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110-112 LEACH ST - BUILDING INSPECTION $(d�- $c1q, To- I U -13�11 3� N©T" K- 'CvNt)© The Commonwealth of Massachusetts RECEIVED °^b Board of Building Regulations and#*VF,@TIQNAI SERVIC S CITY OF Massachusetts State Building Code, 780 CMR SALEM ,_e �. O.Revised Mur 201 l Building Permit Application To Construct, Repair, Remilal�r 1J8fT Rs 4 One-or Two-Family Divelling This Section For Official Use Only Building Permit Number: Date Applied: Building Oflicial(Print Name) Signature pate SECTION 1:SITE INFORMATION LI Pm erty Address: 1.2 Assessors Map& Parcel Numbers /�/61 —11 a C _01 C rl s --- L I a 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 11) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard ',fide Yards Rear Yard lequired Provided Required Provided Required Provided 1.6 Water Supply:(NLO.I,c T0,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone'? Check if yes❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Qwner'ol'Record: fore Nnnte(1'Fint) City.State,ZIP 1 <�s If �gi- 631- o,and S doss Ntrecl Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alter,tion(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units Other ❑ Spccity: Brief Description of Proposed Work': q,p r < 11n NP 2.c,d �LOO.tP — e-pZlgt --- SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and lvlaterials) 1. Building $ QQC) oo I. Building Permit Fee: $ Indicate how fee is determined: Elvlechanical $ ❑Standard City/Town Application Fee ❑Total Project Cost(Item 6)x multiplier x $ I. Other Fees:l (I IVAC) $ List: (FireS 'Total All Fees:$_ _ �.I G Check No. Check Amount: Cash Amount: _ (. Total Project Cast: $ �t 0 Paid in Full ❑Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5 Construction Supervisor License(CSL) C J—/D 2 3 2 1116Gi.45 N? 60k6e7LI License Number Expiration Date Nmne of CSL,holder y -5ff6-- DO of/ S Ul eJr.! I..istCSL fYpe(scebelow) No.and Street T type Description y 5 d�.�0 U Unrestricted(Buildings u to 35,000 cu. ft.) City/lot State,L is Ir Restricted l&2 FamilyDwelling M Masonry RC Routing Covering WS Windowand Siding SF Solid Fuel Burning Appliances I Insulation Tole hone Email address D Demolition c' 5.2 Registered nHome Improvement Contractor(HIC /6 nod Z l ZO �/ //ye�riRi �t/trfA f3- ��'td D�wiL HIC Registration Number Expvatio Date Company Name or FIIC Rcgi rrnt Name No.and Street 4�mad address L,�titi XS U/Far "?t3'(S-.F7-3223 2 c� CtmSt - n.�t Cif / own,State,ZIP Telephone SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLG.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 .......... ❑ 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 Pp ix j 1,0 A-4,d c&r� to act on my behalf, in all matters relative to work authorized by this building permit application. I f Poa{ Pp j2Mnrc(3re // P / Print 00niner's dame(Electronic Signature) 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 contai d in this application is true and ;. --, ra o t t bes of my knowledge and understanding. I rint Owner's or Authorized Agent's Name runic Signature) I Done NOT : 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.naass.gov/oca Information on the Construction Supervisor License can be found at www.nutss.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 ofbathrooms _ Numberofhalf/baths _ Type of heating system Number of decks/porches fypeofcoolingsystem_-- _ Enclosed— -- Open--- -- 3. "Ibtal Project Square Footage"may be substituted for..Total Project Cost" Massachusetts -Department of Public Safety Board of Building Regulations and Stanriaret Construction Superviso>- ds License: CS-102323 cri THOMAS M CORSET 14SFi'M 019ST Lynn MA 01902 = - I Expiration )I lit Ilk Commissioner 01/07/2015 v �A �fzs ffairs Hus� c�urnelG ate\ Office of Consumer Aftairs&Busi ess Regulation OME IMPROVEMENT CONTRACTOR sgistration: 168030 Type: xpi ration:..,1217/2074. Individual EVERETT MCKECHNIE EVERETT MCKECHNIE[ 185 WALNUT ST �C`•.