10 LINDEN AVE - BUILDING INSPECTION (2) 14 � 3
ai
/ The Commonwealth of Massachusetts
191 Board of Building Regulations and Standards CITY j
Massachusetts State Building Code,730 CbIR SALE
Revised M
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or 'Two-Family Dsvelling
This SactioaForOfficial Us n
Building Permit Nu ber• . edss
BuiidingOfficial PrintNe'me),, $i Data
SECTION 1:$11TEAfORMATION.
1.1 Property Adliress: 2 Assessor blip 3r Parcel Numbers
tZoning
cepted street?yes no Ntap Number Parcel Number
rmation: 1.4 Property Dimensions;
Proposed Use LotArea(sq ft) Frontage(ft)
tbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required T Provided
1.6 Water Supply:(V1.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑' Zone: _ Outside Flood Zone? Municipal Cs On site disposal system ❑
Check i, es❑
" SECTIONZ PAOPERT$OWNERSHIPL ''`
2.1 Ownert of Record:
t✓cl�r�.e#tv.e_ NASD. . '"d,rblf. CAA �/t Ol atMS
/ Name(Print) City,State,ZIP
-I � 1-tc3t- SC6 v c� e sh@ �o sa. ne+
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF.PROPOSED WORJV chack all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessary Bldg. ❑ Number of Units. Other ❑ Specify:
Brief Description of Proposed Work':
e ec,V : mpg � ,ek s n�crr1 kt— r� ',1rcx 0c-1ng
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Itetn Estimated Costs: OfRelal Use Only%
Labor and Nratcrials
1. Building ; L.Building Permit Fee:S fiidicate how fee is determined:
2. Electrical ❑Standard,_City/town Application Fee.
'
$ ❑'rctal.ProjectCose(Item.6)xmultiplier x
J. Plumbing i 2. Other Pees: S
1. ,Mechanical (IIVAQ i List' /
?. ,Mechanical (Eirc $
lbtal :VI Fces: .S_
Check No. _Check e\uwunt: _Cash :lutounC
n 1'ntal Project Cult: S j� OOv ❑ Paid in Pull ❑ Out Landing Ilolance Ihta:
- 3
Oetc
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) j
License Number Expiration ate
Name ofCSL Iloldcr
List CSL'fype(sec below)
r e Description
No. and Street
C/ ff2 fc� U' Unrestricted Duiu-n su ling cult.
C ( Restricted 1.4e2 Famil Dwcllin
City/ n,Swt L[j', �I out_ta
l/.rt�J RC R,-r Cuvcrin
lVS Window and Siding
� SF Solid Fuel Pluming Appliances
�/'�t��1<.), I Insulation
1'ele hune Email address U Demolition
5.2 Registered Home Improvement Contractor(HIC)
FIIC Registration Number Expiration Date
1IIC Company Name or I11C Registrant Name
No.and Street Email address
City/ own,State ZIP rele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152.§ 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 .......... No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES
SS FOR BUILDIING�PEMIIT
I, as Owner of the subject property,hereby authorize' 5 �'" �"M ' '
to act on my behalf, in all matters relative to work authorized by this building permit application.
4
Print Owner's Name(Electronic Signature) me
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
Bye below, I hereby attest under the pains and penalties of perjury that all of the information
plicatiion is true and accu et a b m e and understanding.
I ash , i`burized:\;ent's Name(Electronic 3Z 10 Date
NOTES:
I. An Owner who obtains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program),will t have access to the arbitration
program or guaranty find under M.G.L.c. 142A. Other important information on the HIC Program can be found at
www m;u±.suv%uca Information on the Construction Supervisor License can be found at myw.ntas .!.n dL
2. When substantial work is planned,provide the intormation below:
Tutal flour area(sq. R.) (including garage, tinished basementlattics,decks or porch)
tiros; living❑rca(stl. ft.) — Ifabihtble room count
Number of fireplaces.:.---------- Number of bedrooms Number ol'bathroomi of bathrooms Number of hal6baths
f%pc of hcming sy.fcn . _-_._-- Nnntber or deck 'porchcs
I)peol•coolin" ;y;tcm _----_--.- f;neloscd _--- (tpcn ----_-___---
_--
� t. `Ini.ill'nq;rt �yuireFn, t.ir"in.type ;ub;nnit: lt; r"I„t.ill'njertl'o;t"
CITY OF S.ULE.Nf
PUBLIC PROPERTY
DEPARTMENT
U 1YYa7 iu.r•v.
%stun I"h HNG M lnaAT f IM^V MAOla MM 011'e
rrL f'17iif1fl •Y.V.971746964
1401KEOWNER L[CLNSB 9.XZ. BTIOaV
Ptease Riot
Date 1'I 1 2-013.
lob Looadmn I o u,,c -, A,,--
Home Owner Address .Z "-R.-5u d 7 ,E7 J-�l w rbl C�u�J -,L1.Ar
Home O1wa Tslephow -t 8►- le 1- b
Present Mailing Addrew j b U .1L An,- s�
The current exemption of"Homeowners"wag extended to include owns,occupied
dwellings of two Units or teas and to allow such homeowners to cagagt an individyav for
him who does not possess a licenso provided that the owner,acts"supervisor.
