162 MARLBORO RD - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of BuildingRegulations and Standards CITY OF
Massachusetts Sta to Building Code, 780 CMR Revised SALE
12011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Osre-or Tsvo-Family Dsvelling
Sect;'oft.F6rO.fflciajQ_sjOnIy.
OnI
Building Permit Number:
Building Official(Print Name) $ignat Date
y SECTION 1:SITE 7t gATION
1.1 Property Alldrgss i f 7 /1 1.2 essors i4lap& Parcel Numbers
1.1a Is this an accepted street?yes no /S�1 Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq Q) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.a.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑" Zone: _ Outside Flood Zone?Check if yesCI Municipal❑ On site disposal system Cl
SECTION Zt; PROPERT1t'OWNEI aP.!
2.1 Ownerr of Reco�r�dd el
Zxj I �/' ice .r > G7 Z E3
Name(Print City,State,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKr'(check all that apply}
New Construction ❑ Existing Building❑ Owner-Occupied ❑ R'epairs(s) Cl 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief ascription of Proposed Work': i
SECTION 4: ESTUNLATED CONSTRUCTION COSTS-
item Estimated Costs: I . Official Use Only...
Labor and Materials)
1. Building S L Building Permit Fee:S rndicate flow fee is determined:
�. f eccrical g ❑Standard._CityrCovvnApplicationFee.`
❑'total Project Cost(Item 6)x multiplier x
1. Plumbing i 2. Other Fees .S
1. ,Mechanical (IIV.\C) g LisC
i. Mechanical (Fire
inp tressinn) _ $ Total All Fees:.$_
r - Check No. Check Amount: C;tslt Auwunt:.
I'utul •nicct CIM 5�. ��� --- --
U P]id in Fall ❑Outstaudim Valance I,t a:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
^ License Number C. pirat' a Dat
N;une of CSL I loldcr _ List CSL Type(see below)
Type Description
No. and Street U Unrestricted(Buildings UD to 35,000 cu. ft.
LCiljyj (� �/ 7C/ R Restricted 18t2 Family Dwelling
cityi"rown,State, ZIP iVl %clasonr
Routin :Over"'
Window and Siding
JF Solid Fuel nurning Appliances
[ Insulation
Nle hune (T) Email address U Demolition
5.2 Registered Home lmprovement Contractor(tl[C)
HIC Registration Number /E. iration Date
f II mpan amer JIIC Regi mn Name
No. nd Street ' ,ram/ Email address
City/Town,State ZIP Pele hone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 152. § 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
I, as Owner of the subject property,hereby autharize
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print owner's Nsne(Electronic Signature)
Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest undcr the pains and penalties of perjury that all of the information
conk ld in this , licati n is true and accurate to the best of my knowledge and understanding.
Print 0%vttwr's or Author,zed.genius NJ me(-lectrume Signature) Date
NOTES:
Owner 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 not have access to the arbitration
program or guaranty lied under M.G.L. c. 112A. Other important information on the HIC Program can be found at
www n:u+.env%uca Information on the Construction Supervisor License can be found at www m;u,.• �IyD
F
hen substantial work is planned,provide the information below:
lourarea(;q. RJ ___ _ cluding garage, tinished basement/attics,decks or punch)
livingarrca(;y. ttl — Habitable room count
r of tircphtcc;.._-------- Numberuf bcdruamsNumberofhalG'batlu[hd.uiug ;y;teou Namerufdack.,,' Itrclues-- -
f Coo ut� ;yacm __.-_— . _... .._ - _ .__. - .-
t ..—' I,itiII'I t ��.itt11 ant.e��'' w.ryhe ;uh,titnt:,IG,r "I'�,cillRnjertC.�—[
I
CITY OFS.I.LZN12 LA.kSS:lCFiUSETTS
l~, ) BL'1LOLNGDEP.ImmNr
,1��..,>�.� I_'0 CV.I3HLVGTON$TitE&T, 31°FT.00R
T$t- (973) 743-9595
,QUIJE2LSY ORISCOLL FL`t(978) Tk-934.5
ilUY01l l�l056t9ST.P1EAri8
❑RECTOR OP?CIRIC PROPERTY/9LELOLNG CMLAUSSIONEA
Construction Debris Disposal Aftldavit
(required for all dcrnolition mid renovation work)
In accordance with the sixth edition of the State Building Coda, 730 C&f•R I t f
Debris, uid the provisions of b(GL a 40, S 54; section .S
Building Permit It is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as dat3ned by,b1GL c
111, S ISOA.
The debris will ba transported by:
l
f
(name urhaulur)
The debris will ba disposed of in :
i
1
1•t1IJ11(�pf a:(nll� .Ij]P ICd1Il
1 J uc I
CITY OF SALEM, 1/Ia-1SSACHUSETTS
BUILDING DEPARTSIE,�iT
!+ 120 WASHIINGTON STREET, 3io FLOOR
' TEL (978)74S-9595
RuX(978) 740-9846
KIJ[BERLEY DRISCOLL THomASST.PIEm
�AYOl; DIRECTOR OF PUBLIC PROPERTY/BUILDL`1G CONMISSIONER
Yorkers' Compensation Insurance Affidavit: Bui)ders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le ibl
Valve(0usi,m &organizaliorrvindividual): �/^,p Z r—/,/
t
Address:
i
City/State/Zip: r� Ma Phone
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 am a goncral contractor and l
6. ❑New construction
employees(full and/or part-time)."' have hired the sub-connactors
2.10 I am a sole proprietor or partner- listed on the attached sheet.t T. ❑Remodeling
/ - ship and have no employees These sub-contractors have Is. ❑ Demolition
working.for me in any capacity. workers'comp.insurance. 9• ❑Building addition
[No workers;.comp.insurance 5. ❑ We are a corporation and its.
required.]- officers have exercised their 10.0 Electrical repairs or additions
3.❑ lam a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself.[No workers'comp. c.,152,¢1(4);and we have no 12.❑ Roof repairs
insurance required.)t employees.[No workers' 13.❑Other
comp:insurance required.l
'Any upplicam that chcv:ka bon el must also nil Out section below showing their wmkm%rnmpenaation policy infli mation.
t I r,w eowne-m whd submit this affidavit indicating they ate doing all work and then him ottni4c eentr adorn must submit a new affidavit indicating such
:Cunraowrs that chcsk this box meet attached an addidonal,had showing the norrne ofthit subi raracton and Their workers'ramp,policy infruananon.
l am an employer that is praviding workers'compensaton hrsarancer for my employee, Below/x the policy and fob site
iujormution.
insurance Company Nine: &1i1�
,
Policy 4 or Self-ins,Lic. H: Expiration Date: '
Job,Site Addruss:744�_ �%G z City/StatriZip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S230.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
l do herebyf' \'lfy under t s pains nd penalties ojperfory that the hrforinatlon provided above is true and correct.
t
Sl=ire• A Data, 1 /
Ni v
Ojr,,!.l we only. Do nor write in this area,to be completed by city or town offleial
City orTuwn: _ Permit/Llccme# _
Issuing Aulhority(circle one):
1. Board of health Z. Building Department 3.City/town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: -
---_--------- Phone B•