13 MALL ST - BUILDING INSPECTION (3) v
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The Commonwealth of Massachusetts
Gourd of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
o+ Revised t/ur 2011
Building Permit Application To Construct, Repair, Renovate Or fish a
(bee-or Two-FamilY Drvellok
i
This Section For Official Use On1 /
Building Permit Number: Date App ' d:
Building OBicial(Print Name) Sign ore p;tt
SECTION I:SITE INFORMATION
i.l PropMrerty Address:av1 1.2 Assessors Map& Parcel Numbers
\3
L la Is this an accepted street?yes_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
w
7)nml;District Proposed Use Lot Area(sq 11) Frontage(It)
I.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Lune? Municipal ❑ On site disposals stem ❑
Check if,�es❑ >`
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner of Record: 1
Jd� RTT SNC �Jllti• CP, SLY1C-M M/} . G
N;mte(Print) City,Slate,ZIP
15 M 0,-tl 54-
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK](check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
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on 5 J4
SECTION 4: ESTIMATED CONSTRUCTION COSTS
ReinflJC03
Estimated Costs: Official Use Only
Labor and .Materials) y
I. Buildi 1. Building Permit Fee: S Indicate how fee is determined:
'. Electri ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier .xi. Plumb �. Other Fees: Sq. .\leehu Lisl:,___Icehmtressi 'futal :\IlFees:SC'hcekNu. Cheek:\mount: Cash:\nt:Total f.2f UUQ ❑p;tid in Full ❑Outstanding Balance Due:
Sy
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction upervisor License(C'SL) 1
nn CC [Jecnsc Number Ifspvaoon Uatc
Nanc of C'SI. I[Older
Li L sl C'SL T)pe(see below)_� _
�" tJ�� J-S'— T% Description
No. and Strect
�•��, c�y� U (Inrestricted(Buildings u to 35,000 cu. 11.)
SI ( 1�1\R ` 1 U ___ Restricted M2 FamilyDwellin g
C'n"I %n LIP NI Masonry
RC Rooling Cmerin
W'S Window and Siding
Qr SF Solid Fuel Burning Appliances
�`�Y 7� "�0�1 I Insulation -
'fcic hone Email address D Demolition
5.2�egistered Home lmprgv went Contractor(HIC) �s-� 7,5— /
U n A s s C 4�) 11�( I IIC' Registration Number Iispira ion Dutc
I IIC C ompa ) Nano or I IIC Registrant Name
4
No. and Street Email address
City/Town. State,ZIP "felt hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.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...........❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
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I, as Owner of the subject property, hereby authorize -C"i4N0 t P `/— NA &s
to,act on my behalf, in all matters relative to work authorized y this building permit application.
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/"\P,-T-T rOfl1hg ('-A4
Print Owner's Name(Electronic Signature) 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 application is true and accurate to the best of my knowledge and understanding.
Print 0%%ner's or:\uthorizcd Agent's Name(Electronic.Signa(ure) 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
Information on the Construction Supervisor License can be found at y , ,moos?g0 dps
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(sq. tl.) Habilable room count
`'umber of fireplaces.--- Number of bedrooms
Number of bathrooms __ _ Number of half paths
I)peofhe:uingsystem _.�_ _ _-.._.- ---- ....__ __.._----_. ....
1\lie ofCoolingS�slcnl Inclosed Olion
1, "fotul Pmajcct Square Footage"may he substituted for-foIal Project Cost"
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CITY OF S'U.E.NI, NWs.-ICHusETrS
BLLUMNG DEPARTMENT
110 W.ISHC4GTON STREET, 3i0 FLOOR
I-EL (978) 745-9599
Fia(978) 740.9846
KIJ®ERLSY DRISCOLL
MAYOR T140mu ST.Pma s at
DIRECTOR OP PLBLIc PR0PEATY/9t.:=LYG 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 c 40, S 54;
Building Permit M 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
l 11, S 150A.
The debris will be transported by:
Na�ti S��c; C�r�'lu
(name of hauler)
The debris will be disposed of in : r
AU 7-L ,y C)
(name of facility)
/ 3 44111/ 5�
(address of facility)
signature of permit applicant
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/ date
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