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`u " CERTIFICATE OF OCCUPANCY
CITY OF SALEM Issued.?MMI Permit k
SALEM, MASSACHUSETTS 01970 City of Salem Building Dept.
DATE t FI12l-I(::i tY i 'A 19 i'r% PERMITNO.
APPLICANT FA F G l RC). T%I -V ill" F ADDRESS:"ll", "' I 1 3 .. ... -
(NO.) (STREET) (CONTE'S LICENSE)
CITY H`1M..ANI D STATEI'�''�) ZIP CODEI sl i TEL NO-%/i S
R OF
PERMIT TO i 11 WiF ..1 I...D I.N ( )STORY - l J(J t.i;« j I,1„'r:: i ��J.i.,`i DWELNUMLING UNITS
(TYPE OF IMPROVEMENT) N0. (PROPOSED USE)
_
_ _ ZONING ......
AT(LOCATION)!'ll/il/!{ C'
I .1L FNI ) L f',i I DISTRICT---,'
(NO.) (STREET) /
BETWEEN AND
(CROSS STREET) (CROSS STREET)
LOT
SUBDIVISION iIW1-' lUi LOTBLOCK SIZE
BUILDING IS TO BE FT.WIDE BY FT.LONG BV FT W HEIGHT AND SHALL CONFORM IN CONSTRUCTION
TO TYPE USE GROUP BASEMENT WALLS OR FOUNDATION
(TYPE)
REMARKS: t11 (( ['J !I 1441.1.T ( IiINTI 0M J IIiY, ...• `Ic:` 1... 1 I ' (:1 I,
� gg�"4.. I m.l..
AREA ORPERMIT -
VOLUME ESTIMATED COST@ L , '14_'' FEE
(CUBICISOUARE FEET)
OWNER 1'I at"' IJ
BUILDING DEPT. J
ADDRESS::: ) V' 1. .' CI i F T BY -
I
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Z 3�D -3 2- of CK S
The Commonwealth of Massachusetts
m j Board of Building Regulations and Standards CITY OF
G i Massachusetts State Building Code, 780 CM RECEIVE SALEM
„> INSPECTIONAL S R*t=Vtar201
Building Permit Application To Constrtict, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use/Only
Building Permit Number: Date Applied:
r
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
LI Property
1.2 Assessors Map&c Parcel Numbers
1.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zmting District Proposed Use Lot Area(sq it) i9untage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required ProviJed
1.6 Water Supply:(M.G.L c.4n,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
/one: Outside Flood Zone?Check❑ Private❑ — Check if yes❑ Municipal ❑ On site Disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of 2cc d: t / �I^� / ,
Nantc(Prin6 Cily,';ate,'.,I J��-K_)7--CIF/-1�� yT
No.and Slrecl l olcphunc - Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Spccily:
Brief Description of Proposed Work':_
SECTION J: ESTIMATED CONSTRUCTION COSTS
item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ I. Building Permit Fee:$ btdicate how fee is determined:
❑Standard Cityfrown Application Fee
2. Electrical $ ❑'rolal Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (I IVAC) $ List:
5. Mechanical (Fire $ — -
Su ression) Total All Fees: S
Check No. Check Amount: Cash Amount:
C. "Total Project Cnst S ❑ Paid in Full ❑Outstanding- Balance Due:
MCI L.�o Tb c.,(Z(a�U l,�tNoou�S
SECTION 5: CONSTRUCTION SERVICES
5.1 Construct on upe r License(CSL)
=�u� License Num� Ezp' ati n Date
Name of CSL HuIdr;�� YYY///
List CSL"Type(see below) A.& Cj
df 'Type Description
No.and Street, - tjtjy
U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 FatuityDwellin
City/Town,StateState,Ze/� M Masonry
RC Roofing Covering
WS Window and Siding
�� e- SF Solid Fuel Bruning Appliances
I Insulation
Tele hone � Fmwl address D Demolition
5.2 Registered Home Im rroveme t CokA or(HI- I19
1IIC registration Number E. tmC n ate
l l c ' y a c III Nan e
of
No. d Email address
Ci[ /Town,State,ZIP Te elphone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.§ 25C(6))
Workers Compensation Insurance affidavit must be cqmpleted and submitted with this application. Failure to provide
this affidavit will result in the denial of the Issuan of the building permit.
Signed Affidavit Attached? Yes .......... Ef 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 15ee caf/ ){
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby a es nder the pains and penalties of perjury that all of the information
contai 'n this application is true an accur to a best of my knowledge and understanding.
Prinl Ow cr s or AuthunzeJ Agent s- ume '.icctroni :ignauue) Nile
NOTES:
I. 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(FIIC) Program), will not have access to the arbitration
program orguaranty fund under M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.ntass.gov/dus
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 of bathrooms _ _ Number of half/baths
Type of healing system_ Number of decks/porches
Type of cooling system_ Enclosed Open
3. `°rotal Project Square Footage" may be substituted for"Total Project Cost'
�� '/ :1 --- I'hc Cumntumvcahh of�bhusaclutsctts _ _
13uarJol'Building Regulations;mdStandards CI'I'1'OF
Nassachusctts State Building Cude, 780 ChIR
Building Permit Application To CunslrucL Repair, Renovate Or m fish u Rvi
One- or Tiro-Yanult Ure//in,r
This Section For Official Use Onl
Building Permit Number: _— Date Applied:
AAkAAAA
Building 0111cial(Print Mune)
ilplature UOIC
SECTION I: SITE INFOR51A
I.I Pro ert dr 1.2 Assessur Parcel Numbers
P 7� � b It di
I.la Is this an acre ted street? es no Map Nunshcr I'urcel Number
1.3 Zoning Information: 1.4 Property Dlmenslons:
Luring District Proposed My Lot Arcn fsy 11) Frontage I III
1.1 Building Setbacks(R)
Front Yard Side Yanb Rear Yard
Required Provided Required Provided Reyuim-d Provided
1.6 Water Supply:)M.G.I.c.40.§!a) 1.7 Flood Zone Informations 1.3 Sewage Disposal System:
Public 0 Pricate 0 Zone: _ Outside Flood Zone?
Check if a0 Municipd 0 On site disposal s)stem 0
ECTION3: PROPERTY OWNERSHIP'
2,1 Owner'*( cord
Mune(Print) City,Slata-Z11P
/tsio tC,�n rlr� / i%3l��
No.and Stn'cl reiephone bmail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check it apply)
New Construction 0 Existing Building(3 Owner-Occupied ❑ Repairs(s) kheration(s) ❑ Addition 0
Demolition 0 Accessory Bldg.O Number of Units_ Other 0 Speedy:
Brief Description of Proposed Work-:
SECTION J: ESTIMATED CONSTRUCTION COSTS
hem Estimated Costs:
Il.abur;od Materials) Official Use Only
I. Building S I. Building Permit Fee: f I dicate how fee is determined:
:. Ffecirical i ❑Standard CitylTu%m Application Fee
❑Total Project Cost' Item 6).x multiplier x
_'. Other Fees: S
J. \ledtenical ill1 \l'1 S List:
`u nessiont S FONI.\II Fees: S —_ - - -- OZjj 'V .. ._ .
n Tul::l Prrtject Cuvt i Chcch No, -_._ ('hcck:\nnnum . ._.._..(',uh \nunnn:
❑ P.iid in F'ull O Owsl:mding HaLutcc Doc:
sti.x-l ION 5: ('OM I-RUCTION SFRN I( F-S
cast ucli it S Pen iSor K S1 I
ru 61A-11 - - 1.\111rM it ;Ile
wcnw Number
I st 01. 1'\pv(,icv b0oil)
I-�PC I)i:si;riPIiIIn
I I Id
No Lid p1r.", _nM
It Irio,:JJIIIIIIdiIlL
Ki Masollry
L"Nerin'
RC itiflin Cerg
w I sidit
SF solid Fuel IltimingAppliallces
I Insulation
Fmail address D Demolition
I'clo hone
3,2 Registered 110019 Ina jr vitmeng untrilitio, 1110
IIIC'Rcgislraliun umber I'v it sun ate
III , Na 111C i4tr
Email address
No. i Q1
Cirtilown, late P rdephone 35C(6))
SECTION61WORK ql COMPENSATION INSURANCE AFFIDAVIT(M.G.L C. 153
Workers Compensation insurance affidavit must be comill and submitted with this application. Failure to provide
this afflitavit will result in the denial of the issuance at Is building permit.
Signed Affldavit Attached? Yes .......... No.......'.
SECTION ION 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 permit application.
to act on my behalf,in a letters rela4ve to work authorized by this building
o" Date
Print 0%iner's Nuniel(Electronic 4idrla ure
SECTION II IN Ib- OWNERW OR AUTHORIZED AGENT DECLARATION
By entering my name below. I hereby attest er I le pains d penalties of perjury that all of the information
Coil a ned n this tion is true and acc rate to e be r knowledge and understanding.
Print 0%%rI tit;iitithtirih A6xII1*4 Nama 11: tro is Sign;'M-11
NOTE&
I. b building permit to do his her own wark,or an ol, net who hires an unregistered cuntrwor
.fin Owner who obtains a 1111provtIllent Contractor(HIC) Program),will all' have access to the arbitration
(qcit registered in the Hume
programor gilunlat) fund under M.G.L. c. 141.4.other impuriant information on the HIC Program can be found at
%lW\ I Information on the Construction Supervisor License can be found at it
T7111ne5.Pi U:15;lie It rwatiun below:
77—wien substantial ii,ork is p ifeludirt;gilgige.finished basemen(attit:3,decks or porch)
row litior area I q. 11.) fInbitable room cutint
Gruii his ing area I iq- of bedrooms
Numbvir ill liall'ball"
gnuherofhathrrollls Ntlnh%:r%ifJ%NklI, parches
I'1 Ile of healing S)swill Inclosed
I pe ol,%:oolille i.\i1elli
joial Prolvo stitiare I:tl,l I.Igc- null he sIlhNwuwd Ilor kllai Iltili"t Cklsl"