3 LOGAN ST - BUILDING INSPECTION The Comnionwealth of itfassachusetts
Board of Building Regulations and Standardsja
SALEM
I)( crrY OF
Massachusetts State Building Code, 780 CMRSALEI 2011
Building Permit Application To Construct, Repair, Renovate Or Demo
One-or Two-Family fhvelling
This Section,For Official Us , rif
Building Permit Numbet: Date Ap t d
Building Official Print Name
g ( ) Signature. Date
SECTION 1:SITE INFOMN ION.
1.1 Property Adriress: 1.2 Assessors b[ap 3t Parcel Numbers
�LO6ft") �i.
L l a Is this an accepted street?yes f/ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(it)
1.5 Building Setbacla(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided '
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public 0`� Private❑ Zone: _ Outside Flood Zone? Municipal 0 On site disposal system ❑
Check if yesEl
3ECTIONZ; PROP.ERTL''OWNERSHD?!' '.'
2.1 Owner'of Record: n
1 k"Ma CaDITI t�7S e/'Mot �6j-
Name(Print) - y.. e �� City,State,ZIP
{r%►1Ck2 PLAG&13aSTotJ,M 4,1100 (00-90T-)90/ aP a)LC ASH J( c/s
No.and Street j Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSEDMORKs'(check ail that apply)
New Construction ❑ Existing Building Owner-Occupied Q R'epairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition Q Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed kVorka:
4. G/ ab
I Mai J
SECTION 4: ESTINLaTED CONSTRUCTION COSTS
Item Estimated Costs: Of
Rclal Use Only..
Labor and Materials
1. Building ; �j i 1. Building Permit Fee:S' '' Indicate how fee is determined:
2. riectrical ❑Standard..City/town Application Fee,
❑Total P'roj'&t Cost'(Item.6)x multiplfer x
3. Plumbing i 2. Other Fees S
1. ,Mechanical (IIVAQ S List:
i. ,Mech,mic.il (Fite -
inF. ttes,ion) S l'otal All Fees: .S_
Check No. Check Antuunt: ___Cnsh :\umunc
i 1'ut:11 Prnicct twit S G / , --
y�.Cr(i, f (] I wl in Pall 0 Uufstnndin, II il:tnca Une
SECTION 5: co.wi-RUCTION SERVICES
5.1 Construction Supervisor Liecuse(CSL)glow �
License Number Gsp ratio Date
Namc of CSL I folder List CSL'rype(see below)
/3 6fN7dl� AN4= -- rype Description
Nu. and Street U Unrestricted �uildin s u to 35,000 eu. 11-
K RastrictedlSc2F,unil Dwellin
City/town,Stute, Z, r IP A§M
overinnd SidinSF SoliBurning Appliances
Insu
'fele hone
Email address U Demolition
5.2 Registered Hone Improvement Contractor(H1C) r7 j
III it,
Number 7Ex7pinuti Date
I IIC Coon any Name or II�C gi ant Na ne
No.ar�Street Email address
Telephone
1�/!
City/Town,St , ZIP aff
SECTION 6: WORKERS' COMPENSAT(ON INSURANCE AFFIDAVIT(NI.G.L. c. 152.1 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........:••0
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 authorized by this building permit application.
Date
Print Owner's Name(Electronic Signature)
SECTION 7h: 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 a•curate to the b' t of my knowledge and understanding,
Print omicr�i ar Authuri[ed:1-1111 s; am (Electronic Signah �)
n, e
NOTES:
I. r1n t)vvner who obtains a building permit to do hisiher own work,or an owner who hires an unregistered contractor
(nut registered in the Home Improvement Contractor(HIC) Program),will !tat have access to the arbitration
program or guaranty fund under LMLU.L. c. 142A. Other important information on the HIC Program can be found at
www m:ua.,�uv%oca Information on the Construction Supervisor License can be found at www.mas.�v_,IL
2. lVhen substantial work is planned,provide the intormation below:
total floor area(ml. 11.) (including garage, tinished bascmcnttattics, decks or porch)
tiros; living urea(;y. d.) Iiabitablo room count _
(-jrosili Ottll'ica(sq_.._—_._.—___._ \Itlllll)er of bedromns
>Iumbcr of batllrnullls _ Nuulber of lrlltb:uhs _—__------
- — ----
I pc of he.lting ;y talll Number of lack. ' parches
_ --—
Eucla;et I pen
I'ny.rt '�,pl.Ile M.WC" ❑LIV Ile i1 I"Illltdd t,'l I"t.11
CITY OF S•1. ZNf, ;tiL1 &wfjUSETTS
) t� t OttLOcfC DEP.IRTJIEVT
,1�.��� �,t I_'O CV.hHLVGTON STREET, 3'°a"BOOR
rEL (978) 745-9595
(CIJCOERC EY 0 USCOLL FUt(978) 7-W-934S
i L�Y01; CH01G19 sr.PIER"
0MECTOR OF PtOLLC PROP ERTY/st=NG Cox allSstONER
Construction Debris Disposai Aff7davit
(required e0r all demolition and runovntion work)
In accordance with tha sixdl edition ofthe State Building Coda, 730 CL%fR
Ocbris, and the provisions of MGL a 40, S 54; section 111.3
Building Permit y is issued with the condition that tha dabtis resulting from
this wnr!c shall be disposed of in a properly licensed waste disposal facility as defined fll re ul ttig c
I I t, S 1 SOA.
1'hc debris will be transported by:
(nimc ut'haulur) �—
The debris will be disposed Orin
---
(name or(jedity)
Amrw
(, t','Cla of
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;i tamrewV,.mi .t
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L�it uc I
" CITY OF SM E11, l Ia'iSSACHUSETTS
BUILDING DEPARTI1ENT
t 120 WASHIINGTON STREET,3"FLOOR
T L (978)745-9595
FMX(978) 740-9846
KI.,(BFRT RY DRISCOLL
MAYOR T Holius ST.PtERRH
DIRECTOR Of PUBLIC PR6PERTY/BUILDI1NG COMMISSIONER
Workers' Compensation Insurance AfFidavit. Builders/Contractors/Electricians/Piumbers
annlicant Information T I' Please Print Legibly
Name(Business organiratiorvindividual): 1 A' r� �'t� &_4&AgtKLt
Address: 46'_ W I.AAA 6 t 7
City/State/Zip: hlltf✓/b /' M746 Phone#: g?79 'J731-ela9
Are�ou an employer?Check the appropriate box: Type of project(required):
L(^ 1 am a employer with_�_ 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time),* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. ❑Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working,for me in any capacity. workers'comp: insuretam. 9, []Building addition
[No workers'comp.insurance 5. ❑ We area corpomtion and its
required.)- officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL - 11.❑,�,��Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12 'of repairs
insurance required.]t employees.[No'workers'. 13.❑Other
compi insurance required.]
-Any applicant that checks bus sl most also fill out the sections bclow showing their worked compensation policy infurmotion.
I htmeuwnera whosubmit this affidavit indicating they are doing all work and then hit*oulsidecontmcton mast submit a new affidavit indicating such
=Commeton that chuck this box most attached an additional shoal showing the name of the subs ntndas and theirworkero'comp.policy information.
1 um on employer that is providing workers'compensadon insurance for my employees Below/s the policy and job site
ierfornraNan.Insurance Company Name: 4O,ta -V micAN, 1611,
Policy N urSelf-im.Lis N: (�,1G�— ✓-gS'J�3 Sa I'G Expiration Date:
Job Site Address:. .9 C4&402 c7C City/State/Zip: M4 C�?91l
Attach a copy.of the workers'compensation policy declaration page(showing the policy number andTexpiration date).
Failure to secure coverage as required under Section 21A 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigatiatts of the DIA for insurance covcraga vcriticution.
1 da hereby ,er fy under the ns and penaldes of perjury that the btfarmurlon provided above is true and correct
hater 1, .7
Ofjicid use ady. Do not write in this,area,to be completed by city or town aJJkiat
City or Town: Permit/1.1cense#
Issuing,%uihority(circle one):
1. Board of llcalth 2. Building Department 3.Cityfrown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: . Phone fi: