The URL can be used to link to this page

171 MARLBOROUGH RD - BUILDING INSPECTION (2) 0 The Commonwealth of Massachusetts I Board of Building Regulations and Standards CITY OF \OY Massachusetts State Building Code, 780 CMR SALEM Building Permit Application To Construct,Repair,Renovate Or Demolish a Revised Mar 2011 \ One-or Two-Family Dwelling Ju\ This Section For Official Use Only Building Permit Number: Date lied: s Building Official(Print Name) ii 6 me Date SECTION 1:SITE INFORMATION 1.1 Property Add as: 0 ss: 1.2 Assessors Map&Parcel Numbers 1 rn G, o R t i rJ I.Ia Is this an accepted street? es_ no Ma Number fe !P Y P Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning strict Proposed Use Lot Area sq ft) Frontage(ft) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided •— % I j 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.S Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if es❑ Municipal❑ On site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Own`er'of Record- S4 ) enyv% M'\Y} C7\fit? C� Name(Pont) city,State,ZIP rn Ya'a k Cr 2 �- `r7'iSYiYy. No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORKr(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify: BriefDescription ofProposed Work': /, .1.-_\2 �2 A— SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Materials Official Use Only 1.Building $ YO b 1. Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost;(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire Suppression) Total All Fees:$ 6.Total Project Cost: $ Check No. Check Amount: Cash Amount:_ Y O ❑Paid in Full ❑Outstanding Balance Due: 4• ,1 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street Type Description U Unrestricted Buildin s up to 35,000 cu.ft. City/Town,State,ZIP R Restricted 1&2 Famil Dwellin M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances 1 Insulation Telephone Email address D I Demolition 5.2 Registered Home Improvement Contractor(HIC) HIC-Registration Number Expiration Date HIC Company Name or HIC Registrant Name No.and Street Email address City/Town,State,ZIP Telephone 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 .......... O No...........❑ 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. Print Owner's Name(Electronic Signature) Date SECTION 7b: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 accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's Name(Electronic Signature) 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 www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass.gov/dM 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.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" CITY OF S.U.&%4 ,N'LkSSACHUSETTS BUUMLNG DEPARTMENT P• 120 WASHINGTON STREET,3=FLOOR TEL (978) 745-9595 FAX(978) 740-9846 KI�t13ERI.EY DRISCOLL MAYOR THOMAS ST.PIERRB DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COSIMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anplicant Information \ Please Print Legibly Name (Busim-ssOrgtnizatiotvindividual): Address: ` 1 m,f- \ h c c�, d City/State/Zip:__ Ste.�� r�H 0 V Phone #:,, rt C77' 7 �7 - �i `f�7 Are you an employer?Check the appropriate box: Type of project(required): I.0 I am a employer with 4. 0 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub contractors 2.0 I am a sole proprietor or partner- listed on the attached sheet. 7• ❑ Remodeling ship and have no employees These sub-contractors have V. 0 Demolition world for me in any capacity. workers'comp. insurance. 9. 0 Building addition [N workers'comp. insurance 5. 0 We are a corporation and its quired.] officers have exercised their 10.0 Electrical repairs or additions 3. 1 am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs insurance required.]t employees. [No workers' l3 0 Other comp, insurance required.] •Any applicant that checks box 91 most also rill out the section below showing then workers'compensation policy infumution. r I tomeownen who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such 'Contractors that check this box most attached an additimind sheet showing the name of the aub-contractors;and their workers'comp,policy information. I am an employer that is providing workers'compensation insurance for my employees. Below Is the poiley and Job site information. Insurance Company Name: Policy#or Self-ins. Lie#: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers'compensation poilcy declaration page(sbowing the policy number and expiration date)- Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the forth 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 Investigalions of the DIA for insurance coverage verification. I do hereby cortno under thepalns anted penahies ofperjury that the information provided above is true and correct. Si mnum G Date Phone#: / 7 Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/License# Issuing Authority(circle one): 1. Board of Ilealth 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone#: 1 CITY OF S.U1 F—N[, Akss.1CHC'SETTS ©L'tLDLYC DEP.1RTtE\1 120 W.kiHLVGTON STREST, 3'Roo it rEL (978) 741-9599 K1J®ERf RY ORMOLL F.IX(978) 740-9846 MAYOR DIxE THasr.0 ST.PMUS L-tOR OP Pl afjC P1tOPH1tTY/8L: DLNG CONNISSIONER Construction Debris Disposal Att7davit (required for all demolition and renovation work) In accordance with the sixth edition ofthe State Building Code, 780 CMR Debris, and the provisions of MGL c 40, S 34; section 1 I i.l Building Permit M is issued with the condition that the debris resulting from (his work shall be disposed of in a pro i 11. S 1 JOA. perly licensed waste disposal facility as defined by NIGL c The debris will be transported by: �,liL l ( 7n4M4 of hauler) The debris will be disposed of in C` ("'�' ^ M n S C (�ddre�i of Fud,iY) + yn.mre ofpermrt ipphc.nt G