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55 LAWRENCE ST - BUILDING INSPECTION (2)
3 - Iut -I (') 5 $-70 C\sl-t � �13 - i � ✓ Rt�+e� 3 �� 1 The Comnionwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALEM Massachusetts State Building Code,780 CNIR Revised.tfur?011 7 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Divellinq This Section For Official Use Only Building Permit Number- Date Applied: 31001 El..Iding 01'ticial(Print Name). Signature ut' SECTION 1:SITE INFORMATION 1.1 Property Address: q I 1.2 Assessors Dlap&Parcel Numbers 1.1 a Is this an accepted street?yes no Map Number Parcel Number u Zoning Information: 1.4 Property Dimensions: Lot Area(s It Frontage It Zoning District Proposed Use q ) g ( ) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required==Provided Required Provided Required Provided 1.6\Vtiter Supply:(M.G.L c.40,§Sq) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑ Public❑ Private❑ Check if yes❑ SECTI0N2: PROPERTY OWNERSHIP'` 2. Ory ert of Record: S(U Fey Pena Sot� rhO . r�tg7o �nte(Print) City,State,ZIP SS /ct'rPi1CQ tM:� 9Z8- x6rr-6d37 No.and Street Telephone Entail Address SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ 1 Existing Building❑ Owner-Occupied Repairs(s) ❑ Aherntion(s) ❑ Addition O Demolition ❑ Accessory 13 dg.O Number of Units_ Other ❑ Specify: Brief Description of Proposed Workl: 4 1 f b4�\�SPk.Sh�4zp,VA C�,n4J(' AG(' SECTION 4: ESTIMATED CONSTRUCTION COSTS Itun Estimated Costs: Official Use Only Labor and Materials) Building S (o $Do I. Building Permit Fee: Indicate how fee is determined: ❑Standard CityTown Application Fee 2. Electrical S SGC7 ❑Total Project Costa(Item 6)x multiplier x J. Plumbing S ( 000 2. Other Fees: S� t.Mechanical (FIVAC) S List: i. [cc.nical (fire S Total All Fees:S Su re it Check No._Chcck Amount: Cash Amount:_ i (. Total Project Cost: I(� m ❑Paid in Full ❑Outstanding Dahuue Due: < r SECTION 5: CONSTRUCTION SERVICES 5.1 C'onst rue tion Supervisor License(CSL) C S— Oct 5 S V dd. aoiµ t� License Number Expiration Date shn C�v�.vf'e i. Nnnrc of CSL[folder List CSL'fype(see below) Ga. I GwrM(Q S Type I Description No.;and Street �-7O U Unrestricted(Buildingsir tu35,000 cu. lt.) So"key \ ✓''\w Q\ • It Restricted 1&2 Family Dwelling City/(own,Sucre,ZIP id "'fasorry RC Rooling Covering WS Window and Siding T ry SF Solid Fuel Burning Appliances Q79' S10-CVN ,,7 iCGev\ aACa\ Pq( 9 I Insulation 'fele hung Email address 4 D Demolition 5.2 Registered Home Improvement Contractor(HIC) l Sa�4 r� 7/ :I - Py1P(-c,\ CQnk(cte HIC Registration Number Expiration Dote 111(;Cump;my Name ur HIC Registrant Name , C�a la rasa s1 GNW-,'kC-,AA -i(�;rgC No. and Street Email address S4\Pvy�' 0(9-2p 97g SBA-517¢ City/Town, State ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(VI.G.L.c. 15L§ 25C(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 PERNIIT I,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. i Print Owner's Name(Electronic Signature) Date SECTION 7b:OWNERI 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 ac urate to the best of my knowledge and understanding. I'rin vivlf s or Authorized Agent's Nunn(Electronic Signature) Date 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 not have access to the arbitration program or guaranty fund under M.G.L.c. 1 d2A.Other important information on the HIC Program can be found at w-ww.mass Information on the Construction Supervisor License can be found at www.mass. ov:',Ilrs 7. When substantial work is planned,provide the information below: 'total floor area(sq. it.) (including garage, finished basement/attics,decks or porch) Gross living area(sq. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half7baths Type of heating system Number of decks/porches Type orcooling system Enclosed Open ... 1. "folal Project Square Footage"may be;ubmiuned lijr—foul Project Cost" i I 1 !° e• CITY OF S 1LEM, INL-�SSACHUSETTS BUILDING DEPIRT>IE—NT 120 WASHIINGTON STREET, 3"a FLOOR 9 c , TEL (978) 745-9595 FA.e(978) 740-•98.56 KL%rBERLEY DRISCOLL THOwLsST.PIER&H ;tLAYOR DIRECTOR OF PL'i3LIC PROPERTY/OCTLDNG CMLtiIISSIONER Workers' Cornpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Idusiness.Organizaiiowintliviclual): So)hv\ C,,,4e J ,L GeAW;1 CGn�.rQ e'yf�hQ Address: ro a 1 GtNf-en CA S�- City/State/zip: sgw,, \ yn' ,. olQ7o Phone #: '7 7&' -S4TQ -rt 174 ,1re y an employer?Check the appropriate box: Type of project(required): 4. ❑ 1 am a general contractor and I \ I. 1 am a employer with 6 b. ❑New construction employees(full and/or pan-time).• have hired the sub-eantractors 2.❑ 1 am sole proprietor or partner- listed on the attached sheet. • ?• Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, workers' comp. insurance. 9• ❑ Building addition No workeri coat insurance 5. ❑ We are a corporation mid its l P 10.0 Electrical repairs or additions required.] officers have exercised their 3.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions myself. [No workers'cump. c. 152, 91(4),and we have no 12.❑ Roof repairs insurance required.] t employees.[No workers' 13.❑ Other RccAtNrz"n cump. insurance required.] 'Any applicant slut chucks bon NI most also fill out the action below showing their woAco cumpensallon policy inlinmation: 'I lomeowm"who submil this affidavit indicating ihey are doing all work and then hire outside contractors matt auhmit anew affidavit indicating such. �C,nuncturs thug chvck this box matt mtachvd un additiuwl shvrot showing the none of the subeontracton and(heir workers'comp.policy information. I one an employer that is pruviding workers'compensation insurance for my entpluyees. Below is die polky and Job site information. p p hinsurance Company Name: Il p USe Tr\SL----9 10—74 J — G q (04 Policy#or Sclf-ins. Lie. 0: 1 Expiration Date: lob Sire Address: SS k,,rer C,4 St . City/State/Zip: .SG1f-\ mS, U[ri'tb ,%ttacb a copy of the workers' compensation policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a tine up to S1,500.00 and/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. 1 do hereby certify under dre pains and penalties of perjury drat the information provided above is true and correct. o� n Date: 3 ao z ao)!V rr�� tt��r--�� /vp- Phone '1� : 9W_ JUG — �/�7q . Official use only. no nut write its this area,tube completed by city or town off eluL City or Tuwn: ____. . Issuing Aullwrily(circle one)! 1. Board of Health 2. Building Beparrnent 3.C'irytfnrvo Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Penn". _ __ . .— Phone -----____-- nor CITY OF Si1Lzm2 NL-1SSACHUSETI'S t rt ©L:ILDLNIG DEPARnLENT 130� WASHNGTON STREET 3%0 r FLOOR T'EL (978) 745--9595 F-Acx(978) 740.9845 KIN IBERLBY D21SC01.[. ��Z1YO R TT IostAs ST.Pmuz DIRECTOR OF PULIC PROPERTY/StMOLNG C0%L\l155IONER 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 It 1.5 Debris, -and the provisions of NIGL 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,VfGL c ( 11, S 150A. The debris will be transported by: y J �r"K- I�ePo� (name of hauler) The debris will be disposed of in Derr, Sher [ — (name of r'acdity) ---_`—(address of facility) signature of permit applicant �ao�aai�— 'latc