Loading...
8 LINDEN ST - BUILDING INSPECTION (2) U R fs V fhc Commonwealth of Massachusetts INSPE6 IOHI DE—v cE I�, Board of Building Regulations and Standards SALEM 11 i)/J}r Massachusetts State Building Code,780 CNIR 1814 RRa,4'edAltW 1T �h Y Building Permit Application"Co Construct, Repair, Renovate Or Demolish.a One-or Tivo-Fami(y Dtvel it g This Section For Otficial Use Onl Building Permit Number: Date Applie . �� � building Official(Print Name) Signature Date SECTION is SITE INFORMATION' 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers ( LIWOEQ ST. 5ALEM. MR Alup Number Parcel Number I a Is this an accepted street?yes ✓ no 1.3 Zoning Information: 1.4 Property Dimensions: I Lot Area s Frontage It t Zoning District Proposed Use ( 4 it) ron ) ga( 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.Je,§Sd) 1 7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yesO SECTION 2: PROPERTYOWNERSHIP!° 2.1 Ownert of Record: NA'n I.R d3gAc MA ) N7 ale(Print) City,State,ZIP LIIvD S r `l3`6 -426 mthon.brocrp-#0QQr it-c No. and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ 1 Alterntion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': <'OrJS"f2tn G'fIOI` LP20 , ' F>CFtFSZIc7fZ DFZ lC. _. SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials) 1. Building 5 '��C?tX)• OO 1. Building Permit Fee:S Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'((tern 6)x multiplier x J. Plumbing S 2. Other Fees: S I.Mcch:mic:d (HVAC) 5 List: >. \(echanieul lPire rut;d All Fees:S Su ression) Check No._Check Amount: Guh Amount: 6. Total Project Cost: S -3-c3 , 00 ❑Paid in Full ❑Outstanding Balance Due: Tb CAr,�-M-R c,--biz S V T N,l 3 U . r ^! '?2 !A1101T3392H1 SECTION 5: CONSTRUCTION SERVICES 5.1 'onstruction Supervisor License(CSL) C6_ (0(1120`t IZ 22 t S et; ,))L,I,1A 6 License Number Expiration Date Name of CSL Holder list CSL Type(see below) 496, }- LM-IPHOP ST "type Description No. and Strect 5GAN1�0 - , ^� �)p'�� 1 Unrestricted(UFami D elling 00cu. 11.) ,\ rl' W4- 2 Restricted ISc2Fnmil Uwellin Cityffown,State,ZIP hl Masonry RC Roo ling Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Irate Email address U I Demolition 5.2 I egistered Home Improvement Contractor(HIC) O(.(ST K) HIC Registration Number Expiration Date HIC Cogry Name or HIC Regytram NameS„t.. -LF°I(, IIUy't,+�l'GC � _ \�2nrupnc@_ afM�ti(-cowl Email address W City/Town,State ZIP Tele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(b6G.L.c. ►S2.¢ 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 AUTHORIZATIONTO BE COMPLETED WHEN..' i OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,as Owner of the subject property,hereby authorize t9 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: OWNERI ORAUTHORIZED AGENT DECLARATION By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in th's appli fl t is true and accurate to the best of my knowledge and understanding. Print OwoWs or Authorized Agent's Name(Electronic Signature) Dale NOTES: 1. 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 Florae Improvement Contractor(HIC)Program),will no have access to the arbitration program or guaranty land under I.G.L.c. I42A.Other important information on the HIC Program can be found at www.mass.eov:'oea Information on the Construction Supervisor License can be found at www.neus.nov/dps 2. When substantial work is planned,provide the information below: Total tloor area(sq. it.) (including garage, finished basement/attics,decks or porch) Gross living area(sti. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths [.ype of heating system Number of decks/porches Typeorcoolingsystem Enclosed Open_ 1. "Total Project Square Footage"may be.aubstituted for"total Project Cost" CITY OF S:U EM, NIaNSSACHUSETTS BUILDING DEPARTMENT ,3 Y3'<fl 120 WASHIINGTON STREET, 3w FLOOR TM (978) 745-9595 F sa(978) 740-98.46 KI\fBERLEY DRISCOLL a�1 iYOR THOMAs ST.PIERR& DIRECTOR OF PUBLIC PROPERTY/BUIL.DING CONNISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print LeQibIV Manic(nusincsmOrgaairati')WIndivi(iunl): ZUsTf rJ W ILLI AMS Address: 1-1-96 4-iUMPNej:�6 City/State/Zip: SWkMR5CCFT7- PhoneA 7cal 519 252"I. Are you an employer?Check the appropriate box: Type of project(required): I.❑ 1 am a employer with 4, ❑ 1 am a general contractor and 1 6. oNew construction employees(full and/or part-time).' have hired the subcontractors 2.® lama sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity, workers'comp. insurance. y. ❑ Building addition (No workcn'comp. insurance 5. ❑ We are a corporation and its i l i repairs or additions ❑ Electrca required.] officers have exercised their 10. ' 3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.[] Plumbing repairs or additions myself.[No workers'comp. c. 152, §I(4),and we have no 12.❑ Roof repairs insurance required.] t employees.LNo workers' l3.❑ Other cutup.insurance required.) -Any appI cum hat chucks box AI muxn also fill out the xactiun baow showing their workers'eumpensatiun policy in lbrma tion. 'I hancuwm"who submit this affidivii indicating They arc doing all work and then hire outside conlmctors must submit a new afridavit indicating such. C��mrwlon that chak This box must atachod an additional shout showing Ile name of the sub.omncton and(heir workers'camp.policy information. I ant an eutplayer that is providing workers'compensation insurance for my employees. Belo v Is rise policy and job site inlar4ralan. Insurance Company Name: .___-_-- Policy 4 or Self-ins. Lie. tl: Expiration Date: Job Site Address: City/Slate/Zip: 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 klGL c. 152 can lead to the imposition ofcriminal penalties of a tine tip to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to S250.00 a day against the violator. 13e advised that a copy of this statement may Ix:forwarded to the Office of Investigations ol'the DIA for insurance coivcrage verification. I do hereby cerrify�d w der pal is al1dmiairies 4perjury drat the brjarmurlar pro sided above is true and correct 11a tare' Data: Phone l; —4,;6 1 Sg 9 2 521. OJjiciul use only. Do star write in this area, to be completed by city or town official City nr'1'usvn: Permit/Llccme X ' Issuing Authority(circle one): —_ - -_ 1. Board of Ifealth 2, Building Depurtutcut 3.C.'ityseruwn Clerk 4. Electrical laspectur 5. Plumbing Inspector 6.Other Contact Person: _.. Phone n: 1 nn yam. L� Pos- 9' 60 2- 9, 4' 12- c6 471� ----------- + y, CITY of SCkLr-Nf -USACHUSEl 1J t ©U1WLNG DEPAR-ME.YT �'- 120 CU.ISHLNGTON� STREET 1'°FL,�Wit. � OOR ..... °'' T EL (978) 745-9595 FAA(978) 740-9846 KIJBERLEY DttlSCOI_i. AAYO11 Tt mtAsST.PIERn DIR&TOR OF PUBLIC PROPERTY/SCMDLNG CON NI55IONER 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 l l 1.5 Debris, and die provisions of NMI, c 40, S 54; Building Permit # is issued with the this work shall be disposed of in a properly licensed waste disposal nfacility as defined by MG that the debris resulting Loe t l 11, S 150A. The debris will be transported by: Z5t<)—f'l N (J 1(_LA A-rI5 (namu ut'haulur) The debris will be disposed of in �02TI�1 S IDS GAfZT!y�, (name of facdily) — ---(address of racility) I s gnature utpermit cant — ,late A r -- _— �c,�STiN_ �►L�.--i��-�oN�T�vtC I ICE. _ D i _ ------ —- -- - --_ F'12. N ATH Arm l'J- RAGK�I`i- . 2E. NEw ExTE2lo2 DECK COQa P_(/+GT�- CK,-) _ -- COPE = Gores T 2UcTl orJ of -t TWO STAr2 wr��/S �i�i�_ fZAlt_IN��r_ C_ NIA—S(�1-PPOQTS_----- ----- Fo 2 oa ----------- - - ---------------------- To I p\L GAT DATE --- DATE Maker of the Genuine Swiss Army Knife' ql�- 77, C0 The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards SALENI Massachusetts State Building Code, 780 CMR Revised blur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Divelling This Section For Official Use Onl Building Permit Number: Date Applied: Si at a' Date OuilJing 01'ticiul(Print Name). ' SECTION 1:SITE INFORMATION Li Property Address: S\ IZ Assessors Map g Parcel Numbers I.la Is this an accepted street?yes J no M1lop Nwnber Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sy It) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Witter Supply:(M.G.L c.40,§51) 1.7 Flood Zone Information: IS Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if es❑ SECTION2: PROPERTY OWN ERSNIPI' 2.1 Ownerl of Record: throe(Print) City,Slate,ZIP �and a S Email Address No.mid Street Telephone SECTION 3: DESCRIPTION OF PROPOSED WORIe(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Rep-lusisi ❑ Alterntion(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Worke: .. 1'i L i2 SECTION 4: ESTIMATED CONSTRUCTION COSTS Estimated Costs: Official Use Only Item Labor and Materials I. Building S � �---- I. Building Permit Fee:S Indicate how fee is determined: ; ❑Standard City/Town Application Fee 2, Electrical S ❑Total Project Cost'(Item 6)x multiplier x J. Plumbing S 2. Other Fees: 5 t.Mcch;utical (bIVAC) S List: 5. Mechanical l -ire S Total All Fees:S Su ressiun) Check No._Check Amount: CasllAnwunt:_ 6, rot;.tl Project'Cnst. $ �O ,���— ❑Paid in Feu ❑Outstanding Bal:u:ce Duo: SECTION 5: CONSTRucTION 'ERVICES t 5.1 Construction Supetisor License(CSL) Q ; \\i H , S License Number Exl5irkiuh Date Name of CSL[[older List CSL'rype(sce below) N�ndE,' , 'r. e Description i U Unrestricted(Buildings tip to 35,000 cu. It. Restricted 1&2 FamilyUwelling Cityffown,State,ZIP NI Masonry RC Rooting Covering WS Window and Siding SF Solid Fuel Burning Appliances r I Insulation 7'ele hone Email address D Demolitian 5.2 Registered Home Improvement Contractor(HIC) \Isoco� S �(` W ��i `^^� >�""�--� HIC Registration Number Gepir ion Date [IIIC�Company Name orHICRegistrmuNane c NO.and Sire t Email address Cit /To� ZIP 'rele hone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 25C(6)), Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this of davit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ........,ice No...........O 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 t9 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 tru and accurate to the best of my knowledge and understanding. Print Owner'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 nrrt have access to the arbitration program or guaranty lund under I.G.L.c. I42A.Other important information on the HIC Program can be found at www.mass. gay v_aea Information on the Construction Supervisor License can be found at www.mass.�,ov!JL T. Whcn substantial work is planned,provide the information below•. Total floor area(sq. 11.) (including garage,finished basement/attics,decks or porch) Cross living area(sq. It.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths rype of heating system Number of decks/porches '1'ypeotcoolingsysicnl Enclosed Open_ J. "total Project Syuare Footage"may be substituted k)r Total Project Cost" CITY OF Sam E�i, �LkSSACHL'SETTS BUILDING DEPARTMEINT 120\W.ASHL�IGTON STREET, 3sD FLOOR TEL (978) 745-9595 FAx(978) 740-9W KINt$ERL.EY DRISCOL1.. y(gYOR THOMAS STTIERRE DIRECTOR OF PUBLIC PROPERTY/BUnDLNG CON11MISSIONER Workers' Compensation Insurance Affidavit; Builders/Contractors/Electricians/Plumbers Ap tficant Information v Please Print Legibly NainC (l3usin tivOrganization'individual J: W t \hr xj S 1��(i� Address: City/State/Zip: Phone #: 1 Are you an employer?Check the appropriate box: Type of project(required): 1.)&I am a employer with� 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).° have hired the sub-contractors 2.El am it sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition [No workers* comp. insurance 5. [1 We are a corporation and its required.] officers have exercised their !0.❑ Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself. [No workers' comp. c. 152, §1(4),and we have no 12.0 Roof repairs insurance required.)1 employees.LNo workers' 13.❑ Other comp.insurance required.] •Any applicam that checks box sl must also fill uut the scelion below showing their worken'eompensmion policy inanma(ion. t I lomeowrw•n wha submit this affidavit indicating they art doing all work and then hire outside contmcton most submit a new amdavit indicming such. $;mtrxwro that chwk this box mwt anachcd an add,Lional shaet showing the noun of the sub•eontrscton and their workers'comp.pal icy infortnniion, /ans an employer that is providing workers'conspensadan insurance for my employees. lrelaro is the policy mad fob site information, Insurance Company Name: O �y,� ✓fin.-n r Policy N or Sel6itts. Lic. H: Expiration Dated N�// Job Site Address: b �+ ,� City/State/Zip: Attach a copy of the workers'compensation policy declaratlon 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 line up to S1,500.00 and/or 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. Be advised that a copy of this statement may be forwarded to the Office of Invcstiguiiuos ol'dre DIA for insurance coverage verification. i do hereby certify unddeer�d_tee p/a[_'is mrd penalties pequry t/rut the infarmutioa provided above iv true mrd c'orrec•4 Sirsnuurt' L=o] ,,.�! D'ttc' _ . Phone,i: 1 Y- ;oil Official use only. Do tot write in this area,to be completed by city ur town official City or Town: .__ Ycrmit/Llccnse# Issuing Aulhurily(circle one): 1. Board of health 2. Building Department 3.Cilyfrown Clerk 4. Flectrical inspector 5. Plumbing Inspector 6.Other-,._._--- Comae- Person: Phone Ii: [ H . r i CITY OF S:U EM3, ;tiL1SS.ICHUSETTS l _ BUILDL\IG DEPARTStENT t` 120 WASHLNGTON STREET, 3W FLOOR TEL. (978) 745-9595 F.ILX(978) 740.9845 KIJiHEI2LEY DRISCOLL NL-1YO;L T 1go.%uS ST.pIERRS Dlmcroa OF PUBLIC PROPERTY/BCILDLNG COJWOSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5 Debris, and the provisions of NIGL c 40, S 54; Building Permit a this work shall be is issued with the condition that the debris resulting from l 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by NfGL c The debris will be transported by: (lane of hauler) The debris will be disposed of in - --- � c.2 (name of facility) -� address of tacility) signature of permit applicant n