70 LAWRENCE ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
4 �< Board of Building Regulations and Standards SALEM
J �YI Massachusetts State Building Code, 780 CMR Revised Mar 2011
(�1 Building Permit Application To Construct, Repair, Renovate Or De olish a
�DJ One-or Two-Family Dwelling
This Section;For'Off vial Use Only
Building Permit Number:' Date Applied.;
1�
Building Official(Pont Name) _ . Signature ate / '
SECTION L• SITE'INFORNIATIO .
1.1 Property Address: L2 Assessors Map& Parcel Numbers
1.1a Is this an accepted street? yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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 l� Private❑ Check if yes❑ P P
SECTION 2:, PROPERTY OWNERSHDF '
�Owne 2. r of Record: 0
a1rla t C2C/^ S s 011 � h h7 �. d1 9 7
Name(Print) City,State,ZIP
7U L- alvl' ehc y �
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORIO(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. NumberofUni Z 1.0ther ❑ Specify: ro
ief Description of Proposed Work:
Pp
rlia
SECTION 4: ESTI VLkTED CONSTRUCTION COSTS-
Item Estimated Costs: I . Official Use Only
Labor and Materials
1. Building 3 U 6 0 1 Building Permit Fee S Indicate haw fee is determined:
❑ Standard.,City/Town Application Fee.
.2 Electrical $ ❑ - i - - .
- 'Coral Pioject Cost (Item 6)x multiplier x
J. Plumbing ) 2. Other Fees: S
1. Mechanical (11VAC) S List:
i. Mech:utical (Fite Suppression) ['oral Ail Fees: S
Check No. Check Amount: Cssh AInOLtllt:
r,. I'Mal Project Cost: S 0 Paid in Pull Cl Outstanding Balance Duo: --
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Su tervisor License CSL,
Ga ;-16 S GM e S License Number Expiration Date
Name of CSL I folder U
List CSL Type(see below)
-1 U L4 k Pen Type - Description
No. and Street
G( �1 7 D U Unrestricted Buildin s u to 7i,000 Co. It.)
ol f e {+t {°1 q R Restricted 19t2 F;unil Dwellin
CitylTown, State,ZIP bl Nlasonr
RC Rootin Coverin
INS Window and Sidin,
SF Solid Fuel Burning Appliances
3 r� Fob I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(MC) ! 3 r 1 0
G GM 2 f U PC,F h 0, I 111C Registration Number Expiration Date
I IIC Company Name or MC Regis'tralLName
I' r Ce-h t± 5
No.and Street q7 �_ 3 3 r j �-p/ Email address
nrgb &
City/Town State,ZIP Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 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 .......... 0,' 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 C cl kI e f G f/M e f
to act on my behalf, in all matters relative to work authorized by this building permit application.
Cg(h- `(It G On 21'
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.
Prin_t Owne_r's or Autlwrizzd:lgznt's N;unz(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
(nut registered in the Home Improvement Contractor(HIC) Program),will riot have access to the arbitration
program or guaranty fungi!under M.G.L. c. 142A. Other important information on the HIC Program can be found at
Ieww.mass.,,ov.oca Information on the Construction Supervisor License can be found at www.rnass.�I n_:'dL
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics, decks or porch)
Grosi living area(sq. 11 I-labitable room count
Number of I!rep I aces_ -- Numberofbedrooms --_--
Number of bathrooms Number of h:d6'batlts
Type of heating system ---- ---- Number of decks/ porches
---- ------
I,,peor Cooling sy;tclll Enclosed
1. 1 oral PI'ol2Ct S(III:IN Foot.l"c" Illay be slIbdltuted for I firm PI oject edit"
CITY OF S:U.E.Mll INWS:kcf4uSETTS
y, BUILDING DEPAIMLENT
120 WASHIINGTON STREET, 3se FLOOR
Z`�• TEL (978) 745-9595
F.,L((973) 740-9846
,fBFRT RY DRISCOLL THO,%USST.PIEItM1
MAYOR DimcrcR OF PUBLIC PROPERTY/13CIfDLNG CObLMISSIONER
Workers' Cutnpensation insurance Affidavit: Builders/Contractory/Electr(cians/Pfumbers
Applicant information /+ Please Print Legibly
Narna(Duii%4 ,Orpnizatiotvindividual): C of �'� 4 J ( p rs{•ti C S
Address: '70' 6iaw1-tahc Pr s,�
City/State/Zip: f a t h h - Phone H: q 7 r 7 Ll t — Z R 7 d _
\rc you an employer?Cheek the appropriate bolt Type of project(required):
1.0 1 am a employer with 4, 0 I am a general contractor and 1 g, 0 New construction
Jvmplayees(flit and/or part-rime).• have hired the sub.contractars
2.(e I am a sole proprietor or partner. listed on the attached sheet t y ❑Remodeling
+hip and have no employees These subcontractors have V. (]Demolition
working for me in any capacity. workers'comp.Insurance. 9. 0 Building addition
(No workers'comp.insurance 5. 0 We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.0 1 am a hamcownor doing all work right of exemption per MGL 11.0 Plumbing repairs or udditions
myself.(No workers'camp. e. 152,§1(4),and we have no 12.❑Raof rapairs
insurance required.) t employees.(No workers'
comp.insurance rcquimd.) 13.0 Other
•Any uppllcsm owe chceks bas 01 must also(ill our 1h,taatiuo below showing thafr wmkat*'eomptnudun pull i ey initation,
'1 hvnauwm"who suhmit this aalidavit indicating]bay ate datng all work and thce hit*"told@ canuavots must submit a mare aflldavil indicting suck
6m[mcwn that chak[his box must aaaehod=1"llumd chat showing he nwnar ot,the rutKrontnaWra and dhalr workvm-ramp.polity Informadarn.
fain un employer that is providlnR ivorkers'conpensadan lnrarenee jar my employees Below/s the po/fey and fob a•Id
inJorioullan.
Insurance Company Name:
Policy 4 or Self-his. Lie.n: Expiration Data:
Job Sitar Address: Cily/State/2ip:
AItach A copy of the workers'compensation pulley declaration page(showing the policy number and expiration data).
Failuru to secure coverage as required under Section 25A et'NIOL a 152 can lead to the imposition of criminal penalties of e
tine up to S 1,500.00 und/or one-year imprisonment,as well as civil penalties its the farm of o STOP WORK ORDER and it(Ina
of up to S250.00 a Joy against the violator. Ile sdvlacd that a copy of this statemunt may bo forwarded to the Oflica of
Investiguiloas of the DIA for insurance coverage verification.
l do ltrreby verrlJy u, odds Ilrr pulns 014 pruu/das u perjury that,the hiArmurlon provided ubuve it true and correct
ii•snunre: (�iGt/LGsI�'/ -�//ors/ I)afu•
r d, e,i: 9-7 P--- -7 W — Z g 3 r
i011fr•iol rue unly. Do nut wrile in th4 area;, to be completed by city ur town n/JJa•/u!
i
City orTuwn: __ _ Permit/l.leetaae#
Imulnit Authurily (circle unc):
1. IJuurd of lieallh 2. fluildinq llepartmunl J.Cttylfown Clerk !. Cleetrlcai In¢pectur S. Plumbing inspector i
6.Other
Contact yersnn: Phmne;t•
i
f
_ CITY OF SALE, !, >tiL1SS:ICHUSETTS
Bl:[iO4\G DEP.1RT.NZNT
120 TASHLNGTON STREET 3w
FLOOR
T EL (978) 745-9595
FAA(978) 740-9346
1CIJtDERLEY DRISCOI.L
tts'YOR Trgo.% BST.PIERM
DIRECTOR OF PL13LIC PROPERTY/aCILDNr,CONWISSIONER
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 1 t 1.5
Debris, and the provisions of tbIGL c 40, S 54;
Building Permit 1# 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:
�nlQI(1 cf �'C.V11P� l�►vC
(namc ut'hauler)
The debris
�will be disposed of in �1
(nama of racility)
(address Of'tacility)�--
signature of permit applicant
date '—
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L OT 70
AREA- Glg171 S.F.
LO- &S N LOT 74
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2 STORY
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'�45•Lss� 1
LAWRENCE STREET
THIS PLOT PLAN WAS NOT MADE FROM AN
INSTRUMENT SURVEY AND IS FOR THE USE
OF THE BANK ONLY. UNDER NO CIRCUMSTANCES
REFERENCE ARE OFFSETS TO BE USED FOR ESTABUSHMENT
DEED: REC.LBK. 933 9 PG. 3& OF FENCES. WALLS. HEDGES. ETC.
PLAN: RCc. BK. I001 PG 30
To. I Psul IC+G SA V I tJGs 4Arl K
I CERTIFY THAT THE BUILDING(S) SHOWN HEREON MORTGAGE INSPECTION PLAN
ARE LOCATED ON THE GROUND AS SHOWN AND THAT THEY LOCATED
OCATTEED�IZATE G E 5 T Rr E7
CONFORM TO THE DIMENSIONAL REGULATIONS OF THE OF4(q�
ZONING BY LAWS CF THE C ITY OF SALE:M GAIL SALEM
AT THE TIME OF CONSTRUCTION OR ARE PROTECTED UNDER
GENERAL LAWS CHAPTER 40A SECTION 7. L. PREPARED FOR
I ALSO CERTIFY THAT THE PREMISES SHOWN ARE .(�Q SMITH m S GbMES 4
EL
NOT LOCATED WITHIN A FLOOD HAZARD ZONE AS }I Nc. 35043 C AARLO L-0ukt G OMLLS
DMEATED ON THE MAP OF COMMUNITY / 2SOlo2 s 9 O
SAL E'M MA, EFFECTIVE S-5- 85 O" FGIST£Q'�
BY THE FEDERAL EMERGENCY MANANGEMENT AGENCY. Pss JP SCALE: 1" =30' A44Y >, 14 94
A(LANO`' NORTH SHORE SURVEY CORP.
-7 �'� 47 LINDEN ST. — SALEM, MA
0 TE -REG. PROFESSIONAL LAND SURVEYOR 46 I Soo M