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0042 MEMORIAL DR -BPA 14-941 , 1 r - IL4 - �7 , Od ck 2 01 >� The Commonwealth of Massachusetts 'w Board of Building Regulations and Standards CITY F SALEM �c J� Massachusetts State Building Code, 780 CMR Revised Mar 1017 ', . Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Appl' _ j— d3 Building Official(Print Name) Signature Date SECTION 1:SITE INFORMATION _ 1.1 Property Addr 1.2 Assessors Map& Parcel Numbers I.la Is this an accepted street?yes__ze<�no_ Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq it) Frontage(tt) 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner'of Record: Name(Print) City,State,ZIP No.and Street 'telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of proposed Work': P SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials) I. Building $ I. Building Permit Fee: $ Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ ❑Total Project Cost'(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 4. Mechanical (1IVAC) $ List: 5. Mechanical (Fire $ Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ �(� �� ❑ Paid in Full ❑Outstanding Balance Due: 01 old 13 r SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Superviso License(CSL) ! T� � � License Number O6 ExpirationD Name of CSL Holder r7 List CSL"Type(see below) No.and Street Type Description U Unrestricted(Buildings up to 35,000 cu.ft.) l R Restricted 1&2 Family Dwelling City/Town,State,ZIP,/M Masonry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation ele p hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 1s c�So �i4T�� E ��/�L�rST�4l/G'J% IC Registration Number Expiration Date HIC Company Name or HIC Registrant ame -�' Sri.+-,S� ��r No.an irect Email address City/Town, State,Zf 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:OWNEW OR AUTHORIZED AGENT DECLARATION By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information contained in this application i true and accurate to the best of my knowledge and understanding. Print Owner's or Authorized Agent's N '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.gov/oca Information on the Construction Supervisor License can be found at www.mass,vov/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"may be substituted for"Total Project Cost' CITY of; S.Uzm) A[ SSACH US ETTS ©uiLmr, DEPAR-M&NT 120 WASHNGTON STUI ET Y° ; r FCaoa TtL (978) 745-9595 F.Lx(978) 7-W-9844 KI\L501 Y DRISCOLL ,tiL4Y0;t THoacts ST.Fmug DIRECTOR OF PL;BLIC PROP ERTy/at:=LNG CONNI5SIO iER Construction Debris Disposal At'tidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 730 CA,,fR section 111.5 Debris, and the provisions of NIGL c 40, S 54; Building Permit k is issued with the condition that the debris resulting from this work shalt be l 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by tNIGL c The debris will be transported by: (nome ufhaulur) The debris will be disposed of in (name of t' ity> (aJdres.a ot'Tacilily)' siguatura ut-permit•tpp(I it J.uu (2ffice.of Consumer Affairs & Business Regulation - Mass.Gov Page 1^of The Official Website of the Office of Consumer Affairs&Business Regulation(OCABR) Consumer Affairs and Business Regulation Home Consumer Rights and Resources Home Improvement Contracting Home Improvement Contractor Registration Lookup To search by registration number, enter the registration number in the textbox below and click the 'Search' button. Search by Registration Number Search To search by other fields, enter the search criteria in the fields below and click the 'Search Registrants' button. For the State field, use the two character state abbreviation such as "MA "for Massachusetts and "RI" for Rhode Island. All search fields allow partial text so the search will look for any values that begin with what was entered. For example, if yot enter"Fr" in the City/Town field and "MA" in the State field then the search will return records for Framingham, Franklin, and Freetown which all begin with "Fr" and are located in Massachusetts. To return less information enter in more criteria. For instance, entering in a state of "MA" will return a large number of records but entering in a state of "MA" and a city/town of"Medford" will lower the results. Search by Registrant's company's name atulippe Construction Search by Registrant's last name City/Town P everly State Aa— Zip code P1915 Search Registrants) Click on the registration number to view complaint history. You can also view arbitration and Guaranty Fund history. The list is current as of Monday, May 12, 2014, Search Results RESPONSIBLE REGISTRATION EXPIRATION REGISTRANT NAME INDIVIDUAL NUMBER ADDRESS DATE STATUS LATULIPPE CONSTRUCTION LATULIPPE, STEVEN 159850 35 SUNSET DRIVE 06/03/2014 Current BEVERLY, MA 01915 O 2012 Commonwealth of Massachusetts. Mass.Gov®is a registered service mark of the Commonwealth of Massachusetts. ® Latulippe Construction 35 Sunset Drive Carpenter Beverly, Ma 01915 978-836-9973 wc.