19 LIBERTY HILL AVE - BUILDING INSPECTION �� - ---
2 I Ile ('Un1n1UI1N'eahh of M:usachuxctts Board oTBuilding Regulations and Standards CI'I'1' OF
s MassachuseUS State Building Code. 7SO CNIR SALEM
Building Permit �\pplication 'ro Construct. Repair, Renovate Or Demolish a
One- or ruw-family Dwelling
/ This Section For Oir ial Use Only
[7oning
uilding permit Number. ale Applied: dL
Building Official(Print Niune) iigrtaturc Dute
SECTION I: SITE INFORMATION
Pr�pey`,rty ens':1 �` � 1.2 Assessors Slap dls Parcel Numbers
NFL
a Is this an acre tr—d treet? es no M1lnp Numher Parcel Numher
Zoning inrormatlon: 1.4 Property Dlmenslons:
District Proposed(lie Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(It)
Front Yard Side Yurds Rear Yard
Required Provided Required Provided Required pruviJed
1.6 Water Supply:(M.G.I.c. 40,§SqfZ
1.7 Flood Zone Informalion: 1.8 Sewage Disposal System:
I'ub1l Private O ona: _ Outside Flood-Luna?Check if yesO Municipal On site disposals)stein O
SECTION 2. PROPERTY OWNERSHIP'
2.1 Owner'of ecord:
-$ ryliz�$n 6T L- I, LF ��� �d�oot 5`T( Ged4tity MA
Name(Primf City.State.ZIP
49od a���
No.:mJ Slra'et Telephone Fined Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O I Existing Building Owner-Occupied 0 1 Repairs(s) Alteration(s) ❑ I Addition
Demolition O ActxssoryBldB.0 Number of Units_ Other O Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
halt Estimated Costs: OMNI Use Onl
(Lahoy and Materials) Y
I. Building S SD aeiv,,J I. Building Permit Fee: S Indicate how Ire is determined:
2. clectrical a Standard Ciry.Tovvn Application Fee
O Total Project Cost'(Item 6)x multiplier
.1 Plumb1°g 2. OcherFees: SJ. Mechani
cal i MAIt
Useal iFire 'reision rota( .\IlFees: Sheck No. Check :\mount: (%ish \niounCTutul Project Ca e Due:
0 Pyid in Full 0 Outstanding Bal:mc
t
SECTIONS: C ONSrRti("rION SERVIC F'.S
5.1 Coffs ;u'tionSupenisor Lice nse(cSL) —71074
I iansc Nunihcr ry,inuou IMIC
• ,\':nneul'l',' ashler .-_---- A_
Q `C 1, `� 1 isl CSI. 1•)Pe(+cc helua)__"—`_--- --
_OY✓ R_ mg�
UcseripliunN". .md StreetsmteleJ(IhIilJin �s ti to 1S,000 eu. 11.1rirtcd I,r;21'.unil 17Cilvi fawn.. ate,Lll' nlin C'ucerinu,r;mJ SiJin Fuel 1lurning,\ppliances
0ationl'cic Imne Email address llitinn
5.2 Registered Home Improvement Contractor(HIC)
IIIC Itegislr;aiun Number IispirWioo Uutc
I IIC Compan) Name or IIIC Registrant Nato
No.and Street Email address
City/Town. Stale ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 1 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 .......... O No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize 7 o en r l Qpv-/
to act on my behalf, in all matters relative to work authorized by this building permit application
Print Owner's Name Mcctrunic Signatum) Dale
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
contained in this application is true a accurate to the best of my knowledge and understanding
✓�.ri 1��, ZDjZ
I'rinl 1)w ncr's ur:\utharire au's Nance III c runic Rignaturo) Date
NOTES:
\n Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(nut registered in the Hanle Improvement Contractor(HICI Program), will nu have access to the arbitration
program or guaranty fund under\I.G.L. c. 142A. Other important information on the HIC Program can be lound at
w o,l ni.r•. �„ , ..i Information on the Construction Supenisor License can be round at
? \\'lien substantial wurk is planned,provide the information below:
rota) flour area I sy. 11.) (including garage, lmished basement attics,dales or por%:hi
Gross Iiv ing .tea 154. It _-"-, Habitable roam count
\umber of lircplaces -.. Number kit hedrounls .. . .
Ntimberothathrooms -- .—. _. — \lumbcrof'half•hall" . .
