ad:Ie dress: -go 1.1 Assessors Map& Parcel Numbers
3 oZ Gje / /l1 e
I.I a Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(it)
1.5 Building Setbacks(R)
Front 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:
Zone: Outside Flood Zone?
Public❑ Private❑ — Check if yesCl Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 wnert of Record:
Name(Print) Address for Service:
Signature Telephone -
SECTION 3: DESCRIPTION OF PROPOSED WORKt(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of units_ Other ❑ Specify:
Brief Description of Proposed Work'-: 19
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllclal Use Only
Labor and Materials
1. Building S 2-02 I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical
❑Standard Cityfrown Application Fee
S
❑Total Project Cosh(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S ❑Paid in Full ❑Outstanding Balance Due:
�� 5o33
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)/ .Z._/ 4:-� � J' .;,d
0/7 P/ � -r I.i—ccrac Number - Expiration Date
Name ut'C'SI-11 �� _ / �.. n� List CSL type(see below)
`--Y� �� Dc%ri lion
r
Ad Unrestricted u w 35,000 Cu.Ft.
�� Restricted IR2 Famil Dwelling
Signs rc� ./ M Mato Only
JC � '"� RC Residential flooring Covering
Telephune r WS Residential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regyt,ared Home rove nt Cont ct 15f ,9
111 Cu�yany Name or III 'Registrant Name Registration Number
A ress '7 7J,7 J Expiration Dale
Telephone
SE ION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 .......... No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7 RIb:OWNE OR AUTHORIZED AGENT DECLARATION
Ar as Owner or Authorized Agent hereby declare
that the statements and inf rmation on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
IJ, J
Print Name
Signo o' r thon?ed Agent Dale
Si under l ams and penalties of du
NOTES:
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(HIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft.) (including garage,finished basemenUattics,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
). "Total Project Square Footage"may be substituted for"Total Project Cost"
CITY OF S.0 E.N[, ANLksSACHUSETTS
BLMDLNG DtphaT%(L%T
120 W.1imiNGTON Smarr, )'a Roost
TEL (978)145-9595
F.ut(978) T40.96W
ICI\CBEJI .Sy DRI3C0LL 7140hW ST.PMARS
HAYOII
DIItFCTOa or x et.0 PRovaaTY/n aDac coaL%rtsslo-%ell
Workers' Compenaallew Insurance AlIdavit: Builders/ContractorWEleetr(clans/Plumbers
annlleant informatlon Pleas Print L.eilblhl
VatntlMunne.rOrVmranonlnbvdull'�!���r�u' I �'(� — e�I �
Address: 6 'S ��d✓� G
city/Ststdzip > �J ��� 1'hon.
Are yaw an employer!Cheek the appropriate boas Type'tdp►oJaet(requlreO
1.❑ 1 am a employer with 4. ❑ I arts a prtaal conoaetoa=41 b ❑Now construction
employee(Rdl and/or pan-time).• have hired the adle-contracrora
2. I am a slots proprietor IV partner, listed an the satachad shcea t 7. 01t . 1 ling
.hip and have no employes These su►contructors have e. Q Demolition
workin for me in an capacity. workers'comp inau xma
s Y Pe tY• 9. Q Building atiditiom
I No worker'comp insurance S. Q We an a corpond"and is
ngtdralJ
01*=hew ermefaed their I0.❑Electrical repairs ar addition
3.❑ 1 am a homeowner doing all work riaw arditemrt"Pa MOL I I.Q Plumbing repairs or addiNoro
myself.(No workers'comp. a 152,11(4).and we hove no 12.Q Roof mpair
insurance requirad.l t :mpkycm LNG worltale
comp intone"ifirill.i I3.0 Otkw
•Any applkar are re.raa ban tl mrra AM tla.al Ibe artly 16I0110 lwiss Iair wartw'eatgraaile porky indrarrrlera
'e ho w �who shwa d1b amib'b itrdledty grey as doing a0 ware ad tho klw.urtdre.attartan nor edaaa n now a01-ail indieriq rk
dr.Ywr Ink two taus artarlyd as admriwis!Am chewing do moor of As aA.ewousoon as l rrr.lr waraw'rw7.pocky isdw mkia.
/uAn an ttwpleytr that bProv/d/wg workers'e*WPCnradaa/nst mmw w g atyluyeta &dAm fs tAePw'k7 aod/ee sW
/ajormadom
Insurance Company Name'
Policy a or Self-ins.Lie.N: Eapirilion Dow.
Jub Sire Addreso: City/Statwzip: '
.snack a copy of the workers'coopeaeetloe paaey declaration pop(tkowing lie polky moobW end eeplradedl dnb).
Failure to s"use coverage a•iegvimd unda Sectie 23A of MGL C. 152 cam lead to the imposition of criminal penalties are
fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a(in
Of up to S330.00 a day against the violator. Ile advi.*A that s copy of this statemarlt maybe furworded to that ol7lce of
Mccabyatiutu ul'dtw n1A far insurance coverap veitkatwm.
I Ala here 'rnW tnjoth Prins rinl Pwneh/rs efPerjury the#'Aa injMnallew pre'ud.bat is irw en/ewreta
Uute:
,
nJJlei./.ar.,djt na na wr;n;w this W"14 to U'utMPltte,by cis.w fewol"lllrial 1
City or fu,ra: YrrmiN.lrenre l__. ___
Lsuint Autherrty(circle Ine): —
I Iluard of Ileillb 1. Huslding neparemum 1. City/town Clerk 1. flectriul Inspector S. Ilumbing Impteror
6. Other . .
l„inset Person: . _ Phone e•
I \
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
I:Q���+111.\b:+IN)IMkL'1 0 SAI111.M\+iN 111 V
trl'',%r-70-939s I'.\s:H7r•NS'1rJ11
Construction Debris Disposal Aft7davit
(required lur 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 p is issued with the condition that the debris resulting from
this work shall he disposed of in properly licensed waste disposal facility as defined by MGL c
S 150A.
The debris will be transported by: /
piano of hauler)
The debris will be disposed or in :
plans of aci Ity
(lddrma of 1''3610)
4,0we u' ,emit applicaru
7z?/o
,late
Ichn•dl d.K
HomeCare-Solutions
6 Scenic place
Salem,Ma 01970
t
'1 Office:(978)825-0010 Fax:(978)336-0054
MC License#133783 CS License#77147
Put Yom Ilarne In Our Handsl MISCELLANEOUS SPECIFICATION SHEET
Buyer($)Name Date of Contract
r (/10 i 5'
Buyer(s)Street Address,City,State and Zip Code
3a 6 �,Te ICICI�ry �e
Daytime Telephone Number Evening Telephone Number Mobile Telephone Number E-Mall Address
The Buyers)listed above hereby Jointly and severalty agree to purchase the goods and/or senaces listed below,in accordance with the prices and terms described on
this Specification sheet and the front and the reverse of the accompanying CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,of which this Specification
Sheet is a pan. I
SPECIAL INSTRUCTIONS
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N is agreed and understood by and between the ponies that NM SpecNieatlon Shoat,along with CUSTOM REMODELING AND IMPROVEMENT AGREEMENT,conetitutea
the entire understanding between the ponies,and there she no verbal understandings changing or modifying any of the terms. This contract may not be changed or Its
terms modified!or varied In any way unless such changes are In writing and signed by both the Buyer(s)antl the Contrecton Buy,'Ne hereby acknowledge that Buyer($)
has read this Specification Sheet.
Contractor InIn-ii I Date: z w yer's Initials: Date:4-1�' D
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