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330 JEFFERSON AVE - BUILDING INSPECTION ! � 7b The Commonwealth of Massachusetts r j,n2, Board of Building Regulations and Standards CITY OF SALEM ,Ir Massachusetts State Building Code, 780 CMR Revi ed Mar2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Ap 'ed: Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION LI Property Address: 1.2 Assessors Map& Parcel Numbers 332 ;�GF��4i/l a he L la is thin an accepted street^yes no Map Number Parcel Nurnber 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq ft) Frontage(I) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided F77 1.6 Water Supply:(M.G.I.,c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ 'Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes[] SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner[o Record: J Ihod't�/�P�c/ �5,t'/e12?&/& a/l 7G N-e(Print) City,State,ZIP )�eHf6ev live- No.and Street 'Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction CITE wner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) Bl Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Desc iption of Proposed Work': -T/l; / oq ✓Y� /J �(/�.y/ 5' �? /--, YsYS' P 1 fi,_?e/np✓� &11 Am-eh, 1twe F f5th,5 6�, irsr<ir n"e_w�2j� r„yvs an<11 try z��_[�rls. vs� cprl��•tr��ma�o/� g, QL'zei�g tog/ — SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and Materials) Official Use Only I. Building $ i?7t/ 1. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees;,$� 4. Mechanical (HVAC) $ List 5. Mechanical (Fire $ Suppression) Total All Fees:$ q Z� Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ / 67 �cd ❑paid in Full ❑Outstanding Balance Due: ow ?iV_V9_9y9y SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Jahn CUG O�� c>-fo�s3la� , ice License Number Expiration Date Name ofCSL Holder 2 -7 ki /fin 6 J List CSL'1'ypc(see below) No.and Street q (/( Type Description PCu/G U Unrestricted(Buildings u to 35,000 cu.ft.) '/ IJ�I ��G L R Restricted I&2 Family Dwelling City/Town,State,ZIP M Mason ry RC Rooting Covering WS Window and Siding /y ,7' '� SF Solid Fuel Burning Appliances 7�'9T9 3y� p�_v5/&/A-v%446 oCM1CVG�yh I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) fly J61M aw 11 C Registration Number Expiration Date HIC C mpany Name or 1-II Registrant Name A ��f//��l/a/I � , vsH�;�c N :vim sC� co d Stree t et Yfj . ,'tJt O Email address City/TT�own, State,ZIP 6 Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. § 25C(6)) Workers Compensation Insurance affidavit must be a mpleted and submitted with this application. Failure to provide this affidavit will result in the denial of the Issuance o)Tthe building permit. Signed Affidavit Attached? Yes .......... No...........❑ SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT Sa/ I,as Owner of the subject property, hereby authorize �Gl�� /,I /J to act on my behalf,in all matters relative to work authorized by this building permit application. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW OR AUTHORIZED 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 application is true and accurate to the best of my knowledge and understanding. ,7a8dg earf"7 i _ s-IW�& Print Owner's or Authorized Agent's Name(Electronic Signature) Date , 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps 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 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"may be substituted for"Total Project Cost" ° CITY OF SXLEM, NLNSSACHUSETTS t BUILDING DEPARTMF_NT 120 WASHINGTON STREET, 3'a FLOOR TM (978) 745-9595 F.tir(978) 740.9846 KI\BERLFY DRISCOLL ,iA AYOR THO0.Lks ST.PIERRs DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Apirlicant Information Please Print Legibly NainC(13luinesy0rganiratiom'Individuad)f JG0/7 <<46✓G1l yS 1— _ra4ea✓P/A!A f— Address: a7 NaMi 1hps? City/StatdZip: l r- Msr: l//err. Phone ll: 1YZ5 Are you an employer?Check the appropriate box: 'type of project(required): 1.0 1amacmploycrwidi_ 2 R• ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or pan-time).