23 JUNIPER AVE - BUILDING INSPECTION a
The Commonwealth of Massachusetts
Q Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR. 7"edition Budding Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a #:vomwkkas
One- or Tit o-FanI Litt'elling
JThis cti In For Official Use Only
Building Permit m/bbeer: a& A plied:
Signature:
Building Commtsst r/ inspector of sY i Date
SEC N 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
-2 A Parcel Number
1,I a Is this an accepted street?yes_ no Map Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Distinct Proposed Use Lot Ana(sq p) Frontage Ifp
1.5 Building Setbacks(It)
Front Yud Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: I.$Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal M/)n site disposal system ❑
Public t� Private ❑ Check if vcsO
SECTION 2: PROPERTY OWNERSHIP'
ra
. Owner of Reco
�_ .: . �',„ �,,,gJ 36C �arr�P4 �� Thnye-rs A -
ame(Print) / Address for Service:
flr;a. ( I"yyt
Signature Telephone
SECTION 7: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': CLrr t4 S!5cC WM I�UEANK Of:" 'ECIV1 C-
LA ^ s`r
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Official Use Only
XPProject
ng 1. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
cal ❑Total Project Cost'(Item 6)x multiplier x
ing 2. Other Fees: f
nical IHVAList:
nical (FireTotal All Fees. f
on
Check No. _Check Amount: Cash Amount:_
Project CoSri ❑Paid in Full ❑ Outstanding Balance Due:
J
SECTIONS: CONSTRUCTION SERVICES
S.I Licensed Construction Supervisor(CSL) /o�l/Ir7--
a JG�/- �1'�il't✓ Liccnroc Number Expirwwn Date
Nglme of CSL HyWer List CSL Type Lcc ticluw)
a
Address Type I Description
W f'f!6 fj,J S7— U I Unrestricted f2p to 35,000 Cu. Ft.)
R I Restricted 1&2 Family Dwelling
Signature M I Mason Only
RC Residential Rooting Coverin
Tclep v WS Rrstdennal Window and Siding
Sad— 8J j — 7 7 3 u SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Regblertd Nome Improvement Contractor(HIC) 1&' 3 70'5
HIC Company Name or HIC Registrant Name Registration Number
Address iFf'///
Ql /'?!G fo/ $'`ram S`y�`s 113-2�,Vf r Expiration Date
Signarurc Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. I52.! 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 AMdavit Attached? Yes .......... 0 No........... 0
SECTION 7s: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, %�yT r e. )Q ( _i 6L M Da i as Owner of the subject property hereby
authorize l
to act on my behalf, in all matters
relati to work authorized
by this building permit application.
Si nature of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
1. ,as Owner or Authorized Agent hereby declare
tha a statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
J6✓ $11✓
Print Name 9
G��" id/aal�
Signature of Owne6rAi a zed Agent Date
(Signed under the pains and penalties ofperjury)
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. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I0.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basemenbattics, decks or porch)
Gross living area(Sq. FL) Habitable room count
Number of fireplaces Number of bedrooms
.Number of bathrooms Number of halfbaths
Type of heating system _ Number of decks) porches
Typeof cooling system Enclosed Open
1. "Total Project Square Footage-may he substituted for 'Total Project Cosy' I
�\ CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I`.0 q1 120 W.\iIIINU IONS MET• S.\I I`\I, MASi\( III il.I'-iS)PI
frl:978.745A595 4 FAX:978-740-9846
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 150A.
The debris will be transported by:
�O,✓ S/1�I+✓
(name of hauler)
The debris wi11 be disposed of in
(namC of faCl lIy)
6F.'v?Isr' yvtr—�✓
(address of facility)
C-11�140iuture of permit applicant
date
dchi rail due -
CITY OF S.U.E%1, AASSACHL;SETTS
51:BDLNG DEP.%RT\tENT
120 WASHLNGTON STREET, )'a FLOOR
TEL (978) 74S-9595
FAx(978) 740-99"
KI\tgF1tLEY DRISCO[1
�S1�YOA THonu ST.Pmim
DIRECTOR OF PL SLIC PROPERTY/SVI DLNG COMNUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Alatrlicant Information /-- / Please Print Legibly
Nalne (Busimk orpoi:anominhv,dud):
Address: (n /-V at—t-&— S T—
City/Statc/Zip: /3v/t//z y 1,,&4 Of9/sue phone#: �1— &`13 — 7 7 3 Sf
Are you to employer?Cheek the appropriate box: Type of project(required):
L Q I am a employer with 4. Q I am a general contractor and 1
r-a�employees(full and/or part-time).• have hired the subcontractor 6. ❑New construction2.tYl 1 am a sole proprietor or partner- listed on the attached shceL : ?. Q Remodeling
,hip and haven employees These sub-contractors have a. Q Demolition
working for me in any capacity. workers'comp.insurance. 9. Q Building addition
[No workers' comp. insurance 5. Q We are a corporation and its (0.❑ Electrical repairo or addi[iona
required.) officers have exercised their
J.❑ 1 am a homeowner doing all work right of exemption per MGL 1 1.0 Plumbing repairs or additions
myself.(No workers'comp. c. 152.41(4),and we have no 12.Q Roof repairs
insurance requited.) t employees. (No workers' 1 J.❑other.
insurance required.j
-Any applicant nun chocks boa el muss also fill uut the sections below sbuwing their wtrrkm'compenaaion policy,infurrnause,
'I1, neuwrwn who suboul this anitlevir indicating they ate doing all work and thm him ou%We eaetrnman muu submit a new of idavil indicating tack
:C.mtmun that chap this box mud adwhod an slditiud thou showing the tune,of the eu►contractps and their woraws,comp.policy intamution.
l am an employer that lr providing workers'compenradon Insurance for my employees. Below/s the policy and fob life
information.
Insurance Company Name:
Policy 4 or Self•ins.Lie. N: Expiration Date:
Job Site Address: City/State/Zip:
attach a copy of the workers'compensation policy declaration page(showing the policy number and explrades date).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in(he form of a STOP WORK ORDER and A fine
of up to 5230.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of
I nvcauaatiuna ol'the DIA for insurance coverage vcritication. -
/do hereby certify under thea�paiws and penah'les of perfuey that the informadow provided above is true
and turrets.
ci�uriLt!s�7.�h�C Dote: J�(a�/ O l
Phune����afr ` O y�— 7735�
iOfcial we mt/y. Do nor write in this area, to be cunrpleted by dry or town u/ficiaL
iCity or fawn: _ YcrmiUl.lccnse
Issuing Aulhorily (circle one): -- - —_ - —
i j
I. Board of Ileallh 2. Building Department ). Citytrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Qnllac( Person: _ _ __, ___ Phone N: