3 LEE ST - BUILDING INSPECTION (2) .+
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� � The Commonwealth of Massachusetts
°� Board of Building Regulations and Standacr�� RECEIVED ITY OF
� Massachusetts State Building Code,780��R4��j�ONAL SER ICE�ALEM
Revised Mar 2011
Building Pemvt Application To Construct,Repair,Reno���Or.Deu��ish� � : �j i '
One-or Two-Family Lhvelling 11Ub L
This Sectioo For Officia� se Only
Building Pertnit Number: Date Applied:
Buiiding Official(Print Narne) Signat�ue �� ��!
SECTION 1:SITE 7�VFORMATION
.1 Property Address: 1.2 Assessors Map&Parcel Numbers
2J 14e. s��
1.1 a Is this an accepted street?yes_ no Map Number � Pazcel Number
1.3 Zoning Information: 1.4 Proper[y Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Fmntage(R)
1.5 Building Setbacks(k)
Front Yard Side Yards Reaz Yard
Required Provided Required Provided Required Pmvided
1.6 Water Supply:(M.G.L c.4Q§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yesO
SECTION 2: PROPERTY OWYERSHIPI
�2. qwner'of'$ecqr�d:
�'1C15 na��'hn(ne. �� � R1a � �ll q�
N�a,�[,ne(Print) City,State,ZIP (� �I� p /� - I
�l �Q,e� S�' P� -3nQ"-Q)33 I.HQ�11VplI�R.4bl"' qMn��.CO�`'1
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORI{Z(cheak ali that apply)
New Construc[ion❑ Existing Building Owner-Occupied Repairs(s) C7� Alteration(s) fl Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
BriefDescriptionofProposedWorkZ: , ( (� b unkr Ak e
—�nn g1.er lxul�an� � kh�d 41,�r�( �m,ie.�,�,n � n��1.os�
SECTION 4:ESTIMATED COMSTRUCTION COSTS
Item Estimated Costs: �
Labor and Materials OTfiai3l Use Only
1.Building $ 1. Building Permit Fee:$ Incticate how fee is determined:
2.Electrica] $ ❑Standard City/Town Appl�cat�on Fee
❑Total Projed Cos2�(Ite�6)x multiptier x
3.Plumbing $ 2. Ofher Fees: $ ��
4.Mechanical (I-IVAC) $ List <
5.Mechanica] (Fire $
Su ression Totat All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �j� oo ❑paid in Full ❑Outstanding Batance Due:
���-���ayd a
�2����, (���,� �� � c 8
3ECTION 5: CONSTRUCTiON SERVICES
5.1 Construction Supervisor License(CSL)
CS- QL}02o$� )O-3f -Zol4
�J�Q. f j License Number Exp'vation Date '
ame of CSL Holder ` '
� � List CSL Type(see below) V
2l �'1M<?I:-� ,�,.e a��, ,
No.and Street Type Descripi�on
�Jtib.MPS Co f'� �a ��� 0� Unrestricted Buildin s u to 35,000 cu.ft.
C�ty/I'own,State,ZIP � R Restricted 1&2 Famil Dwellin
M Maso
RC Roofin Coverin
WS Window and Sidin
" "� SF Solid Fuel Buming Appliances
�(-SQ4�1360 �(�JCa,� �.radt� �rgJ�r.�on��C I Insulation �
Tele hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) �Q�16 3� �_ -za6
1.3rJc� Paz.no�� �
HIC Re�sVation Number Expiration Date
I-IJ.0 Co�a�yr\Name or HIC Registrant Name
< I 1 \
No.and Street P $���"S�Col�slr.�-hon��� o
S�M�P`�?� � Ma OIqO �- ���559 -i�6o Emailaddress
Ci /Town,State,ZIP Tele hone
SECTION 6:WORKERS'COMPENSATiON INSURANCE AFFIDAYIT(M.G.L.c.152.§25C(�)
Workers Compensation[nsurance affidavit must be completed and submitted with this application. Failure[o provide
this affidavit wil]result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... No........... ❑
SECTION 7a:OW1�kER AUTHORIZATION TO BE COMPLETED WHEN
O WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILAING PERMIT
I,as Owner of the subject property,hereby authorize �p�p��4Q, � qk f bK}�.,�n �� ,
to act on my behalf,�i�all matters relative to work authorized by this building permit application.
�/t 5 Yl�r����r� � z�'-/�
PnYOwn 's Name(ElecVonic Signature) Da[e
SECTION 7b:OWNER�OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of perjury that all of the information
c ntained in this application is true and accurate to the best of my knowledge and understanding.
�('h`{�JA �ISIQ� S'2S'I�
Print Owner's or Authorized Agent's Nazne(Electronic Signature) Date
NOTES:
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 azbitration
program or guaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
�+ww,mass.eov/oca Infortnation on the Constmc[ion Supervisor License can be found at w���v.n�a,s.eov/dos
2. When substantial work is planned,provide the information below:
Total floor azea(sq.ft.) (including gazage,finished basemenUattics,decks or porch)
Gross living area(sq.ft.) Habitable room count
Number of fueplaces 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 Projec[CosY'
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"° ' ' CI"I'Y OF S.�LE�,I, l�L-�SS.ICHL'SETTS
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• ' E3Lu�ivcnta.�Kr»�r
; 4`;��'��5� l?O \X/.1�HL�IGTON SniE•ET, 3�' F100Et
�1�,�..�� " 'I'Et_ (978) 7�5•9595
P.tie(978} 730.98-t6
lU��IiFR( FY DRiSC011.
�`I�L�YOR TNonus Sr.P��.axs
� DIAECiOR OF PCOLIC PROPER7Y/BC[I.DI\G CO�R1155fONER
Woricers' Compensa[ion Insur�nce ACFidavit Uuilders/Contr�ctor.v/Electricians/Plum6ers
Ai�i�ticant Infnrmutinn Piease Print ! e ihiY
V;I111C(ItusinessOrganizatiomin�lividuall: ���/�' 1,C�1/73��On ��� ,
Address: 21 ���''� p1 . _
City/StatdZip: S`"�^'Ps�od-�',/V�a O140`Y phonelf: �9'(- -YAq- 13�D
Are ynu un empluycr?Check the rpprupri�te A . '1'ype uf proJect(requlred):
I.Q I om a cmployer with 4. i;m a gcncral cunlrocior anJ 1 •
�mployees(full anJ/oc part-eime).• have hired the sub-contracwry 6. �❑,N�en cunawclion
' � 3.❑ I am a sole prapnc�or or p:utncr- listmd on ihe attachcd vhect. � 7. L�l«<madeling
.hip and have no cmpluycex Thcse wb-con�ncrore have �. � Demolition�
. �wrking�for mc in any capaciry. �voii<ars'romp. insuranca q. � puilding�dJitiun
�No worken•'comp. insuranca S. Q We are a corpnration mid iu
rcquired.j ofliccrs have excrciscd thcir ���0 E�cc�rical rcpairs or addi�iuns
7.O I ant a Itomcowncr duing all work cighc or exewption p�:r MGL I I.Q Ptumbing repuirs or additions
mySelE[\o workers'cump. c. 152, q I(4),and we have no 12.0 Raof«puirs
insuranct reyuiroJ.J � ¢mployece. �No}vorkon' 13.0 Olhcr
� cump.insurance myuired,J
•,�ny appliv:ml ilut chcc4��ux/I mwi ats�fill uw ilie acaiun 6clow ihowing their warkai mm�renaa�iun pulicy inliumaliun.
�I lomanwiw�n�vho�uhmil Ihis ot7ld�vit indic+tiny�hcy urc daing�II work�nd ihrn hiro uuqidc cnnlmctan mml eiihmil a n<w afl?Javil indi��liny ruch.
�('�iwra<wn�hui ch�ck ihi�Eua mm1 anachal on a.Wiii�lwl:hul ihuwiny il�c n:unu ofihc mbaomncton�nJ ihcir unrk¢r�'comp.pullcy infum;mian,
I uu�un ru�pluyer Uiat!r providing ivorkrrs'comptu,m�lw�i+i.iurunce jor my eurp(uyees !leluw!s�l�a pulfcy und fub sile
iujnnuu�inn.