I'\pe of heating iy stem \luuher ol'decks, porches
_ l)I,en
I I'v po otcooling sy ilenl I'nelascJ
1
"I'od,ll PrUjCCI ti,11111rC I'o,q,lgc Itl;ly 1m.uhitinlrcJ IiV"total Pn,ject Cost"
CITY UE S,ILE,N(. AUS.ICHUSETTS
8l.'MDLNG OE►.1AT\lt?.Nr
I 'O WAi NGTON STUSr, 1'4 FtCCR
rM k973) 745-959S
K)J OERUY OUSCOLL PkX(973) 1 f491ti-td
MAYOR Ikamu StPMUS
O rR=Tc L 0►Pl.Btl C PROP!!t TY
/ectxnrxc ca.Nnitssto.i EA
Construc
tion Debris Disposal At'ftdavlt
(required for all demolition and rcnavation work)
In accordance with the sixth edition orth@ Slat@ Building Code, 190 CjMR section I 11.J
Debris, and the provisions o(,MGL a 40, S 34;
Building Permit 4 is issued with the co
ndition
This work that th k shall be disposed of m a properly licefsaed worts disposal a debris resulting from
l 11. S 1 JOA. posal facility as deBncd by &IGL c
The debris will be transportcd by:
(nuns j f Aauler)
The debris will be disposed of in :
(name of
Iiddrsfl orr�,iti�y)
�y
fnuure of ermif ipplK�nf
IL
CITY OF S.\LE.%[, NWS.\CHUSETTS
13CILCING DEP.itRTmENT
120 \' ASHLVGTON STREET, 31° FLOUR
TEL 978 745-9595
F.kr(979) 7)0_9844
K1\,BEXLEY DRISCOLL TtionlisST.PI AAB
NLAIYOR
DIRECTOR OF 11C9LlC PROPERTY/8l:[iDING CO>LMISStONER
Workers' Compensation Insurance Af7Tdavit: Builders/Contructur.v/Electrlctans/Plumber$
Itnnlleant Infnrm•atinn Please Print /Lezihty
MunclnufiiwsUrg7ngalionlndividual): Ta/ 6 I1AIdL'1 jT- ` ` C- - � r� �•(����'� �Q^1
Address: °l ( �S� r �! �� raif� v
Cily/5tatozip. s,lt.y Mae . 49117U Phone jol - 2S (?
tire you an employer?Check the appropriate bo: 'type of prniect(required):
1.❑ 1 am a employer with 4. am a general contractor and 1 6. ❑Now construction
anlpinyces(full anlUorpart-lime).• have hired the sub-contractors
2.❑ 1 am a role proprietor or puriner- lisidd on the attached A991. t 1. lemodeling
,hip and have no employees These sub-contractors have g. ❑ Demolition
working tier me in any capacity. worker'comp.insurance. 9• Ouilding addition
[No workers'.comp.insurance S. El We are a corporation And its
rcyuireJ.J
officers have exercised their lu.❑ Electrical repairs or additions
3.❑ lain a homeowner doing all work right of axamplion per MGL 1 I.❑ Plumbing repair or udditions
myself.(No workers'Gump. c. 152, 41(4),and we have no 12.❑ Roof repairs
insurance required.Jt cmpluyees. INowarkers' l).QOlhcr
sump.insurance required.J
•an :d y uPPllan dot ahwks but rl must aye rill out the wuiue below showing chair rakes'wmpenudun pohay mdumalton.
'I?, nvuwrum wha,uhniil this alndavil indicating they am doing all work and than him onllide aanlmeta t malt anAmll a new anlJaril indicting,uck
:0,ttinwlun that chwk this boa mot inachud an Wdulurwt.heel shuwing the numa or the aubtonlmctm and their warkm'wmp.pulley inrotnui
lain an rnrpluyrr thuNi pravfdlnX Ivorken'cumpeumlun Grruraneefor my empluyatrs Below is the Polley andjob site
information.
In.+urines Company.Name: _
Policy 4 or Sclr•ins. Lio. it: Expiration Date:
Job SiteAddruss: l9 //lC,-+ �i�ll t^I City/Stute/2ip: ,C4& ,0wrg Q119 >0
.\ttacb a espy of the worker' componsadoa pulley declaration page(showing the policy numbor and saplrsdon data).
Kidurd to wcuru cuvdrage as required under.Suction 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine till to S1,500.00 tin lur one-year imprisnnmcnp is well as civil penalties in the form of STOP WORK ORDER and a Ime
Of till to 577n.00 i Jay igailist file violator. Ile idvixed that a copy of this.+latwnent may lit:furwardcd to the 011ica of
lovc,ti gatiuus tti the DIA for insurance coverage vcriticuliun.
/do/terrby terrify coder that polar oil of pan dlder oaf perjury but the infurnru/tar pro vidd,l ubuve i.v iruet.ard corrrct
r.dure: Ihta:
I)//itid!nee Pauly. /ha"of vrift in this area, td he runlPlUed by city ur lawar njflrid!
City or llnvn; .--- -. .._. Pcrmitil.icvnse i
Homy,,\uthurily (circlouae)t —._. .. _..__
I. Ilo:ird of Ilcallh !. Iluildlny nepoi tiucnl I. Cilylfaun Clerk J. lilectriell I'l,ticcior 5. PhunbinG Inspector
1. 00wir
l�u tll.l�t 0crwo: .._.._.-_ I'hoae d: