16 LINCOLN RD - BUILDING INSPECTION r
!I O The Commonwealth of Massachusetts
I Town of
i Board of Building Regulations and Standards jIllowna
Massachusetts State Building Code, 780 CMR, 7'a edition Budding Dept
1 v to Or Demolish a Building Permit Application To Construct, Repair, Reno
One- or 7lco-Fa ill•Dstelling
This ScclioVF4 Official Use 41Y
Building Permit Num c 4 1 pn#p
Signature: - - --.
m /
Building omissioner/ spectmof Budding Date
SECTION 1: S E INFORMATION
1.1 Property Address:/ 1.2 Assessors Map& Parcel Numbers
_ // �/be it/�✓ d?YJ �
I.1 a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Disinct Proposed Use Lot Area(sq R) Frontage IN
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Requied Provided Required Provided
1.6 Water Supply:(M.G.I.c.40.154) 1.7 Flood Zone Informatlon: 1.3 Sewage Disposal System:
Public❑ Private Cl Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 w rioff Record: /,-" /�fif d/ /2o
Name(P int) Address for
Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(cbeck all that apply)
New Construclion❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition O Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': .._EWr41 , &,>hil r,-/ryr f ie-vh P I yllvnew
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S / 676) cd 1. Building Permit Fee: S Indicate how fee is determined:
❑Standard Ciry/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3 Plumbing S 2. Other Fees: S
4. Mechanical (HVAC) S List:
t Mechanical (Fire S Total All Fees. S
Su ression
Check No. _Check Amount: Cash Amount:_
A Total Project Cost: f �Ob u ❑ Paid in Full ❑Outstanding Balance Due:
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
o
� 72�p�CjNj License ,Number Esp anon ais /te
N.;�of CSL Hylder Lut CSL Type lattt below)
� T� Descn uon
A s
U Unrestricted u to 35.000 Cu. Ft.
R Restricted 1&2 FamilyDwelhn
Signature„ �/� N Noon Only
CJ- 7 �' � C RC Residential Roofin Covering
Telephone wS Residential Window and Siding
SF Residential Solid Fuel Bumm Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(His)
�Tt7ZtdyZrYf/ � L'drirv'YL[7rt l� l
HIC Co y N� HI Registrant Name s egtstnnon Number
�� Y�
Add
Eapir rion Dire
Signature - Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152. 2SC(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 Afrdsvit Attached? Yes.......... No........... O
SECTION 7a:OWNER AUTHORIZAPON TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, L( 0 ,LO tluse as Owner of the subject property hereby
authorize 16 IOZ19 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATION
1, ��a/ /�77t'�/Zo�V/ _ _ ,as Owner or Auth—on'zed Ag'gei['hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf. r
Print
l
Sign .o Owner or Auihoriz Date
(Signed under the psins and penalties of (u
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(HIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L. c. 1s1A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I IO.RS, respectively.
2. When substantial work is planned,provide the information below:
Total noon 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
Tvpe of heating system Number of decks/porches
Ty pe of cooling system Enclosed Open
1 "Total Prolecl Square Footage" may be substituted for 'Total Protect Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
l t0 W.\i111N1':;0..'1 Sfi(LIST • SAI PNI,St.\SiAt.[it 11 I'i S Jl'1
TL1.:978-'4 9j95117AX:978.740.)84E
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 c 40, S 54;
Building Permit At -_ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in
�IlD12 /b!c_
(name of facility)
(address of facility)
signature of lxrmit Applicant
date
Achn:ut'I'uk
CITY OF S.u.Emii NANSSACHUSETTS
BL QDING DEPARTTtEINT
120 WA INGTON STREET. )to�FLOOR
TEL (978) 74S-9595
FAx(978) 740-9&M
KImSEXIEY DRISCOLL
MAYOR THOh[As P1E ST. ItRs
DIRECTOR OF PL BLIC PROPERTY/8V MDLNG CO%L%USSIO-%
Workers' Compensation Insurance AMdavit: Builders/Contractors/ElectrlcianslPlumbers
Applicant Information Please Print Legibly
T r r
Nalne ldusirwv.Ort vuntionlnr4v�du:w11' r�K ZGN/ DA/SiTLCI G��a`y
Address:
City/StatdZip: Eamon aYeOl Phone M: �7P
e on as employer'Cheek the appropriate box: Type of project(required):
I I am a employa with— 4. (_1 I am a general contractor and 1 6. ❑New construction
eanployeq and/or pan-time).• have hired the sub-contracmn
2.❑ I am a proprietor nr paulner-
listed on the attached sheet: 7emakling
ship and have no employees Thee sub-contractors have V. Q Demolition
workingfor me in an capacity. workers' comp.insurance,
Y P tY• 9. Q building addition
[No workers' comp. insurance S. ❑ We am a corporation and its have exercised their
equiied.] otylc I0.❑ Electrical repairs or additions
rtss
3.ElI am a homeowner doing all work right of exemption per MOL 11.0 Plumbing repairs or additions
myself.[No workers'comp. c. 132.41(4).and we have no 12.Q Roof repairs
insurance required.] t employees. LNo workers'
comp. insurance required.)
13.Q Other
'Any applicant this duds ben 11 msar 31"rill tin the f lim below showing thak waken'cmnpanu hen policy inluridoo.
't Lvs.eownsa who submit this aMldsvk indicting airy are doing ail work arse then hip oultiee counicsora must submit a new.arlldavit indicting suer
:f,murstop then ch.ek this ben mum anachod an addiliusd slits showing Ilw rum•d Isla aa-Cmllilore and they wodisra'cony.policy information.
/am as earpbyer that b pmvid/ng workers'compemadox/nsarwme for my empfuyres Below/s the policy andM rim
information.
Insurance Company Name: .I O b j
Pnlicy M or Sclf-ins. Lic.#* Expiration Date:
Jab Sire Addreu: �Z A111C a1 OC10 -SgL&_`740City/StatdZip: � 44 -01�Vd
,%track a copy of the workers'compensation policy declaration pop(showing the polky number and expiration date).
Faiium to secure coverage as required under Section 25A of MGL e. 132 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment.as wall as civil penalties in the form of a STOP WORK ORDER and a floe
of up to S230.00 a day againsl the violator. Ile advisaxl that a copy of this statement maybe rorwarded to the OtYce of
I nvcau gationa ol'dte MA for insurance coverage veri tication.
/do hereby seal It err WiRs rand pen N r wry r at rho urformadon provided above is true and correct
/ Dole! 0
Poore J,
Ofaial sae mdy. Do no!ware in Mir area, le be.anrp/e!d by airy or/own nJJ/aiuL
City or futon: _ Pcrmit/l.lccnse M__..
Issuing.%whonly (circle one):
1. Iauard of Ilrahh 2. Rui fill nu Department ). Cityf row n Clerk J. Eleclrical Inapec to► 5. Pf um bin% Inaper lot
6. Other
C„matt Person: - _ .— -- Phone a: