38 MEMORIAL DR - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITI� OF SA Y Massachusetts State Building Code,780 CMR,7 edition
RevisedJmru uy
{ Building Permit Application To Construct,Repair,Renovate Or Demolish a 1,2008
A� One-or Two-Family Dwelling
CCCJJI This Section For Official Use
Building Permit Number: Date plied: ( (o
Signature: '
--.B@IctngCommi o - pictor.ofBuildings _
SECTION 1:S TION
1.1 Property Address: 11 Assessors Map&Parcel Numbers -
lAa Is this an accepted street?yes X no Map Number Parcel Number
13 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 Rear 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❑ Check if yes[] -
-Zone:._ Outside FloodZone Municipal❑ On site disposal system O
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner�ofRecord:
v�nS �{CCa�rr�a�5 'a9 ✓Vl P.rv.e rrrl -�r
Name(Print) Address for Service:-
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ - Existing Building C9 Owner-Occupied RI Repairs(s) ❑ 1 Alteration(s).❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed WorV: 2U v l o va Q2a,
t
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item and Materials Official Use Only
1.Building $ ?OO i 1. Building Permit Fee:$ - Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
O Total Project Cost'(Item 6)x multiplier x
3.Plumbing $
a0 2. Other Fees: $ ... .
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ -
Suppression) Total All Fees:$
6.Total Project Cost: .$ Check No. Check Amount: Cash Amount-
7 O Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
-}- t 0666o,3
N"OOd - License Number Expiration Date
Name of CSL-Holder �+
G tb �.J2. Jal�2W1 MA List 11,Type(see below) •V -
Address - T on '.
�. U Unrestricted( to 35,000 Cu.Ft.) -
Si - - R Restricted 1&2 Family Dwelling
M Only
g78- 735-63JrS7 ., ,j. - . RC Residential Roo Coven -ewe,
Telephone WS Residential Window and sidin_
• "-'` SF Residential Solid-Fucl Burnie Appliance
Installation
- I D I Residential Demolition,
5.2 R red Home rovement Contractor(HIC)- )(7
%
HIC Company Name or 1-�C Regish-mrt Name -. .Registration Number
G:oss FIo� �etlemt WA o1�7�
Address �/ 7�a27�.;t0i3
q79-735-0-35 7 Ecphation Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L r-152 g 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----------K No...........❑
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
authorize to act on my behati in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWl NER'OR AUTHORIZED AGENT DECLARATION
1 -- wW s H TW a o� ,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 Owner orAuOmrizedAgent - Date
(Signed under the pains and penahies of )
I 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(IUC)Program),will not have access to the arbitration
program or guaranty fund under M.Gl._c. 142A.Otter important information on the MC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq.Ft) (including garage,finished basement/attics,decks or porch)
Gross living area(Sq.Ft) Habitable room cord
Number of fireplaces Number of bedrooms
Number of bathrooms Number of halt7baths
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 r CITY OF S.1LE1 i, liI�1SS.�CHUSEM
• ' BLIMM DEPARTaIENT
i 2D Q7ASH1 ;GT0N STREET.310 FLOO&
TEL (978)745-9595
FAX(978)740-9846
KIMB R EY DRISCOLL
AMAYOR THOMAS ST.PWJM
DIRECTOROF PUBLIC PROPERTY/BVI DL'3G CONIMISSIONER
%Vorkers'Compensation InsurancL-Affidavit Builders!Contractors!Electricians/Plumbers
An icant Information -- - - - - - - ` Please Print Leaibix
Name(Busiltesa.0rWira6orVlm6v1dto3): � � �cJ\- *�Q
Addmss: Lj Gfa 55 Ao42,
CityiStatc/Zip.'S a\Q,v, M A O lC17a ph=#: q -7 8 73 5 . 0 3 5`T _
Are oa am employer?Cheek the appropriate box-. Type of pro]eet(required)
3,�1 am a employer with [ 4. 1 an a general contractor and I 6, 0 New construction
employees(fell and/or patt-time).' have hind the sub eannacwrs
2.0 1 am a sole preprietuar or partner- listed on the attached sheet Remodeling
ship and have no employees These sub-oomtac oat;have & 0 Demolition
working for me in any capacity, workers'cutup.insurance. 9. 0 Budding addition
[No workers'comp,insurance 5. We are a corporation and its
requbvd.] officm have eserund their 10.0 Electrical repairs or additions
3.0 1 am a homeowner doing all work right of ettemption per MGL I t.0 Plumbing repairs or additit>na
myself.[No workers'comp. rn 152,§1(4)�and we have no 12.0 Roof rem
insurance required.]t cmPloyem[No workers' 13.0 Other
comp-i ]
'A uPPaModnot punks boart coup also Ga nut ibe sopiw bcla9iowivs t4irwotkus'�tryrn�m Wticp mfutttudea.
