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20 LINDEN ST - BUILDING INSPECTION 21� s cK � z� ��c �a RECEIVED EE o The Commonwealth of Massachusetts Board of Building Regulations and Standards (CITY OF Massachusetts State Building Code, 780 Cb Revisey,IR 1015 FEB 19 ®M sed,tfur 2011 V Building Permit Application To Construct, Repair, Renovate Or Demolish a r!� One-or Two-Fnrnify DwrUing �J This Section For Official Use Only ' Building Permit Number: Date.Applied:. Building OlTicial(Print Name). Signature _ Do(e ' SECTION 1:SITE INFORMATION' 1.1 Property,)ddress: 1.2 Assessors Map&Parcel Numbers 1.1 a Is this an accepted street?-Yes r� no Map Number Parcel Number 13 'Zoning Information: � Zo 1.d Property Dimensions: i ning D� iisssttrict Propose Use Lot Area(sq ft) Frontage(It) 1.5 Building Setbacks(R) Front Yard Side Yards Rear Yard Required Provided Required P rovided Required Provided 1.6 Wnt/er Supply:(rvl.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public QX Private❑ Zone: _ Outside Flood Zyne7 Municipal ja On site disposal system ❑ Check if 3es SECTION2. PROPERTY OWNERSHIP'` 2.1 Owner of Record: osenQ Gdv3A� P A �hme riot) City,State,ZIP 4j , spa Gem'/.r�n/c 2.✓� rf78 6>7 7J� A�n No.and Street Telephone na ss SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ 1 Existing Building 911 Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑LAccessory Bldg.❑ 1 Number of Units Other ❑ Specify: Brief Description of Pro osed WorV, e tM 4 e �/ R N o .go v i io /e "kS 4k, SECTION 4: ES (MATED CO RUCTION COSTS licm Estimated Costs: Official Use Only Labor and Materials) F3. Pltimbing uilding S SO OO / 1. Building Permit Fee:$ Indicate how fee is determined: ectrical $ QD� ❑Standard City/Town Application Fee ❑Total Project Cost'(item 6)x multiplier x 'S Iko0C) 2s Other Fees: $ d.Mechanical (HVAC) $ List: 5.i\lechenieal (Fire ,S Suppression) Total All Fees:S Check No._Check Amount: Cash Amount:_ G.Tutal Project Cost S �7D QQ(j ❑Paid in Fuil ❑Outstanding Balance Due: C:TIi�C 60 L{ 2 c1� 31?b ,c�ALLA�m u i i SECTION 5: CONSTRUCTION SERVICES i7Nanieof truction Supervisor License(CS1�7 t iccnse Number Expiration Uate SSLL Ilolldeer List CSL'fype(see below) Tye - Description No. ;md Street d Dui ldin s itRUnsrersccte to 35,000 cu. 11.) fwellinatitrted Cit M Masonry RC RoofingCovering l // 0 WS Window and Siding e�8. 985����I7• SF SolidIuelBurningApplianccs / / S a A" 1 Insulation 'iele hung in tl ddress I Demolition 5.2 Registered Home Improvement Contr ctor(HIC) /_� 0 j HIC Registration Number Expiration Date HIC Con an Na e r IIIC Re 's ant Not e / e%✓ �n�n irtaD�® Q4 �9 w/ fb ad S • t �7 M�126 7 'ma"" City/Town, S IP 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.......... SECTION 7arOWNERAUTHORIZATI JO BE COMPLETED WHEN' 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 Namc(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 know edge and understanding. te 'rint04ner'sorAuthon o ,Agent'sName(ElU ic nature) D, 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 rrof 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 svww etas;eov'oca Information on the Construction Supervisor License can be found at www.masssov'dys 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) ' (including garage, finished basement/attics,decks or porch) Gross living area(sy. tt.) 6B b Habitable room count /O Number of fireplaces_ Number of bedrooms Number of bathrooms _? Number of half/baths type of heating system G w S Number of decks/porches 'fypeof cooling system ,t/OAkg- Enclosed Open 3. "I'otal Project Square Footage"may be substituted for"Total Project Cost" CITY OF SiUENM ;N-Ws.1CHl;SETTS p Bt:11.mG DEPARTMENT 120 WismLNGTON STREET, 3'e FLOOR ozo TEL (978) 745-9595 F.ur(978) 740-9846 K1.