20 LINDEN ST - BUILDING INSPECTION (3) P 1 ds s3
The Commonwealth ofblassachusetts INgPECT10NA SEf� EpSp
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CbfR 'p IIrr,, ee��pp b Avil�,JS 2011
Building Permit Application To Construct, Repair, Renovate 0[9901nB1i§h a
One-or Two-Family Dwelling
LO This Section For Official Use Only
_ I Building Permit Number: Date Ap ted:
(1 Building Official(Print Name) : - Signalura, Date
SECTION 1:SITE INFORMATION.
1 Lt Prope�r'ty Address: S e % 1.2 Assessors Map dk Parcel Numbers
b �L
1.1a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zon g Information: / 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Wate Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal On site disposal system ❑
Public Private❑ Check if es❑ P _
SECTION2: PROPERTY OWNERSHIP,'
2.1 Owner'of Record: �o� l'9�d
EraR. ��
P ih) City,State,ZIP
9-d L.OQ/�ovc� �.e��e �7g98S3t=97 e
No.mid Street Telephone (Piatail ss
SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply)
New Constructio Existing Building❑ Owner-Occupied O Repairs(s) ❑ Alteration(s) ❑ Addition
Demolition ❑ Accessory Bldg.❑ Number of Units ;L— Other ❑ Specify:
Brief Description of Proposed Work-:
c,v o e e PEA' cs �P eK1`S�
rY s e A oxe-<Q, A,)SECTION J: ESTIMATED COt UCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
1. Building S / I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ d0 / ❑Total Project Cost?(item 6)xmultiplier x
3. Plumbing $ O P Qther Fees: S
q.Mechanical (HVAC) S G 6 p / List:
5.,\lee=al (Fire i Total Ali Fees:$
Su ressian)
Check No._Check Amount: Cash Amount:_
6. Total Project Cast: .S ��d a0 ❑Paid in Full 13 Outstanding Balance Due:
SECTION5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
S k Ga License Number Expiration Date
;one of CSL Holder
List CSL'rype(see below)
Le1_?1'4_.✓< b2! _
Nu.;mJ Street � Description .
/� U Unrestricted(Buildingsa to 35.000 cu. tl.
f-�a� ,V Restricted l&2 Famil Dwelling
City/rows,Sta P M Masonry
RC Rooting Covering
WS WindowandSidin
Q e h SF Solid Fuel Burning Appliances
1 Insulation
Telephone &nai a D Demolition
5.2 Registered Home Improvement Contractor(HIC) '137,f 9
�v G.< ti O A- HIC Registration Number Expiration Dale
HIC Cum��.ttnny ame or III C R istranl N:une `
�^ LttCee-.6'I-0A7G�R c' -- K10AJi C,0W)
Nr"*-A/ D !./lil.9 61960 6�7 Ema a ss
cityrrown-staG,ZIP___ Telerihone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M G.L:c.15L§2$C(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...........0
-OWNER .THORIZATION,TO BE COMPLETED.WHEN.
SECTION9a
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:OWNEW 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 this application is true and acc ate to the best of my k vledge and understanding.
,moo,✓ Z
Print 0% ner's or Authori c Agent's Nai ( lcctro •Signature) Date
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 Home Improvement Contractor(HIC)Program),will wot have access to the arbitration
program or guaranty fund under b1.G.L.c. 1 a2A.Other important information on the HIC Program can be found at
www muss gov:'oea Information on the Construction Supervisor License can be found at www.mass.eo+:'dns
2. When substantial work is planned,provide the information below:
Total fluor area(sq. R.) 'r (including garage,finished basementtattics,decks or porch)
Gross living area(sq. ftJ Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'type of heating system Number of decks/porches
Type orcooling system Enclosed Open
3. "Total Project Square Footage"may be.substituted for"Tutu1 Project Cost"
QTY OF SALEM, MASSAmUSEM
} {` BUILDING DEPARTMENT
120 WASHINGTONSTREET,YwAoOR
nL.(978)745-9595
KIMBERLEYDRISOOLL FAX(978)740.9846
MAYOR THOMAS ST.PIERRE
DIRECTOR OF PUBLICPROPERTY/BUMDING OI)MUSSIOMR
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 c40, S 54; Building Permit#i is with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
osA r
(name of hauler)
The debris will be disposed of in:
ffibme of facility)
( dress of facility)
� Y
ignature of appl' ant
Date -
The Commonwealth of Massachusetts
Department of Industrial Accidents
4 I Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
\Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information i Please Print Lel4ibly
Name (Business/Orgauization/Individual),7�F—S le> rrA!rA_io
Of
Address:�0 ee2l.,5 A,-1c �,e/tJe City/State/Zip: �0�� /1'14 5 / &hone#: 9)T 7�- 36 p
Are you an employer?Check the appropr ox: Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7, _P�New construction
2�I am a sole proprietor or partnership and have no employees working for me in g, ❑Remodeling
any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself.[No workers'comp.insurance required.]t 9. El Demolition
4.❑I am a homeowner and will be hiring contractors to conduct all work on my property. I will 10❑Building addition
ensure that all contractors either have workers'compensation insurance or are sole I L[]Electrical repairs or additions
proprietors with no employees.
12.❑Plumbing repairs or additions
S.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet. 13.❑Roof repairs
These sub-contractors have employees and have workers'comp.insumnce.t
6.❑We are a corporation and its officers have exercised their right of exemption per MGL c.
14.❑Other
152,§1(4),and we have no employees.[No workers'comp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
:Contractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
I ant an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lie.#: Expiration Date:
Job Site Address: City/State/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 MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
I do hereby certify under the pains and penalties ofperjury that the information provided above is true and correct.
Si ature: Date:
Phone# x
Official use only. Do not write in this area,to be completed by city or town official
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
NORTH
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COUCTIONANI7 Rev�Date : 20HN12% 5t, Scale:
' Joseph R. Gagnon n5516N51GN CLAUSE;
978.985.3697 Al Interior d;men5lon5 shown 5U3MITfk FINAL 5alem, MA 01901
HIC: 137495 are measured to the interior 2-62015 Date: 2-I-2015
MCSL: 031807 flm5h 5urface5tothe FIr5t door plan and
nearest inch and building Notes: Fa5t Flevatlon
areas derived there from Al2PI110H FL001?AP,�&+ / 121 U51' /�—
are approximate areas, WOF05Q7 MUM HEIGHT, 62" by: SAH Sheet: