20 LINDEN AVE - BUILDING INSPECTION (3) The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
Thus Section For Officiat Use f)n
Building Permit Number to Applied x x
.> it 11��
Si nature • . Date
Building Official(Print Name) g
SECTION 1 SITEYNFORMATION -
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
Ma Number Parcel Number
1.1 a Is this an accepted street?yes t/ no
p
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal El On site disposal system ❑
Public❑ Private El Check if yes❑
$ECTION`2; PROPERTY OWNERSHIP':::. ,
2.1 Owner'of Record:
'yo '0 y C'D 'V AIC rG S Name(Print)(Print) City, State,ZIP
No. and Street Telephone Email Address
SECTION 3::DESCRIPTION OF,PROPOSED WORK' (check all thatapply)
New Construction ❑ Existing Building Cl Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work':
v
SECTION 4: ESTIMATED;CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labor and Materials
1. Building 1 Building PermifFee $ Indicate how fee is determined:;
❑.Standard_City(Town Application Fee.'
2. Electrical $ eVo ❑Total;Project C6'st'(Item 6)r inultipliei- x '
3. Plumbing $ &V 2. Other Fees:
4. Mechanical ([VAC) $ List
5. Mechanical (Fire Total All Fees: $
Suppression)
CheckSlo. Check amount Cash Amount'.
6. Total Project Cost: $ �� [YU0 -U) ❑.Paid i.n Fult - ❑Outstanding Barance:Due:
SECTION S: CONSTRUCTION SERVICES
rNimeofCSLI[older
ction Supervisor License(CSL)
- 2t} /CyC f�y�- License Number Erpiratio Date
List CSL Type(see below)Type Description .
r 'A 29 9 2 U Unrestricted Buildin s u to 35,000 cu. it. ..
R Restricted ISc2 Family Dwelling
Crty/Town,State,ZIP r l Masonry
RC Raofin Coverin
WS Window!n'
Siding
c7 SF Solid Fuiances
•f ��L Cadv --V4 HJ I Insulatio
Tele hone —T Email address D Demoliti
5�gistered Home Improvement Contractor(HIC)
_mac cvyu>_ FIIC Registra s nation Date
HIC Cof�pany Name or FIfCRegistrant Name ess
.S�t-mot, {N( 4• ai �7o 3�p&•-93Z•s;iY'-�
Ci /Town, State, ZIP Tele 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 FOR BUILDING PERMIT
1, as Owner of the subject property,hereby authorize Sy P y 0,9 V/NS 1&
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: OWNEW 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 and accurate to the best of my knowledge and understanding.
c%-�- // ! Z
Pratt Miter's or Authorized Agent's Name(Electronic Signature) Date
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 not have access to the arbitration
program or guaranty fund under NI.G.L. c. 142A. Other important information on the HIC Program can be found at
www.massoov/oca Information on the Construction Supervisor License can be found at www.mass.eov:'dgs
2. When substantial work is planned, provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics, decks or poach)
Gross living area (sq. ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt/baths
Type of heating system Number of decks/porches
Type of coolingsysten Enclosed_ Open
�3_ "[Total Project Square Footage" may be substituted for"Total Project Cost"
a
CITY OF SUENvI, lr'L�SS.,xCHUSETTS
BUILDING DEPARCNIENT
120 WASHNGTON STREET, 3'D FLOOR
TEL. (978) 745-9595
FAx(978) 740-984d
KI\IBERLEY DRISCOLL
MAYOR THDhtAs ST.PuiRm
DIRECTOR OF PUBLIC PROPERTY/BUILDING COX12MISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Amilieant Information / Please Print Leeibiy
Name(Busii%ssorgtnizatioraindividual): / 6f CA?—
Address: !? J-,e.V72q.,
City/State/Zip: 5�4 /,Y� _ Phone hl:
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am it employer with_0 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(felt and/or part-time)." have hired the sub-contractors
2.511 am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These subcontractors have R. C] Demolition
workingfor me in an capacity. workers'comp. insurance.
Y a h• 9. ❑Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MOL I l.❑Plumbing repairs or additions
myself.(No workers'comp. e. 152,¢10),and we have no 12.C] Roof repairs
insurance required.l t employees.[No workers'
comp insurance required.] 13.0 Other.
;Any applicant that shacks brat At must also rill out thd toctim bolowshowins their warkom'compenwdon policy information.
1 fi mownen who submit this affidavit indicating they am doing all work and thtm him ouuidecontractam mtnt submit a am amdavil indicting such
:Contractors that chock this box most atlachedan additional shout showing the name of tho eb contrAGWro and their workam,comp.policy information.
l um an employer that Is prevlding workers'compensadon insurance for my employees: Below Is dje po/ley and Job stfe
feforovallam
Insurance Company Name:
Policy#or Self-ins,Lic, N: Expiration Date-
Job Site Address: City/StatetZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 und/ar one-year imprisonment.as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. He advised that a copy of this statement May bo forwarded to the Oflice of
Investigations of the DIA for insurance coverage verification.
l do hereby y a ider the p ns and p!naltles of perjury Mat the infuriirutlon provided ubuver is i a and correct.
siumi -c�X".� Dahl: l�� Z
Phoned;
OJ]Wal use only. Do not write in ttris urea,to be coarpleted by city or town o/pelat
City or Town: _ Permit/1.1cense
Issuing Aulharily(circle one):
I. Board of licullh 2. Building Department 3.Citytrown Clerk S. Electrical Inspector 5. Plumbing Inspector
6.Olher
Contact Person: _, Phone#:
CITY OF S�kLEM, N'LksSACHUSETI"S
BL'IMCs'G DEPARTMENT
3 N 130 WASHNGTON STREET, 3aD FLOOR
TF-L (978) 745-9595
FA-Y(978) 740-9846
fCr\tBERL.EY DRISCOLL
l L1Y0R T Ho.% s ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BCILONG CO\LMISSIONER
Construction ]Debris Affidavit Disposal
p tfidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit #----
, is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transportt/cd by:
�o f L� ��9 ✓C��L��
(name of hauler)
The debris will be disposed of in :
(name of facility)
(ad ress cf facility)
r 9
stgnatute o'permit applicant
1 / it tC
d.bm:�iCd.w
cv `y f 1. SLAB TO BE OPENED TO RUN NEW BATH
PLUMBING OVER TO NEW EJECTOR PUMP
2. CONTRACTOR TO CONFIRM ALL DIMENSIONS
PRIOR TO START OF PROJECT
I � r
I
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OIL TANK
STORAG q BATH
EJECTOR PUMP FOR NEW
BATHROOM AND LAUNDRY SINK
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LAUNDRY'--
i............................
i,
_________________ _ __ __ __ _
_ _________________________________
_____________
LOSE UP OEfENING i I
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i.................
FAMILY ROOM . . ......•.•
STORAGE
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