'Ilameowoaswhosuboit this aR&wb indicating 04y ate doing nit mukatW d=hue ov>6ide ooun mteaw mbolt atttw affidavit lice
ConumoodW dmkIbis boor oast aUcbd an addifioolslmtshowing the a roe ofdw d,.wnyapps and thdrtvwknn'm.p.policy infannatisn.
'I'm an employer that it providing workers'compenraaon insumaee for my employeex Below is the policy and job site
information.
lmwmncc Company Name:_ L \JQ��y tFY\.J fit- y ot�
Policy ft or Self=ins.Vic.N: NA/Cc),- �c�S - 32-] 9�SS" 2 N Expiration Date: '7" O -1 'Z
Job SireAdeirtss: rnPYVlnr�u� t/Ce CiryiState/Zip:='Sot,Ioenrt fir
Attach a copy of the workers'eampensntion policy declaratlan page(showing the policy number and expirallon 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 S1,500.00 andior 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 covcrago verification.
I do hereby certify wnhT dw pants and peaahim ofpe/Iatythat the Mformamen provided above is true and correct
sil,nalurr t Dare.
P_honc9 -73S - 0357
Dfcial use only: Do not write in this area,to be completed by ary ortowu ogxhd
City or Town: Permil/Liec=#
Issuing Authority(circle one):
I.Board of Health X Building Department 3.Cdyifown Clerk 4.Electrical inspector,5.Plumbing Inspector
6.Other
Contact Person: phones g:
F
WORKERS COMPENSATION AND EMPLOYERS LIABILITY INSURANCE
POLICY 't�
Liberty
Mutualrr
AR INFORMATION PAGE
Liberty Mutual Group
175 aerketey Street Boston,MA 02117
Issued by LIBERTY MUTUAL FIRE INSURANCE 165B6
Policy Number WC2-31S-377255-021 Issuing Office 181
NEW BUSINESS NEW Issue Date 08-31-11
Account Number 1-377255 Sub Account 0000
1. Insured and Mailing Address FEIN 271976112
JRB BUILDERS INC
4 CROSS AVE
SALEM MA 01970 RISK ID 859092
Status 03 - CORPORATION
Other workplaces not shown above: SEE ITEM 4. PREMIUM-EXTENSION OF INFORMATION PAGE
2. Policy Period: The policy period is from 07-30-2011 to 07-30-2012 12:01 A.M. standard time at the
Insured's mailing address.
3. Coverage
A. Workers Compensation Insurance: Part One of the policy applies to the Workers Compensation Law of the states
listed here: MA
B. Employers Liability Insurance: Part Two of the policy applies to work in each state listed in Item 3.A. The limits
of our liability under Part Two are:
Bodily Injury by Accident $ 100, 000 each accident
Bodily Injury by Disease $ 500,000 policy limit
Bodily Injury by Disease $ 100, 000 each employee
C. Other States Insurance: Part Three of the policy applies to the states, if any, listed here:
SEE END WC 20 03 06A
D. This policy includes these endorsements and schedules: SEE EXTENSION OF INFORMATION PAGE
4. Premium: The premium for this policy will be determined by our Manuals of Rules, Classifications, Rates and
Rating Plans. All information required below is.subject to verification and change by audit.
Code Premium Basis Total Rate per$100 Estimated Annual
Classifications Number Estimated Annual Remuneration of Remuneration Premium
See Extension of Information Page
Minimum Premium $ 500 (MA) Total Estimated Annual Premium $ 2,523
Premium will be billed ANNUAL
Producer 0004-152882
GILBERT INSURANCE AGENCY INC
137 MAIN STREET (RTE 28)
READING MA 01867-3922
Sales Representative 3000
Sales Office Name WESTON
01987 National Council on Compensation Insurance,lnc. WC 00 00 01 A
All Rights Reserved Ed. 07/01/2011
Insured Copy
4
• L
CITY OF SM.E3I, NLAssivm sEm
'- BLlMLKG DEP.MMIEVT
120 W.ASHLNIGrON STREET,P FLOOR
TEL (978)745-9545
FAX(978)740-9846
I nWERLSY DRISCOLL
MAYOR THOMM STYIERRE
DiRECrOR OF puBLic PROPERTYjBunmiKG coianssio.%iER
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:
(name of hauler)
The debris will be disposed of in :
T�s�er S�-�•o�t
(name of facility)
(address of facilitt )
W
signature of permit applicant
11 - s' - H
date
Jchrivli Juc