106 MARGIN ST - BUILDING INSPECTION the Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
N OF SALF:M
tty j Massachusetts State Building Code, 780 C'MR, 7 edition Revised Junuury
Building Permit Application To Construct:Repair, Renovate Or Demolish a
One-or Two-Fu ilv Dwelling
This Sectio For Official Use Only
Building Permit Numb Date Applied: �7 7 G
Signature: 1'jr �! t>
Building Commissions/Ins t of Buildings Date
SECTION 1:SITE INFORMATION
/ 1.1 Property Address: 1
1� 1.2 Assessors Map& Parcel Numbers
J< l0(o N/X�la/N S'T.
I.la 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 11) Frontage(ti)
1.5 Building Setbacks(R)
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: 1.3 Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es0 Municipal O On site disposal system O
SECTION2: PROPERTY OWNERSHIP'
2.y�-,,Ownert of Nt�ord•--1(�� � � !"�'1
l-sti2�fJ (,(crcLfyat'-OILI �� n! � " � h Sri
r
X Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building O Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other O Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: 011lclal Use Only
Labor and Materials
I. Building 5 I. Building Permit Fee:S Indicate how tee is determined:
❑Standard CityRbwn Application Fee
?. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (IIVAC) S List:
S. Mechanical (Fire 5
Su ression Total All Fees:S [��
Check No. Check Amount: Cash Amount: t `�
X 6. Total Project Cost: S d f ���) ❑Paid in Full ❑Outstanding Balance Due:
s lr—r7 1 a F Herz�/,�/
v
it
SECTION s: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervlsor(CSL)
License Number
VV Expiration Dale /
Name of CSI.- I lolder I.ist CSL Type(see below)
25 S Sy � <-T Eau srtl2
rioe Description
AddI ss U (Inmiricted(up to 35,000 Cu.Ft.
-- Restricted I@2 Family Dwelling
Signature£3 M M Only
61? 2i 03P RC Residential Roofing Covering
I"elephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
s.2 Registered HomtJe Improvement Contractor(HIC) ' Z�i353
CUB/fKlc� Cr✓y ST72� G rtG rJ
HIC Com any Name or if Registrant Nume Registmlion Number
z� S Svyf., sr.
Ades 617 C345 Expiration Date
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. I52. f 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 ..........O No...........O
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.
Sianatum of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
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(honer or Authorized Agent Date
ISianed under the pains and Penalties of 'u
NOTES:
1. 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 rW 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.
?. When substantial work is planned,provide the information below:
Total floors area(Sq. Ft.) (including garage, finished basement/anics,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"may be substituted for"Total Project Cost"
at
�t tssachusctfs- Dcp:n7tncnt nl public d�t1y
' . Board,nl .Ruiidin RcCulitionv �utd St ndirrd$''
'ConstructiottSupervisor License• ,,
License: CS 898M
Restricted to: 00
DANIEL ZIMMERMAN:
25 SO SYDNEY ST APT 1
DORCHESTER. MA 02125 '
�-•G !y j� Expiration. 9lJ/2010
'('onunissidhct-. e
Trp:,3821 ,
BuBra ofeg(N`lPn�aBo�f!•sa n r s r;
_ HOME IMPROVEMENT CONTRALTO `fit;i
.;n:. Registratlori0. 146444.:
? Explratlon. 4/27/2011 Trill 283531a
�Y Dan
COMMON CONSTRUCTION +
DANIEL ZIMMERMAN=
25 SOUTH SYDNEYST Al '
•. DORCHESTER,MA 021 Administrato' t,
.m
CITY OF S.U.&M9 NLASSACHUSE'I'I5
BL'D.DCIG DP�.6gT1t'r iT
120 W.UMMIGTON ST%Zffr. )"s IZOOR
TM (979) 145-9599
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Address: 25 �a✓T/ I
City/StatuZip `1� 12c I 1 5 7�2 M/� _ Mwe>•N: �7 �2( G 3�I S
F
mpley�!Cbmk the appeepr/aew tees Type of project(re9W►M'
mpleyw with f. Q 1 ata a gtmerni cmernesor awl 1 b, ❑Now coesaueum
ce(1w andtor pars-rinse)-' have hired tie MAKWw can
listed m tit atttrchad Beret= y. Q Rer a t"ing
ole ve =canp.r eyes o- These ste►eownear s hove s. Q Do.. itiats have m oopbys�far me is any capacity. workers'eompoinwnaott 9. Q Dreil ling addhimken'coop`inJIMMlsca S. Owe see a cooponalm seed is I O.Q FJaearical repairs or
roquiradl offs have etawdwd date
S.Q 1 am a horeuowner doing ad work ^tllM eyff1eP�Yee M� 11.❑Pltetrtking mpeirs orsdttltlean
myself INe workers'comp. r- 13%f 1(4)L and we have no I2.Q Reertepsers
insururcarequired.)-a mplOyew&INewam' IS.QOshee
camp Inouance regleieeil
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In.uranceCompany Name: riyMl A/UCE Sf�FG//�/!S�
Policy e or Self•ina. Lie.p EsPirasion Daw.
tub Sim Addr6ae: City/Stawzip:
,%teach a so"of the workers'compansatlse PONY daifinli n pop(skewing Ike pellet'number and eapbatNn ditto)6
Failure to scum coverage so required under Sall"25A of NOL a 152 can lead to the imposition of criminal ponaldes of■
rine up ro S I.500.00 and/or one-year imprisom"Otw+L wed an civil peaskies in the fares of a STOP WORK ORDF.A artd a floe
Of up to s:So.00 a Jay aWinst the violator. lid 3dviwd that a wpy of this oagemenl maybe furwurded to the Ocoee of
In.otrymiu+u +t'rhe f7lA for insutanco cov.rap v yilk,twa.
/dM AweJy rraJ/j maAw the pwias end pear/e%s wjper/a7 der rAw ia/eratedow proedtlwd v#~is cow wad ertwreea
. .•n mrr Y_ Ours:
P`+rnt a•
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Gry or ru+tte: errmk/I.Ieearf
ICeuent.%urhenty Ieirele inch
I ItuarJ u(Ilvallk 1. Rudding Mpartmvnt ). Cityrrowe Clerk J. fleciricaJ Impector S. Plumbing Inepeetor
6.thher
l•,utad Person: _ _ _ Pllone At.
r
CITY OF SALEM
PUBLIC PROPRERTY
i -6�1 DEPARTMENT
IFI:w }1.4%VIleP\t:%76:�Sa11M
Construction Debris Disposal Affidavit
(R.yuired fur all demolition ultd mnovrtion work)
In •rccurll:urce with the si.xlh edition of the Mate Duildin`Code, 730 CMR section 111.5
Debris, and the provisiuna of MGL a 40,s issued
MGL e
Ouildinl{ Permit N _ is issued with the condition that the debris resulting ftom
phis work shall he disposal of in a properly Gcamd waste disposal facility as deflncd by
111. S 150A.
The debris will be trunsportcd by.
JAB �n.i-7�ac rr�
1,urea ut hauler)
'1'11e debris will be disposed of in :
N - , Inor-e_ �GtOtt��
(nam 01 act ay
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, analare id Iwrniir�pyli►,rM
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