#13145tatas7 8 Licensed- Insured Proposal Page No. of Pages PROPOSAL SUBMITTED TO PHONE DATE STREET JOB NAME CITY,STATE AND ZIP CODE JOB LOCATION ARCHITECT DATE OF PLANS JOB PHONE We hereby propose to lumish materials and labor necessary for the completion of: � (WE PROPOSE hereby to furnish material and labor-complete In accordance with above specifications,for the sum of: ) Payment to be made as follows: dollars I$ All material Is guaranteed to be as specified. All work to be completed In a substantial workmanlike manner according to specifications submitted,per standard practices. Any Authorized Signature alteration or deviation from above specifications Involving extra costs will be executed only Sig �. uPon written orders,and will become an extra charge over and above the estimate. All agreements contingent upon strikes,accidents or delays beyond our control. Our workers Note:This proposal may be are fully covered by Workmen's Compensation Insurance. withdrawn by us it not accepted within days. ACCEPTANCE OF PROPOSAL The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. ,,1�f _ i, - Payment will be made as outline above. Signature Date at Acceptance: l,` /i�f Signature CITY OF S:1LE2vI, NL-�SSACHCSETTS BUILDING DEPARTMENT 3 R 'A'6 1t F 120 W.1SHLNGTON STREET, 3""FLOOR TEL (978) 745-9595 F.A.r(978) 730-98-t6 KI%,fBERLEY DKISCOLL A.11YOR THORNS ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUMDLVG CONNIISSIONER Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbero Applicant Information Please Print Le ibiv Milne (0usinuss.Organirarioro'Imlividual): ,/��/l �� /J`�S"/��j�ry��J Address: City/State/Zip: Phone #: Are you an employer!Check the appropriate box: 'type of project(required): 1.0 1 am a employer with 4. 0 I am a general contractor and 1 6. ❑New construction tployees(full and/or part-time).* have hired the sub-contractors 1 am a sole proprietor or partner. listed on the attached sheet.t 7. ❑Remodeling '*hip and have no employees These sub-contractors have 8. [] Demolition working for me in any capacity, workers'comp. insurance. y. Building addition (No workers' comp, insurance 5. 0 We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.0 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.❑ Roof repairs insurance required.) t employees. [No workers' [},� cutup. insurance required.) Other- Any applicant ilea checks box 01 m",also rill out the xelion below showing their worker'compensation polity inllnmorion. 'I Lnnwwtsrs who.whmit this arltttnvil indicating they are doing all work and then hire outside contractors mml suhmil a new afrdavit indicating such. Cumrwwrs Ihul chcvk this box must anachod an additional shad showing the none of the sub-contncton and their workers'comp.put icy information. /ant an employer that is providing workers'compensation insurance for my employees. Belotb Is the poky and job site information. w �/ Insurance Company Name: is /y�p. Policy JI or Sclf-ins. Lic, d: /_' S�5/U��,�y�'S761� i ` _`-"'�!/ Expiration Date: Job Site Address: �fZ / l��' � i rate/Zip: Attach a copy of the wortrers'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 ofcriminal penalties of a ire up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line cf up to Sli0.00 a day against the violamr. Be advised that a copy of this statement may be furwardcd to the Of rice of htvesligutions of ilie DIA for insurance coverage verification. /do hdreby cerrify under ie sins a d pe Ines of perjury that the heforanmlae provided abave is true and correct taw: OJJiciul use only. Do nor write in this•area,to be coutpleled by city car town agirrial City or'I'utvn: PermiU1.1cense# Issuing Aulhorily (circle one): 1. Board 11f Ilealth 2. Building OLpirlmunt 3.Cdyfrown Clerk 4. Flectrical Inspector 5. Plumbing Inspector 6.DtLer Contact Person: Phone 7: