8 MEADOW ST - BUILDING INSPECTION ,� -. CPU
"Try- I Li '5 C�
SPECTIONAL S �jp+g�lumvealth of Massachusetts CITY OF
Bourlot i3t.Ping Regulations and Standards SALEM
�J 1 2014 APR -�1z;kachUS�etts State Building Code, 780 CNIR Revised Ahir 2011
n Building Permit Applicat1 Y1ro Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Otficial Use Onl
Building Permit Number: A e
Building Ot'liciul(Print Name) a D e
SECTION 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map 8r Parcel Numbers
��nn �fleas 4;L
I.i a Is this an acce ted street?yes no Map Number Parcel Number
t.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(s q tl) Frontage(11)
1.5 BuildingSetbacks(ft)
Front Yard Side Yams Rear Yard
Required Provided Required Provided Required Provided
1.61Vater Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if es❑
SECTION 2: PROPERTY OWNERSHIP)'
2.1 Owner of Record:
57it AU kJ
n�Fine(Print) City,State,ZIP
g IV)F-4D'W 57- 41 n 3 3S' 6s 6 S
No. m:d Street. Telephone Entail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check that apply)
New Construction❑ Existing Building❑ Owner•Occupied ❑ Repairs(s) Altemtion(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other Cl Specify:
Brief Description ot'ProposedWork': 01i7 ?Q C_(-( S
CdrvL w-" P-521rc-
.,/t' �Soc0
SECTION a: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item Labur and Materials)
I. Building i. Building Permit Fee:3 indicate how tee is determined:
❑Standard City/Town Application Fee
2. Electrical 3 Cl Total Project Cost'(item 6)x multiplier x
}. Plumbing 3 2. Other Fees: S
4.`icclumical (MAC) IS. List:
i. Mechanical (Fire S "rutal All Fees:3
Suppression)
Check No.—Check Amount: Casit Amum:t:
6.Total Project Cost: 3 0 ❑Paid in Full ClOutstanding Balance Ihrc:
n
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS License Number FxNvrat
oS 0o n
Name of CSLL lolder List CSL'rype(see below) J
3q � � S� f Description
Nu. and Street
Ly)u,� �V19 U Unrestricted BFami su toing 0cu. 11.)
o��oa Resuicted13c2F:uni1 Uwellin
Citylrown,State,ZIP NI Nfasonry
RC Roofing Covering
WS Window and Siding
`r, 2 SF Solid Fuel Burning Appliances
J "IZ 6Iq J I ion
Tele hone Email address Demol
U Demolition
5.2�Regi'stered Home Improvement Contractor(11IQ foZ(o�fo2 y /�
1al co(6r- H[C Registration Number spiv ion Untn
I IIC Company Name or UIC Reggmst out Name
alvAcV
No.,ind:Weet �'5 6'613
2 Email address
C-f PAL rn4- C) GD 2 ✓ t J
City/Town,State ZIP role honn
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NI.G.L.c. 15L¢ 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
t,as Owner of the subject property,hereby authorize
t9 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 DECLAIL\TION
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.
Zw�\av� UN 2 v
Print Owner's or Authorized Agent's Name(Electronic Signature) 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(111C) Program),will liot have access to the arbitration
program or guaranty fund under I.G.L.c. 1 d2A.Other important information on the f-IIC Program can be found at
w rvrv.nnass. •oL rO htrormation on the Construction Supervisor License can be found at rvww.mas.cov'Jgs
2. When substantial work is planned,provide the information below:
rota) floor area(sq. 11.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
1'ypc of Cooling system. rnclosed Open_
i. '1'uial Project Square Footage"may be substituted for,,total Project Cost"
f
CITY OF SiU_ENI, %L-kSS ACHLSETrS
1 BUILDING DEPARTMENT
lr 120 WASHINGTON STREET, Sao FLOOR
T EL (978) 745-9595
R x(978) 740-9846
KIJCBERLEY DRISCOLL
MAYOR T HO?.W ST.PIERM
DIRECTOR OF PUBLIC PROPERTY/BUIIDL\G CONLftISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information ^� ' Please Print Legibly
Nutne (13usincs' JOrganiaatiom'Indivirluet): l�,J�N ( .CSC
Address: 31 4A 1A/4t A City/State/Zip:�—�I-m - O/V .) Phone #: 7 �' Sq� 61 7�/
Arc n employer?Check�(he appropriate box: 'type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time)." have hired the sub-contractors
2.El ani a sole proprietor or partner- listed on the attached sheet,t 7• Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp. insurance. y. Building addition
[No workers' comp. insurance 5. ❑ We are a corporation mid its
required.) officers have exercised their ID.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MOL I I.❑ Plumbing repairs or additions
myself. [No workers'comp. c. 152, 91(4,),and we have no 12.❑ Roof repairs
insurance required.)t employecs. [No workers'
comp. insurance required.) 13.0 Other�,f QF1 1It t�P/1_I
-Any applicant that chocks box 01 mwt also GII out the sech on below showing their woken'compensation policy intbrmation.
