43 LINDEN ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
t 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
77777
This;Sectio'- For Official Use Only
Building Permit Number ; D e App ed.I:
VuU,'Idihg
1 Official(Pant Name) . Si attire Da e
SE(- ION I: SITE FORt�CA,1ON 5 .
1.1 Pr gp rt ddress: 1.2 Assessors p& Pa el Numbers
�
y�.1UOtCatJ
1.1 a Is this an accepted street?yes_ no_ Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
Pr
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 On site disposal system ❑
Public,t� Private❑ Check if yes[]
SECTION 2i�'PROPERTY`OWNERSHIPr,` ,
2r...: :�n��r/tjo�Re
Name(Print) City, State,ZIP
- 3 L,;V\ cLg r q7qNo. and Street Telephone Email Address
SECTION 3,DESCRIPTION OF PROPOSED WORK (check'all that.apply)'-
New Construction ❑ Existing Building( Owner-Occupied, Repairs(s) AIteration(s). Addition ❑
Demolition X Accessory Bldg. ❑ Number of Units Other ❑ Specify:
s
of Description of Proposed Work :
rr r,C K o A1
+ e
SECTION 4: ESTI MATED CONSTRUCTION-COSTS
Estimated Costs: Official Use Only. ;
Item Labor and Materials -
1. Building $ p p p J 1 mg Permit.Fee $ Indwate how fee is determined:_
Build
❑ Standazd City/Town Application Fee .:
2. Electrical $ OU v ❑ TotaPProject Cost„(Item 6)x multiplier x
3. Plumbing $ j O UDt� 2.. Otherfees: $
4. Mechanical (I-IVAC) $ List:
5. Mechanical (Fire Total All Fees: $
Suppression) - - -
Check No. LL Check Amount: Cash Amount
6. Total Project Cost: $ wo 0 Paid in Full 10 utstanding BalanceL Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Cmtsh-uctimt Supervisor License(CSL) LS_f762C�J:y �� f S ac)
R .HGloP�1 License Number Expiatim Date
Name of CSL Holder
3 /Z es VI i e-r (' (�j List CS Type(see below)
No. and Street I"� Type, Description
f `f �`�� U Unrestricted(Buildings s u to 35,000 cu. ft.
/ ' R Restricted 1&2 Family Dwelling
City/Town, State, IP vf Masonr
RC Roofing Covering
WS Window and Siding
(,�2 / / SF Solid Fuel Burning Appliances
361 A/W [ Insulation
"fete hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or FI[C Registrant Name
No. and Street
Email address
City/Town, State, ZIP Telephone
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
[toact
Owner of the subject property, hereby authorize
on my behallf,, inall_matte�rssrellaattive to work authorized by this building permit application.
QD �� t mil! �1 1C�( l 1 idA(1 f
Print Owner's Name(Electronic Signatl.14y Date
SECTION 7b: OWNER' 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 ap lication is tru and accurate to the best of my knowledge and understanding,
!� C�
Print Owner's or Authorized Agent';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 M.G.L. c. 142A. Other important information on the HIC Program can be found at
vvwvvuuass.eov/oca Information on the Construction Supervisor License can be found at www.ntass.�ov/dos
2. When substantial work 's pJa n , provide the information below:
Total floor area(sq. ft.) (including garage, finished basement/attics, decks or porch)
Gross living area(sq. R) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system� i_c�0 r_ Number of decks/porches
Type of cooling system Enclosed_ Open t/
3. "Total Project Square Footage" may be substituted for"Total Project Cost" -
l
"r CITY OF SALEM, NLksSACHUSETTS
BUILDING DEPARTMENT
3 N• 120 Vll.NsHLNGTON STREET, 3Atl FLOOR
TEL. (978) 745-9595
F.Ax(978) 740-9846
KI.NtBRRt F.Y DRISCOLL
NLAYOR T 140.%W ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLtiIISSIONER
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 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 transported by:
aor4 S i ci Ca"^�y`�t5
(name of hauler)
The debris will be disposed of in
5� e�
(name of facility)
(address of facility)
eA
signature of permit applicant
y-
date
III
i� CITY OF S:U EMI, lLXS&XCHUSETTS
BUILDING DEP ARTNIEUNT
,\ !!• 120 WASHINGTON STREET, Ye FLOOR
TFL (978)745-9595
F.Aa(978) 740-9846
KI\IBERLEY DRISCOLL
MAYOR THOMAS ST.FIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG C0\641ISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Etectrlcians/Plumbers
Applicant Information_ _ _ Please Print Le ibly
Name(Busitt,ys.Organizati°tvindividual): �efCq cf 0 I�Q.vJQ(ter
Address: 1:5 50W'e, R81
City/Statc/Zip: MCA Phone M,
Are you an employer?Check the appropriate box: 'type of project(required):
1.0 I am a employer with 4. 1 am a general contractor and 1 6. ❑New construction
employees(thll and/or part-time).* have hired the subcontractors
2.1;T I am a sole proprietor or partner- listed on the attached sheet t 7• N Remodeling
ship and have no employees These sub-contractors have S. 0 Demolition
working for me in any capacity. workers'comp. insurance. 9, 0 Building addition
[No workers comp. insurance 5. ❑ We are a corpomsion and its
required.) officers have exercised their 10.0 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'camp. C. 152, 41(4),and we have no 12.E] Roof repairs
insurance required.)t employees.[No workers' 13.0Q Other,
camp.insurance required.)
•Any applicant that chucks box ei must also 1111 out the scaioa below showing thew wmkM,compensation policy information.
!Ih"cowners who suhmlt this affidavit indicating they am doing all work and then hire outsidee contract=must submit a new amdavit indicating such.
:Contractors that chuck this box most attached an additional shoat showing the none of the aubaoniradors and their workers'comp,policy infommtion,
l am an employer that Is providing workers'compensation Laurance for my employees: Below is the pollcy and Job site
hrformation.
Insurance Company Name:
Policy#or Self-ins. Lic. 4: 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 sucuru coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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. He advised that a copy of this statement may be forwarded to the Ofrice of
Invesaigutiuns ufthe DIA for insurance coverage veriftcaliun.
l do hereby r jy under th pains and p tallies of perJury that the i"Arinallon provided above is tree and correct
si�ature: ) t}�Zk-z -- Data. 1 �1�(z—
P o #. 50�- 36 t - �,144
Official use only. Do not write in this areas robe catrtpleted by city or town a/Jlcla!
Citynr'fown: Yermtt/t,lcense#
Issuing,%uihurily(circle one): — ---_-
1. Board of licallh 2. Building Deparinwal 3.Cilylfown Clerk 4. Electrical.Inspector 5. Plumbing Inspector
6.Olher _..
Contact Person: -----._.._ Phone#:
Massachusetts
Board Of Build in �ePartment of Public g
LicenSen°a Oep,latlons and Standard,
6
GERARD -I ,2
33 S()TTEEHER '.
Commissioner _ Expiration
11/1r,�2014