357 JEFFERSON AVE - BUILDING INSPECTION (2) The Commonwealth of Massachusetts CITY
Boardy; chose of BuilJing Regulations 80 Standards
71ds
t Massachusetts State Buildin Code, 780 CMR, T°edition OF SALEM
Revised Jurmury
Building Permit Application To Cun truct. Repair, Renovate Or Demolish a 1. 200.1
Onr-or Twu Fumily Dwelling
is Salion For Official Use Only
Building Permit Nu er 11 Date Applied: �L •7�i• f D
Signature: l- 1 10
Building Comr9fishond.1 Ins for of Buildings Date
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
J
1.to Is this an accepted slree v y s_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq I)) Frontage(tt)
1.5 Building Setbacks(ft)
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? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑ p P� y
SECTION 2: PROPERTY OWNERSHIP'
2.1 O ner of Re d:
L ye �e r. 55P , ZVA JzT s
Name I rint) Address for Service:
l W.571'q
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': rf2grtt
V — GI/
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Oflicial Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical S D O Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2-0 D 2. Other Fees: S
4. Mechanical (HVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
q Check No._Check Amount: ZG Cash Amount:_
6.Total Project Cost: S 100 ❑Paid in Full ❑Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) WnweLN
9
��Li/�zrs�N at . SL-I lolde� (see below)
restricted u to 35.000 Cu.Ft.tricted 1&2 Famil Dwellinure son Only
RC Residential Routing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
51 RegT yome Improvement Contractor(HIC)
HIC Comp• y ame or If IC Registrant Name Registration Number
Address /
�'(/�`� Expiration Date
Signature Telephone
SECTION 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...........O
SECTION 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, L` , as Owner of the subject property hereby
authorize to act on my behalf,in all matters
-relative to wo a rtze by this building permit application.
/ 14 c,.
wre'6f nir D e
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
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 67V�7
Pri e
Z- 6
i um of Own or Authorized Agen Da
Si ned under the airs and nalties of r'u
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 Home Improvement Contractor(HIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L.c. 1 d2A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.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"may be substituted for"Total Project Cost"
CITY OF S.U.E.`I, ANWSACHUSEM
BLMDLNG DET.%ItT%MrT
120 W,kit1 NGTON STRIM, )m FLOOR
TEL (978)145-9595
FAx(978) 74119&W
KI1,C3EUAY DROLL T140blAs ST-I MRAs
V(AYOII DIR=m R OP FL BLIC PROPERTY/RL•QDLVG CO-%L%0S31ov ER
Workers' Compensation Insurance AITldavit: Builders/Contractors/ElectrlclansiPlumben
a r (leant In moms to —� ean Print Legibly
/t,c '1 �1, /�pI
VatTd Itlwtrsrsrortaturuion lnJrvtdual)' 21fz5h r 1/ z e /Lo `
Address: Q _!!�a lDzjl/ S- CA D/t ( , IVA 07,37S
City/StatriZilr 1'bone Ill. 2 32 la 0
,%re yo s employer!Check the appropriate beat Type of project(regrircd$
1. I am a cmploya with ; 4. ❑ 1 no a pricral contractor and 1 6. ❑New construction
employees(full and/or pan-time).• have hired the ssnb-conowma
2.El I am a sob pvePtiemr tx Penner
listed on iliaamached shM 7. ❑Remodeling;
.hip and have no employee Theca sub-eomrocim have N. ❑Demoli[ion
working for me in any capacity. workers'comp inwtsom 9. C3 Building addition
(No workers'comp Insurance 3. ❑ we am a corporation and its 10.❑Eloctrical captive or additions
requirtxl) o171tes have ennctsed their
3.❑ I am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.(No worker/comp. t 132,11(4),and we haw no 12.❑Roof repsirs
insurance required./► cmpbyetra.(No werkms 13.010
I omp in ttrrance required.)
'Any JPPuraal the anode bas eh won 4M no aw the conies below Attains tkeb sratbwa'mttgwterkw Pdk7 idixnWloe.
'1 hntsrunnere who sul we Ab aA1Mie idletlq they an Joint ill#and cite hie auerir e'aayseeore newt rahwk a nw armdwit indfdlnt cud.
<•.ottansrs the/chock Ibis boa iwd aneehd as aJditttwd %m Janine Ate am,(the aAaetweeon sat,ha*warb",rang Policy inaoanrtlGL
i arse an emp/eyer that it pevvid inR aorkers'eompeaaw4n inssnnn fir tg rseployeas ROAM/s tAe pN/a7 0&df A db
inforanotit a
In.uranca Company Name:
enlicy N ur Self•ins.Lie.N: 04` WefO 19 325 Expiration Data.:12146 116
Job Site Addicts: ,�� City/SlawZip:
mach a copy of the workaro'compensation policy daclaratlote pap(skewing the polky number and expired"dsh)6
Failum to secure coverage an required under Section 23A of MOL c. 132 can lead to the impoxilion of criminal penalties of
fine up to SI,5oo.00 and/or one-year imprisonment as wall as civil penalties in dw form of a STOP WORK ORDER and a tin
of up to S230.00 a day agoinst the violaror. Ile adviwd that a copy of this statement maybe furwarcicd to the Office of
Inccsttgariuns of ilia MA for insurance coverage v ritieation
i Je hereby cc d or a pains and ponalder a/perfuey that the in/nrwadon provided u/�jeva if true end a arrecs,
41
[6 ,,u,,;I,r,d
a iai use wJy, no not writs in this Brea,to be.vmpkied by city or toss ni/iriet �
I
orruwn: YrrmiN.lcenuN__. __ __
ing.%ulhurtly (circle unc)-
ofIlraOh2. Ruilding Department 3. ceytrown Clerk t. Electrical Inspector S. Plumbing Inspector
_
l"ntacl Pcnon: _ . _ - Phone it:
�S CITY OF SALEM
j PUBLIC PROPRERTY
DEPARTMENT
,111 f.: N111 '•Nlw I'•11
110 A'.w II.\I,I0.N)rBLrT•S.0 1'%1, Sf.Ni.\11II
l'F1 9,71-74 9i9S 1'.\!(:978.740.1846
y
Construction Debris Disposal Affidavit
(required 1'ur 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 a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
JA _�L,
(name of hauler)
The debris will be disposed of in
,0L(/-/7d n/1
(name of i'aollty)
taddrcssul-facility)
%ig azure of permit pplirant
v
Jatr
71a�sachusetis- Deportment ptPu6lic Sant,,
1 Board ti Building Regulations and Standards
.construction Supervisor License
> h.
License: CS 78437
..
Restricted to: 00
GILBERT J BONOAN ' a
416 ADAMSVILLE RD
i..
f
WESTPORT, MA 02790 �
Expiration: 11/9/2010
('nmui.�iuuer Tr#: 6345