• have hired the subcontractors 2.❑ 1 ana a sole proprietor or partner- listed on the attached sheet.t 7. 0 cmodeling ihip and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. - workers' comp. insurance. 9, ❑ Building addition (No workeri camp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their I0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions myself. (No workers'sump. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.) t employees. [No workers' 13 ❑Other comp.insurance required,] •Any applicant awe checks box NI meat also fill out the section chow showing their workeri compensation pal icy m6 mnation. t I lomnswners who wbmit this aMMvit indicating they ate doing all work and then hire outside contractors must suhmil anew afridaviI indicating such. $'"mtmclors that check this box mtut anached an additional Amt showing ate noire of the subeontradors and their workers'comp.policy information. I are an employer that is providing workers conrpertsat/on insurance for my eurpfoyees. Help,is the policy and job site information. - Insurance Conipany Name: UA. -Y✓jl✓ �.� Policy p or Scif-ins. Lie. d:.L✓C✓R- 1I S' 3�T/7A7 "Oa 3 Expiration Date: !e G>-.2el-1q Job Site Address: 3'?(oSPFF•ef� Q 1/0_ City/Slate/Lip: SG.IP/r/ Mt,. Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Suction 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a ine up to S1,500.00 und(or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to S250.00 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. /rfo hereby c•rru under thr puler u penaties of perjury that the inforaaion provided abuve Lv true died correct Si"n,Ittlre � /,�� Date: Phone�1: � j75 l� 7ol' Ff'l -1 y Ojjirful use only. Do not write in this urea, (o be completed by city or town official City car"town: _ Permit/I.lcensc k - - - — ..--- Issuing Authurily(circle one): 1. Board of Ileaith 2. Building DLparnucnt .1.Ci(ylrown Clerk J. Electrical Inspector 5. Plumbing Inspector 6. Other . .-.__ Contact Person: _ ,.. __ Phone V. CITY OF S'lCzNfj A-1SSACH US Errs 1 r4. IXILDLNG DEPAR-MENT 120 WASHLNGTON STREET, Jw FLOOR TEL (978) 745-9595 KIN(3ERI Y DRISCOLL F.,a(978) 740-9845 A AYOR THOJLUSTTMRRB DIRECTOR OF PUBLIC PROPERTY/BI'ILDLgG CO%WISSIONEA Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of NIGL c 40, 5 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 t�IGL c 111, S 150A. The debris will be transported by: y (nameut'hauler) The debris will be disposed of in (name oe facility) _1a 5w�mf��tt�d sal rr� (aJdres.s or tacility) riynaturr of Perm it appticmtt A-NC3819/T-3850-3-part carbonless contractors propos a{]uop® Jay Page# of pages F O JOB NAME JOB# JOB LOCATION YC SU / qv�M M� O 20 DATE DATE OF PLANS If / f�blA CEy � �QL �_ ARCHITECT FF ereby submit specifications and estima es for _ _._� JY _.- ��e__._ C� —_.Doc Lr_ ,d�_ ';na ° /�-- sow&/i, s av' �Cv o p� �7 �" "A , li: o rwcs` ,vs� ll ��'1 �i-G1� we0� � 7 / r � 5 — 7;'lf� (j� //q----- og .v�_ifLs— _rU �9f�_ L�G �rK _— �c �Fir°G� llt�o C —i�LrmBi�L �,Cod� L",6' iY-✓'L l/(Jc, 67 oc ties--- --- __ - u - ,nog. l� -¢ �,---- - ------------ - -- ------ F74 ereby t0 furnish material and labor—complete in accordance with the above specific "ons for the sum o �q� — /©oo /Jocury - I Drr ©� �fi ql, �1 / Dollars o be made as follows: «. �� py4' Wh=�v ���l � �' {/fvG F��ie cN coimje7l— 0 r — paiation from above specifications involving extra costs Respectfully eexecueony upon written order,and will become an extra charge submitted over and above the estimate. All agreements contingent upon strikes, accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. acceptance of The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. - Payments will be made as outlined above. Signature LDatecceptance I —'L a�J� Sigd A-NC3819/T 3850 09-I1 \ P.r�i 6�0 '' 4�c/ �R'8 4ry 3 / ct 2"x8" rim joist l 2"xH"joists $ �� 16"O.C. "x12" joist °> � .� � Ny L/�osr anA;g: 2,r4� a,r�� yxy 3 �*. ��� �, 8h`