In�uranccCmnpanyVame: A��IIQ lA$..__.__'_—
Pulicy il ur SclGinn. Lic. d: qJ �LZZ�O2 �3 ---._ Enpiratioit Dmt: �"I,�-/� .
lub'SircA��lr�ss: �3 �Kt S�'. Cily/Stat�/Zip: Sa �c.�, /lilc F.71aao
,\�tach a cupy uf lhe �vorleers' carnpensatluu pulicy declnr�tton pu�e(showing the pollcy number and ezplr�tlan d�te).
F'ailure W vccure cuvtrnga:u«quired under Seclion?S.\oC�(GL c. 152 can IeaJ to ihe imposi�ion ofcriminal�en�itiea ofa
line up w S I,SOQl70 ui�d/ur une-ytar imprisonmcn4 as wcll as civil ponalticx in�hc furm uf n STOP LVOR!<ORDER anJ a linc
�FU�1[O S�]O.00 d II:IY JSJIIISt fllt VIUI;1@L IIG�tIVISI'lI II1pI�LU�IY U�II115 9f.11CRil'pl ItlJY�C funv�rdcd io ihe 011iee ol'
luresiigaiiuns al'thc nlr\ for insurance cuvcrigc veriti�aliun. -
/�lo/rerrby rrrri y mrde�Uir puin.r uaJ prn�ftirs o�pzrjury�hur Nrr bijuni�ullan provideJ uGuvr ir��ur artJ currrtt
;�,��� � �t ��,� u,,��� �' —Z�—/�1
�m��„� � �d'1_ 5"9R - i36'n --
0//iciu(esc m�ly. Du n✓I ivrilt in fhr:s�rcu, (o bt comylefeJ by city orlorvn n�Jk'iaL I
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Cirynr�fu�rn: __. _-- Pcrmit/I.lccnsc� � .
I.�.vuing,\ulhurily (cirdcunc): --....-_... ..--'.. . :�—_ I
I. t>u;uJ ul 1(t��lih 2. 17uildln;; Dcp�.�riwrnt .{.(�i�ylfnuu Clcrle J. F.Ice[riui hispcefur 5. Plnmbing Inspeeror i
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`' r � �,�� CITY OF SALEM, MASSACHUSETTS
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,<s„����j BiIILDING DEPARTMENT
���,'�; .,,r �1 120 WASHINGTON STREET,3RD FLOOR
"�n��" TEL. (978) 745-9595
FAx(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR TY�oMns ST.I'iExt�
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMIvIISSIONER
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:
��a,� �o�s�,��o� ���.
� (name of hauler) �
The debris will be disposed of in:
/vor�3/de CC�/�/l�
(name of facility)
�n�ef5 2� � Sa�' ,Nlti ��4 �o
(address of facility)
�
gnature of applicant
� �Z�_,y
Date
I
;
,
. � �fff Massachusetts -Department of Public Safety
8oard of Building Regula[ions and Standards
Coa�truction Supen�isor �
3
� License: CS-040208 -
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� BRUCE E PARADj§E � ', � �
21 ELM PLACE , � , F :
. SWAMPSCOTT14tA U�907� ti : � . .
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Commissioner � 10/31/2014
. � r�/rc`�n�iunonmen((/r a/Gi��m��rrr/iuclG .
. . � Office of Consumer Affairs&Business Regulation
. , y —�OMEIMPROVEMENTCONTRACTOR _
egistra[ion: j03634 Type:
� �'Expiration: 7/9/2016 Individual
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. BRUCE E.PARADISE .
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� 21 ELM PL. q���
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ALL DIMENSIOfJS AND � DESIGN PLANSARE PROVIDED FOATHE FAIR d��NED FOR . BY � BY SCAL£ DWG
&IZE DESIGNA710N5 � USE BY tHE CLIENT OR HIS AGEPoT IN �.j�}�-�..k����� ��cv�U�n(G` � R�" 2O � No.
GIVEN ARE SUBJECT TO COMPLETING THE PROJECT AS LIS7ED WITHIN �
VERIFICATlON pN JOB iHIS COPITRAC7 DESIGN PLANS RElIAAIN THE . �p/+��dT[�U�(�N Qt-�'C� .'
SITE AND A�JUSTMQdT TO PROPBiTY OF 7HIS FfRM AIdD CAN INOT BE .
. FI7 JOB CONDITIONS. National IGtchw & Baih/lssociation �{SED OR REUSED W{7HOUT PERMfSSION. � , , , . „ , �
N359259-8002 � ' �