172 MARLBOROUGH RD - BUILDING INSPECTION - The Commonwealth of Massachusetts
OF
Board of Building Regulations and Standards CITY S M
Massachusetts State Building Code, 780 CMR
4 / � Revised dMar Mar20Il
O \ Building Permit Application To Construct, Repair, Renovate Or Demolish a
I One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: _ .. ::Date Applied: -
ui ding Official(Print Name) ' Signature. Date
SECTION 1: SITE INFORMA
Ll ProperX Ad'tss: I (�, 1.2 Assessors Map&Parcel Numbers
�r]2 /"It?if, C2 rm h JT
1.1 a 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 ft) Frontage(ft)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIPxj
2.1 Owner'of Record:
be-11m.-a.j. ctn � Crx a vvt
Name(Print)'^n ( City,State,ZIP
1:7 Y'IQ� nv M vn Sj- 978 85.5, 71
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=.(check all that apply) . ,
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) X I Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work : a Aa _ v v-Pm,t�^s —rcrrnve_ wall
cros+t.-ttvt n�'�'�-� /�) s spa.:..{��`cu�� �1•.;nyl4_, l� ��.e-cJ� wi riw
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only `
(Labor and Materials -
1. Building $ O00 1. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ l 2GO s
❑Total Project Cost (Item 6)x multiplier - x
3. Plumbing $ 10 0 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ .
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ 3 2, \0 o ❑Paid in Full ❑ Outstanding Balance Due: '
(��/✓�7CCJ�.�cifJ�f�it_'E�(JISI�-
' SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS
�� _�y�� License Number Expiration Date
Name of CSL Holder l
11 ( aa List CSL Type(see below) L)
�'Tin.,e+�td IMF Type Description
No.and Street
U Unrestricted(Buildings up to 35,000 cu.ft.
R"'J ti Ot A 7 R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
;N V.2 2722A i t iT�,�COYN is t h I Insulation
Telephone Emat address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
$e.t.si- L� w 0, lte7oz5 B-2-12
HIC Registration Number Expiration Date
HIC Com$any N e or HIC Registrant Name
No..�gd Street Email address
Cx�d P1A(o� 7BI y�z 272 8
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 .......... ❑ 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: 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.
",.a, 4.,,.� b
Print Owner's or Authorized Agent's Name(Electronic Si ature) Date
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 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.uov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dos
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"maybe substituted for"Total Project Cost"
i CITY OF SALEM, i1vWSACHUSETTS
BUILDING DEPARTNEENT
p• 120 WASHINGTON STREET, 3w FLOOR
TEL (978) 745-9595
FAX(978) 740-9M
KIJIBERIEY DRISCOLL
THOMAS ST.PIER
MAYOR RIi DIRECTOR OF PUBLIC PROPERTY/BUILDING CO?L%aSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name tBusiness:Organizationilndividuaq: 1,0J) Ti&VU6,14 �tn1�•-v��t.e�p ILG
Address: 6914 . e,�,ll c.+
City/State/Zip: "it&er mwP,/ 7 Phone M: 7�e) gA42 2?2-F3
Are you an employer?Cheek the appropriate box: Type of project(required):
1.❑ 1 am a employer with 2, 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors tit
2_❑ 1 am a sole proprietor or partner- listed on the attached sheet.t ?• tpl Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workers'comp. insurance S. ❑ We are a corporation and its
officers have exercised their 10.❑ Electrical repairs or additions
required.]
3.❑ i am a homeowner doing all work right of exemption per MGL i l.❑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' 13.❑Othet
comp. insurance required.]
'Any applicant That chocks box NI must also fill out the section below slowing their workers'wmpensuion policy infunnation.
I fnmeowren who suhmil this affidavit indicating they are doing all work and then hire outside cant actors must submit a new,affidavit indicating such
=C.'amra�mn that check this box must attached an:dditiwtal sheet showing the na ne of oho sub�eommcbrs and their wotkeo'comp.policy information.
I am an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and Job site
information.
insurance Company Name: Ll� IYh�Y-tyu_I �Y-�t91D
Policy H ur Self-ins. Lic.p: 1(,[S' 2 ,31 S^�48305.�-0]I Expiration Date; It -.2.S -IX
Job Sire Address: 172 I�a. �ary fit City/State/Zip: & 1� I'YA _
t,Attach a copy of the workers'compensation policy declaration page(showing 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
fare 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 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
Investigations of the DIA for insurance coverage verification.
I do hereby eerd rider thr ins and penoh%s ofperJary that the information provided above Is true and correct
i m t ore Date: —I Z
Phone X:
Official use only. Do not write in this area,to be completed by city or Iowa affhlat
City or Town: PermittLicense p
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: Phone M
CITY OF SiUX. . 2ANSSACHUSETTS
• 13UELD ,NG DEPkRTNIENT
120 WASHNGTON STREET, 3•'FLOOR
T1EL. (978) 745-9595
FAX(978) 740-9846
k1.,ffiFRi RY DRISCOLL
NMAYOR T HONW ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BI;IIALNG CONMSSIONER
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# 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
111, S 150A.
The debris will be transported by:
re Sic e. i�.e,
(name of hauler)
The debris will be disposed of in :
(name of facility)
Sa1E V� ror 0 0'jm
(address of facility)
signatur of ermit appli ant
date
debriwtt-dux
CERTIFICATE OF LIABILITY INSURANCE
THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER.THIS
CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES
BELOW, THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORMW
REPRESENTATIVE OR PRODUCER,AND THE CERTIFICATE HOLDER.
IMPORTANT: B the Certificate holder In an ADDITIONAL INSURED,the poliWiss)must be endorsed. B SUBROGATION IS WAIVED,subject to
the tame and conditions of the policy,carbain policies may require an endorsement. A statement on this certificate does not Confer rights to the
ceNflcals holder in Rom of such endorseme a .
vamuceR JOHN MCLAUGHLIN AGENCY CONTEACT RPM:
828 LYNN FELLS PARKWAY PHONE
MELROSE, MA 02176
E-MAIL AnORESS.
BOUFk&R(BI AFFORDING COVERAGE MNC0
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INSURE PLANNING&CONSTRUCTION LLCINSURERS:
64 HAVERHILL STREET nauptBtc:
READING MA 01867 INSURER 0:
NBURER E
COVERAGES CERTIFICATE NUMBER: miew REVISION NUMBER:
THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD
INDICATED, NOTWITHSTANDING ANY REQUIREMENT,TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN,THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
EXCLUSIONS AND CONDITIONS OF SUCH POLICIES.LIMBS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS.
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Workers cornpermadon Insurance Coverage applies Only to the workers Compensation laws Of the state of MA.
SJMICATE HOLDER CANCgLLATION
SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION DATE THEREOF, NOTCE WILL BE DELIVERED IN
ACCORDANCE WITH THE POLICY PROVISIONS.
AVrAORMeREPVJEBERTATNE
Jail Eldri e
®INO-all ACORD CORPORATION. All rights reserved.
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