68-70 LINDEN ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code 78 CMR Vh edition OF SALEM
7 g 0 cd
Revised Junmrr
� Building Permit Application To Construct, Repair, Renovate Or Demolish a /. +oox
1
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: 3,
Signature:
Building Co missioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
1,,��Pproperty Addres/s: �/ 1.2 Assessors Map At Parcel Numbers
fJCJ 9_> LI i✓ SV `?i Z l S
1.la Is this an accepted street?yes_✓no Map Number Parcel Number
1.3 ning Information: 1.4 Property Dimensions:
�Z 5,0
Zoning District Proposed Use Lot Area(sq R) Frontage(11)
1.5 Building Setbacks(it)
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:
Public Private O Zone: _ Outside Flood Zon 7
Check if yesf Municipal 0 On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 'or Record: Q_C�
Name(Print Address for Service:
97e- 2; Ys- 1'8 S
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK?(check all that apply)
New Construction O Existing Building T1
Owner-Occupied ❑ 1 Repairs(s) el Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.Cl I Number of Units__ Other ❑ Specify:
Brief Description of Proposed W rk LAe..✓ L4,
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S /OO ozrc� 1. Building Permit Fee:S Indicate how tee is determined:
❑Standard Ci !Town Application Fee
2. Electrical S Z S U ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S \ k
4. Mechanical (NVAC) S List:_
5. Mechanical (Fire Suppression)
S Total All Fees: E V
Check No. Check Amount: Cash Amount:
6. Total Project Cost: S �z ��c7 ❑Paid in Full ❑Outstanding Balance Due:
r di d( z6x
t
r
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Constructions Supervisor(CSL) C
?_ z. ["/✓S (a= License Number Expiration Date
Name of C'SL- I lulder List C'SL'fype(see below)
r Dewri lion
Adds �t - U llnrcsuicted u to 35,000 Cu. Ft.
R Restricted 1&2 Famil Owellin
'i aturc M Mason Only
2, ���- ��i RC Residential Roofing Coverinit
felcphone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Insiallauun
D Residential Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 2SC(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...........13
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 to act on my behalf,in all matters
relative to work ized by this building permit application.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
1 ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name _
Signature of Owner or Authorized Agent Date
(Sixned under the pains and penalties of 'u
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_W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.116 and 110.115, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/attics,decks or porch)
Gross living area(Sq. Ft.) 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 of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF S. .E.tit9 IINLkSSACHL:SE-M
aLmDLVG 0".IRTILNT
I'_o W.\9NI.VGTaN STuir. Y FLooR
TEL (978) 74i9S99
F.%x(978) 74496"
KBCOEALEY DIIISCOLL 7110sugST.1"a2lRR
gAYOIL DlnaeratO/neLK PROPERTY/N RDLVGCO-%L%nssICLNFA
Workers' Compesssttoe Insurance Af ldeeit: guilders/Contractors/Eteetr(elsnsr'Plumbers
A,le Meant lnrsrmatlols Mesa Pr(ltt Lesribht
V�t11e1tluur.nr.Orw�rsnawlnJrvrdtull: ��'�- ��s � _
Address*•
City/State/Zip: Morse
.\re you as employer!Cbsek the apprgrtaa beat Type of Project(regdreO
�. ❑ I No a ganenl c000wW and 1
1.(3 1 am•canPloyet with tr C3 Net c 'oe
alnployew(No and/or pan-dow).• have hired rho sub.contracae
2.❑ 1 am a wed prsprielar or partner- listed an the awadrd farces 2 7. eneodaling
;hip oral have no employe" Tlwo sub-comnemre hero R Q I]nnnlitlae
worbin rar me in an c \vorkes'comV6 irtwaaca
g y l S. ❑ We am a e ad is 9. Duihluy addilioe
(No workers'comp. irrwranco °
otYkws have elsaeisod their 10.❑Eteariratl repairs or addition
rc
). am a ho neow"w doing sill wank rifle of per MOL I L[3 Plumbing repain or additions
myself.(wale workers'comp. C. I3Z�1(4Lsell!s we hoes no 11(3 Roof repoirs
insurance required.)► .mpl 3 (Ne wood ass' 1).❑Othor
ca eura aP,innw regain M&l
•.,+y appwe+'~ctarshe am et nwtel Awe to wr tlo elatlm aelew a' ' Pans waehew•opgomo im PO•r inamwAdes.
'I Gwmrwmw who ruawe doh allldwit wAldq Ihey an aows an wells ad does No wMide mereeelr~rrAN&a rowel arerWls wa4aiw are►
dr cbells iW M miss awwAml m aN'iw.a Ji-&Aawly the free error wismeraw end ih*wraw•rwrF VoWky iwrer
law eel torV/sys rbet tr�r.rJd/wg tewbers'cew/ewmrlew/wsenweefM rV satPelayees edlkrar 6 till PAD swd/M�s4s
informadm //+�//
InNrrance Company Vame'U .n
Policy e or Sdf.inL Lie.M: Eapiratioe Darr.
Job Sin Addmar CityiglawZip:
mrseh a espy of the werbn'compeoafte Valley da host se pop(sbewing the Polley aembaf and eeplratlee daft)`
Failure to socirtecover p as required under Seetlon 23A of.MGL a. 132 can lead to the Wpoekiae of criminal pmalries of■
fine up to S 1.J00.00 and/or one-year imprisonmeneo as well as civil patakies in the form of a STOP WORK ORDER and a Ras
Of up to S230.00 a day ivainse the violator. Ile aiM.*W that a cupy of this stage rMn1 maybe forwarded to rho OtYleo of
h»c.nyariuru,af due nlA for insurance cowntpt.vilkatioa
1,10 hereby eertify uw/M rA 'war rod pens/Nes a Rer/eq Mer sAe injerwwr/ew preri"ubw is ffw4eel a w►ed
i
:3 /v
OQlcid ne un/yt ne not write in this urewl/i be•wwp/i/d by ai y of Nwve n//lriud t
City or ruuvn: -
Lsuint.\ulhonty Icircle une►:
I lluard u(Ilrallb 2. Rwlrllny nvparrmwal ). City/rows Clerk A. electrical Inspector S. rlumbine In•peenr
6. other
L�,.dsct rcnon: . _ -. Phone s:
J
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
1',11: MIS\ '•Mlv,'dl
\I .n'P a141 M.70-riy •,I:IVt'y711743-9 46
I'rt:�7t-7 .
Construction Debris Disposal Affidavit
(required t'ur all demolition;utd renovation work)
In accurdance wish the sixth edition of the State Building Code, 780 CMR section 1 I I.S
Debris, and the provisions of MGL c 40, S s4;
_ , _ is issued with the condition that the debris resulting from
Dui Wing Permit H f in a properly licensed waste disposal facility as derined by MGL c
This wink shall he disposed o
111. S 1 st)A.
The debris will be transported by:
oAS-v— 2�C z
s � Q.
,narna ut'hauler)
The debris will be disposed or in :
?e4 ��
n;uneulacilty .
,aaamxllr raCdityl
,Ianaturo of immit applicant
/ ' 3 / ` D
.late
1 ..issachti.c,y, - Dcpartutcm nt Public sarell
�Q) No:u'd of Building Rc�ul:Uiom :tnd `landards
�-/ Construction Supervisor License
License: CS 69780
Restricted to: 00
ERIC M EASLEY
PO BOX 4542
SALEM, MA 01970
c—
y'J�` Expiration: 5/3/2oll
..nun i—i.m,.r Tr7: 15316
i