DP.FII MON 0/HOMEOWNU
Person(s) *he owns a pared of Lod on which hefshe resides or Intends to reside6 on
which thaw I; or Is intended to bo, a one or two Amity dwelling attached or detached
stavetures atceessotry to such uag and/or farm syucturva A perms who constructs more
than one home in a two year period shall not bs considered a homeowner, Such
"homeowner"shall submit to the Building OQlci4 on a form acceptable to the Building
Oillcial, that he/she be responsible for all such worts performed under the Building
Permit
Ths undersipted "homeownce assumes responsibility for compliance with the State
Building Code and other applicable bylaws and retuisdonst,
Pre underigrted"homeownce certiAa that Wilt@ understands the City of Salem
Building Department minimum inspection procedures and requirements and that he/shs
.viIf comply with said procedure requirements.
HOMEOWNERS SIG;fA PL'RB
IPPROVAL OF 9IlILONG OiSPECTOR
See other side far stets code
0
QTY OF S"v-&Nf, JA-U kCHUSETI-S
6CLI-OLYG ❑EPARTUFUNT
, n t� ,�
�� I?Ol'f/13NL`tGTOVSTUST, 3 RCOR
A
T -L (978) 745-9593
I<ISCOERL.EY DRISCOLL FAX(973) 7•1O.9344
r L�YG,Z DIONVU Sr.Pima
DIXECTOR OF FCOUC PROF ERTY/st:=LYG CONWISSiO.NER
Construction Debris Disposal At'f1davit
(required for all demolition and renovation work)
In accordance will' the sixd' edition of the State Building Code, 730 CbfR section l l LS
Dcbris, and the provisions of NMI. c 40, S 54;
Building permit M is issued with the condition that the debris resulting from
I t, S I SOA.work shall be
I
l 1 disposed of in a properly licensed waste disposal facility as defined by LvfGL c
The debris will be transported by:
'-'bispose—1 (n�or1� 0��� r 13223(0
(nintc ul'haulcr)
('he dtibris will be disposed of in
lv�"�1t� ur Ctcdily)
o
(.tdures.t ut'ruilily)
22
,ignanuc • .
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i CITY OF S UL EJNI, iNaSSACHUSETI•S
13UIMLNG DEP.1RTniE.NT
120%V.\SH ,PIGTON STREET,3ia FLOOR
TEL (978)745-9595
Rut(978) 740-9846
KI.NIg F Rt RY DRISCOL L THOMAS ST.Pmna
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BI:IIDLNG CO.1L\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Pleas Print Le ibl
Name(Busiit &Orpnizatiorvindividuaq: G• J
Address: �� d 4aY2-�a �
CitylState/Zip: Phone
Are you an employer?Check the appropriate box: 'Type of project(required):
I.P I am a employer with_� 4. ❑ I am a general contractor and 1 6. Now construction
employees(full and/or part-time).' have hired the sulxontractors /
2.Ellama sole proprietor or partner- listed on the attached sheet t 7. 1�Remodeling
ship and have no employees These sub-contractors have S. (]Demolition
working.for me in any capacity. vorkers'comp insurance. 9. C1 Building addition
(No workers'comp.insurance s.' We are a corporation and its.
rcyuircrL)
officers have exercised theft I0.❑Electricals repairs or additions
3.❑ I am a homeowner doing all work C/ {�-i' right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(No workers'camp. �c. 152,}1(4y,andwo have no 12.QRoofrepairs
insurance required.)t umployea.INts Workers' 13.17-1
Othe
comp:insurance required.].
•Any applicant that chwks box 401 most ahas till out the iecliou bdow showing their workets'cpmpeasatlen polity infurmation.
!i tnmeowtstrs who submit this sd1davit indicating they am doing all work and thou him oinside"mrsctcn most submit a new,affidavit indicating such.
=contrxturs that chwit this box must anachud an addiduwlsheet showing the name of the sub mraclon and their worked'comp.put icy infomudon.
l am art employer that Is provlding workers'compensadon lnsurance for my employees Below is the policy and Jab site
h1formadatn g
Insurance Company Name:
Cc�
Policy 4 orSeff--ins.Lic.N:r"'r� :��� ��-4Car /Ecpimtion Data: �
Job Site Address:� e—�//—)08tJ CitylState/2iP: jr� ",)-7
Attach a copy of the workers'compensation policy deelaraflen page(showing.the policy number and expiration date).
Failure to wcure coverage as required under Section 25A ofnlGL c. 152 can lead to the imposition ofcriminal penalties of a -
One up to S 1,500.00 undlar one-year imprisonment,as well as civil penalties in the form oft STOP WORK ORDER and a tine
of up to 5250.00 a duy against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investiguliuns ul•the DIA for insurance coverage verification.
1 da hereby too id ry that the lnfartnudnn provided a save is true and correct
t P Dar • e�Z
Phone,,..
0V lal usr anty. Do not turite in M&urea,to be completed by city or town ofJ1rlaL
cityor'ruwn: _ Permit/Lleensed
Issuing Aulhority(circloone): --
I. Board of Mullis 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: . Phone tit:
(