'I Luneuwness ,ho.,ubniit this affidavit indicating they am doing all work and then hire outside cammetors most submit a new affidavit indicating such.
K;oniracturs that check this box must arlachcd an addiliunid shwl showing Ilw n:une of the sub-contractor,and their worken'comp,policy information.
I ans an employer that is providing workers'contpeusatioti insurance for my employees. Below Is the policy mid job site
inforcuarion.
Insurance Company Name: L i�FIZT M✓71/� 1
Policy f♦or Self-ills. Li�sr tl: 32 a -33
Expiration Date:
Job Site Address: 0 Mi tA0ayu 5-7- City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure Io secure coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$230.00 a day against the violator. lie advised that a copy of this statement may be forwarded to the Oflice of
Investigations of the DIA for insurance coverage verification.
I do hereby certify under die/ A
pubu mid penalies of perjury that the information provided above is true and eorreci.
Si^_onure' 2,a//��(( ` Dater Y
Phone 1: 2S 1 ,5"l 61 q3
OJficiul roe only. Do not write in this area,to be completed by city or town offlehrit
City or Town: Permitit.lcense#
Issuing Authority(circle one):
I. hoard of lieulth 2. Building Department 3.Cilylrown Clerk J. Electrical inspector 5. Plumbing Inspector
6. Other
Contact Person: ,. _ _: Phone#:
I
�hvr.
CITY OF S�V-ENft NLNSSACHUSETI'S
l`Tt t BUMNIG DEPAR-M&NT
Al 130 WASHNGTOY STREET, 1'0 FLOOR
TEL (978) 745-9595
F.tv(978) 740-9844
tUNtBERI.EY DRISCOLL
AW011 I7-10JNS ST.PIER=
DImcma OF PUBLIC PFtOPERTY/8L:MDLNG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the six-di edition of the State Building Coda, 730 CMR section l l 1.5
Debris, wid the provisions of bIGL 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 rVIGL c
111, S 150A.
The debris will be transported by:
ti
y ��iC Dr��OSp L
(nama ut'hauler)
The debris will be disposed of in
— (name of acility)
------(address of tacility)
signature u/re ufpermit applicant
,late --
usc.&ins.
{'S ?7
RIECH COLE 781-592-6193
CENTRY
PrODGs31-Submitted-To.-_ Phone ( Date
-
r
treet job NTame
`6 ST
I City,State,Zip Code Job Location
�. �fM
Architect Date of Plans Job Phone
t
1 J7EM o EIS%INrr DceuC -4
NEVI cIXLI V ;oSzS PPD 604 61Z-e7E Fc,077/.,&,S
CrtrAj (oM?e51jr De—ZV'1 vj_ AA9 PVC CAYVn -r 5Ci27 00CqZ6 S 11
r d"A 4 `ZA)O P& S t TT TURP&I ��CCtS�Ei2 S
e4ovz�- 6 jAiTt5 r}-s IDe5Tt�� /
1t,47�U , \3Y11A(. Wll�Dow5 + TrM64 .51011v6- v,t+tT2P 14�e4f4la(�.l
Cuap&t SsbE n Aew P+�3ccFASS 11N+j
New 570 eNI �RZo lu7 GA,712,(
QfMoL2 �1( +DE3Q+ 5 P12o7EcT FELL $vQi ACf S
SHEEU+�A� ItL �?OZ M1TC r + FSf?ftriu.uS
We propose, hereby,to furnish material And labor-complete in accordance w ecificat 0PS- t
of ���
Dollars (S ). ii
Payment to be made as follows: 200 z� s" a d� o a o st I
All material is guaraXieed to be as specifies. All work to be completed in a workman-like manner according to
standard practices. Any alteration or deviation from above specifications involving extra costs will be executed only
upon written orders,and will become an extra charge over and above this estimate. All agreements contingent upon I
strikes,accidents, or delays beyond our control. Owner to carry fire, tornado, and other nece sary insurance. Our
workers are fully covered by Workman's Compensation Insurance
Authorized Signature:
NOTE: This proposal may be withdrawn by us if not accepted within days.
Acceptance of Proposal: The above prices, specifications,and conditions are satisfactory and are hereby accepted
You are authorizedZdoe work a�specified. Payment will be made as outlined above. i.
I p'% i
Signature Date: i
Signature:
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