` 'i ' LYNN,MA 01905 -- Undersecretary ! CITY OF SALEM, MASSACHUSETTS BUILDING DEPARTMENT d 120 WASHNGTON STREET,3" FLOOR TEL. (978) 745-9595 KIMBERLEY DRISCOLL FAX(978) 740-9846 MAYOR THOMAS STTIERRE DIRECFOR OF PUBLIC PROPERTY/BUILDING COMMISSIONER 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 c40, 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 deposit facility as defined by MGL c 111, S 150A. The debris will be transported by: 14ACKS PA gag 9-V&A4V- r— (name of hauler) The debris will be disposed of in: 5e lG /Y f 'bR 09 rr Y PQ� �!'0/L/ (name of facility) (address of facility) Signature of applicant dO Date CITY OF SiV_ENI, NWSACHUSETI'S BUILDING DEP.1k&-BffNT 120 WASHLIIGTON STREET, 3w FLOOR TFL (978) 745-9595 F.ILX(978) 7404846 KI\1BERLEY DRISCOLL S:,M,NYOR THist sST.PIERAS DIRECTOR OF PUBLIC PROPERTY/BUn.DI\G CO',LMISSIONER Workers' Compensation Insurance Affidavit: !Builders/Contractors/Electrlcians/Plumbers Applicant Informatinn Please Print Legibly Vill: l /r5 IRA, 4, L I'W� Qy/Address: I ('1� J fi AA L ni6 S 7f City/State/Zip: AA-- mass 0/0o phoneft:_Z8l Are you un employer'!Check the appropriate box: 'Type of project(required): I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 cnployces(full and/or part-time).* have hired the sub-contractarx 6' ❑New construction 2.❑ lam a sole proprietor or partner• listed on the attached sheet. t 7• ❑Remodeling ship and have no employees These sub-contractors have B. ❑ Demolition working for me in any capacity. workers'temp. insurance. 9. ❑ Building addition (No workers'camp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions myself. (No workers'comp. c. 152,§1(4),and we have no 12-El Rool'repairs insurance required.) t empluyecs. (No workers' Il.❑ Other camp. insurance required.) •,any applicant thal ehvuks bus AI must ilia rollout the ceutiun below showing their workers'compmullon pulicy inf nrmatlan. 'I Inmuowtwn who submit this nlldnvir indicating ihry art doing all work and(lice hire outside contnetors mist suhmil a new urdavit indicating such. $mnmumrs Ihul chak Ihis box man machot an addiuiural joi l showing Ilia name of the sub con,ncWn and their worken'camp.pulley infum uion. i mar un entpluyer dial is propidhtg,vorkers'contpettsadun hn.turaneefor my employees. Delon,is the policy and jub slid foformadnn. Insurance Company Name7000 -(�q-A.__ Policy 4 or Sclf-ima. Lie. 6: O D O © 4 I � 2_ Expiration Date: I L) / Job Site Address: 48^ Lc(A 1A C City/State/zip: ,leach a copy of the workers'compensatloo Policy declaratlon 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 imposilion orcriminal penalties of a fine up to S1,500.00 und/or one-year imprisonmcn4 as well as civil penalties in the farm ofa STOP WORK ORDER and a fine Of up to S2i0.00 a day against the violator. 13e advised that a copy of this statement may be funvarded to the 011ice of 61vc,Iigatiuos ufthc 0IA for insurance coverage verification. /do hereby cer y under the pans and penoldrs ujperjury that the injurmation provider/ubuve is true and correct Si.rn Cur : Dam g .l(j ZDN __ Phone4� 01 ''P./-�Sf U//ic'ial use wily. Do nor write hi this area, ru be completed by city ur lawn ojjiciuf City nr'fmvn: PermitR.lccnsc p - i Ltsuing Authority (circle one): — _--- - --- 1. Huard of lleaith 2. nuildln., I)eparhncnt I C'itylfnwn Clerk 4. Electrical (uspcctur 5. Plumbing inspector 6. Other Conf.iet Person: Phone a: