20 LINDEN ST - BUILDING INSPECTION (4) 4
The Commonwealth of Massachusetts ECE�NLF
Board of Building Regulations and Standards . INSPEC 10NMIMVIC
Massachusetts State Building Code, 780 CMR Revised blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demoli ,�i N V 2$ Ali: Z
One-or Two-Fmnily Dwelling
This Section For Official Use Oat
Building Permit Number: Date.Applied
�— i ature . - Date
Building Official(PontPt Name). � K!t
1 SECTION L•SITE'INFORMATION'
LI Property Address: 1.2 Assesson binp 5t Parcel Numbers
G1�o e,y s r �A le.t
L l a Is this an accepted street?yes no M1fap Nwnber Parcel Number r
Mback
g Information: j I.d Property Dimensions:
� o
rict Prop Use Lot Arcm(sy tt) Frontage(R)
ngSetbncks(ft)
Front Yard Side Yards Rear Yard
d Provided Required Provided RequiredProvided
Supply:(M.G.L c.d0,§54) 1.7 Flood Zone Information: 1.8 Sewage Qisposal System:
Zone: Outside Flood Zor�7 �Oo site disposal system OPrivate OSECT[ONZ: PROPERTYOWNERSHIP"
t of Re ord:
M(PrA5e,
t��hme(Pro ) Q City,State,ZIP � -
�o L�Z4Q. 4IV 97X q�cr3rc97 P �a3 A A.4 M
No.and Street Telephone Ema Ad •s.
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction 0 Existing Building Owner-Occupied O Repairs(s) O I Alteration(s) O Addition ❑
Demolition KI Accessory Bldg.E3 I Number of Units_ Other O Specify: ,
Brief Description of Proposed Work :
�d�iTn.tJ 'f.vy a f1s
SECTION d: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S 3 Q O Q.r I• Building Permit Fire:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(item 6)x multiplier x
3. Plumbing $ �'%glher Fees: S
d. Mechanical (tIVAC) S List:
5. Mechanical (Fire $ Totai All Fees:S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: p paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Conitructioli,Supervisor Licensee(CSC,) —/
os18��' -9 �
'7--SPA!` /v ` GI�Q�p License Number Expiration Date
• •N:unc oFCL Holder List CSL'rype(see below)
-Type - - Description
No. and Street :
U Unrestricted DuilJin s tip to 35,000 cu. tt.)
D R Restricted 1&2 Family Dwelling
Cityfrown,St• ,LIP M "Vilsonry
RC Rooting Covering
WS WindowandSidin
J d�j OS��+�f�.U6�•z'odif SF Solid Fuel Doming Appliances
97g 9r'2697 v 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /-�7 7 7
i /C • KAd HIC Registration Number Expiration Date
f IIC Cum any Name or HIC Regis . it Name -
�p /���.A�L L]� / /P rAP�Ii CD IrL�K �.SO.yA•`�GOM
No. and Str•et q �r� E it Jdress
PA Dw 1l14 �14�� �7P9lzs'36 7
Ci /Town, a ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.g 25C(Q) .
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 .......... F
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 +� K>-4 ZA✓X1i,/
t9 act on my behalf,in all matters relative to work authorized by this building peter tt application.
OS
Print wner's Nmne(E tunic Signature) Date
SECTION 7b:O NEW 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.
rint O% aer's or Authorized ent's Name( 'c•tron' ignau re) VDate
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 nuf have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program can be found at
�evvw.mass.eov'oca Information on the Construction Supervisor License can be found at www.mas.��ov�'Jys .
2. When substantial work is planned,provide the information below:
rotal fluor area(sq. ft.) ~ (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 0.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
'rype of heating system Number of decks/porches
Type of cooling system Enclused Open_
3. "Total Project Square Footage"may be substituted for"rotal Project Cost" OOD,
If
a° Q-1-Y OF SALEM, 2VLASSACHUSETTS
BUILDIING DEPARTMEINT
§ t o 120 %V.•15I4C4GTON STREET, 3-FLOOR
mod. TEY- (978) 745-9595
Rt x(978) 740-9846
KjNIBERI -YDR2SCOLL ItlontAsST.P»✓alts
t;�i1YOR
DIRECTOR OF PUBLIC PROPERTY/B(:Q.DI\G CO\LVI5SIONER
Workers' Cmnpensa(ion Insurance AMdavit: Builders/Contractors/Electricians/Plumbers
nnilcant lnformatinn Please Print Legibly
Name (Htnitacss.Orgmtiratinru'Individu:d): - OS / G.� A re6 /
Address: ,-,10
City/State/Zip:2E<r 9,4 Phane N: `I7,�fs- 7-
Are you an employer?Check the appropriate boa: Type of prnJect(required):
1.0 i am a employer with 4. 0 I am a general contractor and 1 6. ❑New construction
, _,pliployees(full and/or part-time).* have hired the sub-conuilctors
2.!)'J lam a sole proprietor or panncr- listed on the attached sheet. t �• [1 Remodeling
,hip and have n0 employees These sub-contractors have S. YrDernolition
working for me in any capacity. workers'comp. insurance. 9. 0 Building addition
INo workers'comp. insurance 5. 0 We are a corporation and its
required.]
officers have exercised their IO.O Electrical repairs or additions
3.0 1 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.) f employees.(No workers' 13,0 Other
cutup.insurance required.)
•Any applm-1 Our check!bat 0 mist also roll uu1 the acetian Meow showing their wodm'eompensadon pulisy information.
'I lomeuwm"wAo submit this antbovit indicating they in doing all work and thin him outside contractors mini submil a nmv affidavit indicting such
fumrwtun that chak this box mint anachd in additional shot showing the name of the subwemractun and their workers'comp.policy information.
fain an eurpluyer that is providbig workers'compeasmlon hourancejor my employees. Bohrry/s rbe polley andJub Nile
in/urination.
Insurance Company.Name:
Policy it or Self-imt. Lic. 4: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy,of the workers'compensalloo 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 oferiminal penalties of a
tine up to S1,300.00 and/or one-year imprisonmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a line
of up 10 5230.00 a day against the violator. De advised that a copy of Ihis statement may be rurwirdcd tothe Office or
In vesl igadotm offlic DIA for insurance coverage vcrilicaliun. -
/du hereby cert fy under Nte polas turd penaldes ulper%ury that the information provided above is true and c urrec•c
Si,n t e Dote:
Phoncil 7
OJ/irial use unly. Oo not write in Ildi area,to be cumpleted by city up torus a/JJriat
City
Issuing Aulhurity (circle one): ---
1. Heard ul'lleallh 2. Building Deparlutcul i.cityfruwn Clerk J. Electrical Ltspcctur 5. Phnnbing Inspecrur
b. Other
I
Contact l'crtnn:
QTYOF SALEM, MASSACHUSETTS
F . .. fp BUILDING DEPARTMENT
120WASHINGTON STREET,3mFLooR
TEL. (978)745-9595
F
' KIMBERLEY DRISCOLL FAX(978)740-9846
MAYOR THOMAS STYIERRE
DIRECTOR OF PUBL c PROPERTY/BUILDING COMMISSIONER
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, 5 54; Building Permit## is issued 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, 5 150A.
The debris will be transported by:
E�P�G z P is�osa
(name of hauler)
The debris will be disposed of in:
(namCajof facility)
dress of facility)
Ygnaf'u-re of appl' nt
Date