3 LEMON ST - BUILDING INSPECTION JO CW46�*L 7
.� The Cotnnwuwrtitit of Massachusetts
} Board of Building Regulations and Standards CITY OF
Ij Massachusetts State Building Code, 730 C1•IR SALELI
Reviser!blcu 1U!!
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family DtveUing
This Section For Official Use Onl ..
Building Permit Number Date plied'
Building Of cial(PrintN e)'. Sig atur ate
SECTION I:SITE IN AIATION
1.1 Property Address: 1.2 Assessors Hip dt Parcel Numbers
3 /_eM. n ST,
1.1a N this an accepted street?yes no Map Number Parcal Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.3 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided RequiredTd1spos&I3Y3tCM
I'6 Water Supply:(M.O.L c.40,§34) 1.1 Flood Zone Infbrmatlon: 1.3 Sewage Dispo
Public❑ Private Cl' Zone: _ Outside Flood Zone? Municipal❑ On sit
Check if esC PO
SECTION Z; PItOPERTtd'/O�W4VERSH{D�'!p" ':
Name(Print) city,Statq ZIP
� �.f�.vlc)/1 S)•,
No.and Street Telephone Email Address
SECTION 3. DESCRIPTION OF PROPOSED WORK''6back all that apply)
New Construction ❑ Existing Building C1 Owner-Occupied Repain(s) 01 Alteration(j) lD Addition O
Demolition Q Accessary Bldg. ❑ Number of Units_ I Other Q Specify:
Brief ascriptionofProposed Work: o Vc) VAI ; L`f4
i aJ c w
SECTION 4: ESTINIATED CONSTRUCTION COSTS-
rtetn Estimated Costs:
Labor and Materials Official Use Only,_
I. Building g 0 C� I. Build ng Permit Fee:4 Indicdta haw fee is determined:
2. rlectrical 3 3 Zp QSfandard.Cityfrown,Application Fas
0"rotas Project Cost'(Item 6)x multiplier c
3. Plumbing S UvC). 2. Other Faes S
t. .Mcchunical (IIV.\l ) > List:_
i. �kch.uiic.tl (lira
in ve,;iun) } 1•oolAll lees: j
Check No. Chcc!<,\manor: ('.ish :\uwunt
fnfal I'rnjcc[ ( 'na $ l ?/ 3 2�/.Cla - __...— . . -. .- ._ .. _
t] I lid in Pall 0 t)nht:unlinq I lal:utea I hn;
SECTION is (:O;VS'fItUCTION SERVICES
5.1 Construcliun Supervisor License(CSI.) � S', .�
G-r�r — U/�/�ri rr/f
License Ni
m Expiration Date
I,une of M lolder 1 j� List CSL Type(see beluw) U In r�Si1 c%
I > �S dal,Sa/' / U ` Type Description
Nu. and Street U Unrestricted Duildin s up to 35,000 cu. 11.
10 �l, O (��� R Restricted ISt2 Fantil Uwellin
Q
(,ity/Torun, State ZIP tbl Rootinr
RC ootin Covcrin
IVS window and sidiIIIII4r
SF Solid Fuel fTunting Appliances
I Insulation
Q
Email address U Demolition
1'ela hung
5.2 Raghtered Home improvement Contractor(HIC) `7//
f r •f rn �2^ �d� ! ern a rs HIC I egistmtion Number Expiration Date
I IIC Company MIMI or 11IC• Registrmtt mna 6-"rY Q 1-"arr, jo r /-e,--r/e/;n -
1 C r it i— Email address
tJa.and Street
Cityl own S.te ZIP Teie hone
SECTION 6t WORKERS'CONIPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.9 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 cif the building'permit.
Signed Affidavit Attached? Yes.......... No C3
SECTION Tat OWNER AUTHORIZATION TO BE COMPLETED WHEN
OW NERrS AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property,hereby authorize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Data
Print Uwner's N:une(Electronic Signature)
SECTION 7h: OWNERr OR AUTHORIZED.kGENT DECLARATION
By entaring my name below, l hereby attest under the pains and penalties of perjury that all of the information
coma' J in d s. jqion",, true and accurata to the best of my knowledge and understanding.
—Date'
_ D•tte
I'r' it Orvnar' .\utlturi�ed;\gull's N,une(Electrmtie Signature)
NOTES:
Orvner who obtains a building permit to do hisrher own work,or an owner who hires an unregistered cuntrnctor
(nut registered in the Honte Improvement Contractor(HI Program), will nn hava access to the arbitration
progrun or guaranty brad under M.O.L. c. Ia2A. Other important information on the HIC Program can be round at
rr rs ry m:u+.t:uv%ace Information un the L'unstrt'tion Supervisor License can be found at rrww.ln,tss.,,tau
t \Yhm sub;lautiul work is planned,pruvidu the information helot`.' a finished basemendattic;,decks or porch)
total tloor.ue:r(;.I. lT.) ---- _(including y: ; g ,
f tibitable norm count --
lro;; living areal(;rl. R.) -- Number of bedrooms
Nnmbcr of tireplacc; Nuutber of half b.0 . . ----
hs --
\IIImllcrotb.tthro,III .i -- --_—_ . ---
II.Itc.ttlt..uiuµ ;y+lout — Fuclo;cd pelt
I ,. .- t pt ir•� I' , I t;a' in.ry ha ;tth•Ittnl,,l hq I Cil I'n�pr.! l'��_I_.
CITY OE: 54V-E,1,t, I.�,LtSSACHUSETTS
�.?;�,� )� QL'tLO6VCf]t;F.lt1'titE.VT
1?0 VV"M6VGTON STIUS7, 3'FCOOt
TtL (973) M.9595
Kt1t0ERLHY OCUSCOLL FI'c(973) 740-934.5
AMA •l (OuuST.PtEvts
DrLECTO,tOFat:UL1C PROF RA Y/at:MovaCO.a115StO,VEA
Construction Debris Disposal Aff7dayit
(reyuirid for all t1cmalitian and rcnovetion work)
in accordance with the sixth edition of the State Building Coda, 730 C&fR section I
Debris, and the provisions oeXfGL e 40, S 54;
Quilding Permit
ull b 9 is issued with the condition that the debris resulting from
this svor!c shall be disposed a P in a properly licensed waste disposal facility as deBncd by ,LfGL c
l 11, S 150A.
The debris will be trusported by:
Chn )�bri:r will be disposed Ut in : '
((wme of ricaily)
-� � hV
iipwgre i7rNcrmif.I
NPlic.uu
J
!" CITY OF SALEM UNSSACHUSETTS
Suimmi;DEPARTNL&NT
120 WASHLNGTON STREET,r FLOOR
TFL (978)745-9595
Fiat(978)740-9846
Kl.%BERLEYDRISCOLL THob,WST.Pi M
.MAYOIi
DIRECTOR OF PUBLIC PROPERTY/HCII.DLYG CONMIISStONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electrfelans/Plumbers
4nnlicant lnfi>rmation Please Print Lelzibly
Name(ausiixss.Drganiraiiorutndividuaf):1"t6r r ,,f,)1 l,-�9J;60 A-1 fp.),t, C
I
Address: 77 t_i A\ 5 r�
City/State/Z[p: M(24 h G Je— Phone#: /X —z�M y— 57 97
,%reiptrain employer?Check the appropriate box: Type of project(required):
I. I am a cm to cr with 4. El am a general contractor and I
P y • have hind the subs onitactors 6. El Now construction
employees(firll and/or part-time).
2.❑ I am a sole proprietor or partner- listed on the attached.sheet t 7• ❑Remodeling
,hip and have no employees These subcontractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No worker'comp:insurance 5.'❑ We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
J.❑ i am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions
myself.[No workers'comp. a,152,§1(4J,and we have no 12.❑ Roof repairs
insurance required.)t employees:[No workers', I J.❑Other.
comp:insurance required.].
•Any opplicunt lot shush best As I most also fill out tho action below showing Ihoir policy infurmadon,
t 11,m mvmcs who submit this arridavit indicating they ant doing all work and that Idle outride contractors mutt submit a new anldavil indicting such.
:Cumraoron Ihot chuck this box mwt attached an uWitiutal shsst showing Iho mama of the sub.Mntrackni and their worker o'camp,policy information.
fain an etrrplayer that is provfdlttq workers'compensation insurance for my employees Below is the policy and Job rife
injarrnuNam T y^ \ /J
Insurance Company Name: �J .L Ac1pCs.J"1 h't iTy
Policy 4 or Self-iru�Lic.(N: / G—( yh�' d I Expiration Data: �•t
Job Site Address: e. „Q, ST MvNtnteJZip: 5, /�A , tji 9 c)
,lttach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MOL c. 152 can lead to the imposition of criminal penalties of a
tine up to SI.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S250.00 a day against ilia violator. 13e advised that a copy of this statement may be forwarded to the Office of
Investigutiorw ul'thc DtA for insurance coverage verification.
i do hereby cord ader t Lq7ad penalties er/ury that the hrfurmution provided above is tr a and correc6
Dare:
P n d• -
Of,riciai use only. Do not write in this area,to be completed by city ar town offtefuL
cityar'ruwn: _ Permiu7.lcensed _
rssulag Authority(circle one):
1. Uourd of health 2. Uuildlnt.,Department 3.Cityffown Clerk 4. Electrical inspector 5. Plumbing Impeetar
6.Oilier
Contact Person: . _ _ Phone It:
t