\IBERLHY DRISCOLL "'NL-%YOR ' MOANS ST.PiERRB DIRECTOR OF PUBLIC PROPERTY/BumDI.%,G CO\L\IISSIONER Workers' Compensation Insurance Afftd'avit: Builders/Contractors/Electricians/Plumbers A t ilicant Information Please Print Le (bl NamelnusittLssOrgsniraliun,'Individu:d):DLO- /C frA.lf� Address: o� Cep/.ate City/Statcaip: Q©P oplfo�lt! Arc you can employer?Check the•appropriate box. Type of project(required): 1.❑ I am a employer with 4. ❑ 1 am a general conlraeior and 1 6' ❑{New construction (full and/or pan-tim,o)." have hired the s'ub•contractors 2. 1 am a sole proprietor or partner- listed on the attached sheuL t 7.jgjRcmodeling ip and have no employees These sub-contractors have B. 0 Demolition working for me in any capacity. workers'camp:insurance. 9• Building addition I No workers'comp.insurance- 5. ❑ We are a corporation and iu required.) officers have exercised thelr 10.0 Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.[]Plumbing repairs or additions myself.[,No workers'comp. C. 152,§1(4),and we have no 12.[]Roorrepairs insurance required.) t employees.[No workers' comp.insurance required.) 13.❑Other •Any upplic:un our chsckr boa el most also rill nut flit fectiuo W.owshowing their"$hen'eompensall"policy ingmnaflon. 'I Tnmeuween,who w1unif this aff1davil indicating they arc doing all work and then hire wiside confinement mini ruh,ot a new allfdavil indicating such $'mnnxtua fhm step ihit bus mint mfachal an addniuful:hnt showing Montano or the"Itcon racton and their wnfkm'comp.pulley inrumution. I an,can eurptuyer that Is providing)porkers'conipenradon hesurance for my employees Belofv is the policy and jvb$ite /ufunnution. Insurance Company Name: -"---- Policy ii or Self-ills. Lic.0: Expiration Dale: Jab Site Address: City/State/Zip: ,Mach a copy of the worlters'compensatlou pulley declaration page(showing the policy number and expiration date). Failure to sccure coverage as required under Suction 25A arMGL c. 152 can lead to The imposition of criminal penalties of a tine tip to SI.500.00 and/for one-year imprisonment,as well as civil penalties in The farm of a STOP WORK ORDER and a find of up to S230.00 a day against flit violator. De advised that i copy of This sratement may bf rurwarded io the Oliicc or Invsrefigmivas ul'Ihe MA for insurance coverage verification. /do hereby cerd y under t/te allis mfJ f litev ofperjury Mar rife hilbrnnurimr provided above it true and correct Dawd �.__/Z'I� Phoned: (VA iul u�c unly. Do our Wile if'1/ds urea,tote completed by city or town n/Jiriut City nr'ruwn: _= Permit/Llconse Issuing Au timrity(circle one): I. Board of health Z. Duilding Departntria;i.Cllyrrufsn a Clerk J. Electrical luspcclur 5. Plubing Inspector I 6. Other Cuulad I'e,in):... CITY OF SALEM, MASSACHUSE M i ` l BUnDINGDEPARTA ENT 120 WASHNGTONSTREET,3'mFLWR 7kL.(978)745-9595 KROBERLEYD&SOML FAX(978)740-9846 MAYOR THomm ST.PIERRE DIRECTOR OF PUBUCPROPERTY/BLUDWG 0[)AWSSIOMR 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 00, S 54; Building Permit i1 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: (name of hauler) The debris will be disposed of in: name of facility) ddress of facility) jign ture of appli ant Date i