18 MANNING ST - BUILDING INSPECTION The Cummon%callh of Massachuscts Town of
Board of Building Regulations and Standards
/� Massachusetts State Budding Code, 780 CMR, 7'6 edition ifamdo
g Detp~i
Building Permit Application To Construct. Repair. Renovate Or Demolish a i
One- or Tuu•Funufr Duelling
Thq Section For 1licial Use Only
Building Permit Nu X Date Applied:
\ $IgNNfe:
Budding ommt stun r/ s 4811ildings Date
S TION 1:SITE INFORMATION
1.1 Prre Add t— 1.2 Assessors Map d Parcel Numbers
I.1 a Is this an accepted street-. yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zonng District Proposed Use Lot Area(sq n) Frontage(N)
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.40.154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site disposal system O
Public O Private O Check if es0 y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owy�f Reeoxd;UMs/ /p ?�/�'
lG�l L ,r OO
Name(Print) Address for Service:
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied O Repairs(s) O 1 Alleration(s) O Addition O
Demolition O Accessory Bldg.O I Number of Units_ Other O Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical S 0 Total Project Cost'(Item 6)x multiplier x
J Plumbing S 2. Other Fees: S
J. .Mechanical (HVAC) S List:
S Mechanical (Fire S Total All Fees. S
Su ression
/�yy heck No. _Check Amount: Cash Amount:_
b Total Project Cost: S P— -�V� ❑Paid inFull ❑Outstanding Balance Due'
Z
SECTIONS: CONSTRUCTION SERVICES
S.I Lic nsed Construction Supervisor(C L) /
Q' Lacnse Number Esp/I Ju)on Date
N .I Ft�lder� ,,/ List CSL T v
TVPC I Description
Address
U Unrestricted I up to 35,000 Cu. Ft.
R Restricted 1&2 Family Daellin
M Masonry Only
ll RC Residential Roolinit Coverm
Telephone w'S Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Instillation
D Residential Demolition
5.2 Regl;le{egA0:7 Improve) �Comncjgr(HI ' � 7 9�
HIC Co (J/Nf a�IC R gtsCtrant Name Registration Number
Address ter—
Expiration Date
Signahue Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 132.1 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
I
affidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes.......... O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I 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.
Si attire of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I , 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. (t
f✓
Print Name n
/G� 7
Signature o ner or Authorized A Date
Si ned under the ams and penalties of r 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 MW 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 I MRS. respectively.
2. When substantial work is planned, provide the information below:
Total Goon area(Sq. FI.1 (including garage, finished basement/altics,decks or porch)
Gross living area(Sq. Fl.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halfbaihs
Type of healing system Number of decks/porches
Type of cooling system Enclosed Open
3 'Total Project Square Footage" may he substituted for-'Total Project Cost"
eta CITY OF S.1I.EM, Aus kcHusETTS
r B1:aDLNG DEPARTM&NT
120 WASHLNGTON STREET, 3se FLOOR
TEL (978) 745-9595
FAX(978) 740.99"
KIJBERIFY RISCOl1
,LEY D DR THOh1A4 ST.P[EM
DIRECTOR OF PLBLIC PROPERTY/lIUMDING COWNRSSIONER
Workers' Compensation Insurance Affidavit: guilders/Contractors/Electr(cians/Plumbers
A s licant Information Please Print e 1
Naine (ousins ortanizatiomiri,hvtdual):
Address:
City/State/Zi • IW Phone* o5_1r='3G'��
,%re you to employer?Cheek the Appropriate boa: Type of project(required):
I. a em to er with 4. ❑ I am a general contractor and 1
P Y 6. ❑New construction
employees(full and/or part-time).• have hired the stebeonttactor
2.❑ 1 ain a sole proprietor tar partner- listed on the attached sheet : y- ❑ Remodeling
ship and have no employees The=sub-contractors have it. ❑ Demolition
workingfor me in an cps i worker'comp.insurance
Y Pac tY• 9, ❑ building addition
[No worker'comp. insurance S. ❑ We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repair or additions
3.❑ 1 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.❑ Roof repairs
insurance required.]t employees. two workers, 13.❑Other
comp. insurance required.)
.Any applicanl this chalu 1101 Of muA alas rill out tlw tepsrioa below ahowisg Thalia worlass'compensariwt policy infumwion:
'I hwwasmers who subsoil this affidavit indicting they ar doing all work and thm him ousside c rrsea mo muu salmis anew allldavit inditasins such.
:C.,m muss shot chrek This bops mud attached an m Imial rheas showing this tmme of Ills wb. hsinsbn and their walnuts'comp,poliey iafantmow.
/am an employer that b providlnir workers'rompensazbn lnauranee fer my employees. Bdaw b fht pol4y atrd/ab alp
information.
Insurance Company Name:
Policy Nor Self-ins. Lie. p: Expiration Date.-
job 5ite Address: Cityistate/Zip:
,%pack a copy of(be workers'compensation Policy declaration page(showing the policy number and expiration dab).
Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a rise
of up to 5250.00 a day against the violator. lie advised that a copy of this statement maybe forwarded to the Office of -
Inc chi sat ions ol'dte MA for insurance coverage verification.
/do hereby certify stood a ins d pe a/! perjury that the information provided above is true and Correct
';i,•r I Ir Dute:
Phan �:
? eclf--3AL
-
iOffifWMI use on/y. Do nor ratite in this area,10 be canlpleted by city or town ojflCild
City or fuwn• _ _
_ Permit/LlcenseN
Issuing.%ulhonly (circle unc): j
I. Iloard of Millis 2. Ruilding Department 3. Glylfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
l_onlact Person. _ ___ __ Phone ill:
CITY OF SALEM
< 5 PUBLIC PROPRERTY
r' DEPARTMENT
�4V!et
nI'.I r.!NI I'.1''•N Iw. '•I 1.
120 W.V I II.\Y.I ON S IRLET ♦S.\I r\1,tit.\S1.\(I It SI I I,J 19!'
'fEl: )78-743-9595 • 1':\s:979-74C19846
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 ft is issued with the condition that the debris resulting front
this work shall be disposed of in it properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by:
l2 C-'
,47 (name of hauler)
The debris will be disposed of in
(name o((aci ity)
(address of facility)
signature t pe applicant ICI'
date
Jebn:all d,e