47 MEMORIAL DR - BUILDING INSPECTION (2) �, ---- I he C'ununonsceahh ol'Massachuscus _ .
l� Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code. 780 CeIR SALEM
qi� 13"ildi'19 Pennil ,application To Construct. Repair, Renovate Or Demolish a
One- fir rim•Fain-dY Dwv ie,�r
This Section For 011ici se Only
Building Permit Number Dal Applicd:
lhiilding 011lciul(Print N,une) gnaturc Date
SECTION I:SITE INFORMATION
t I.1 Property Address: 1. ssors dlap& Parcel Numbers
�n brerne&A"i I)/ 2 Asse /-OF A
I.la Is this an acce ted street? ,es no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
I )^APB (ia�)
Zoning District Proposed Use Lat�i reu(sq 11) Fronlage(11)
1.5 Building Setbacks(It)
Front Yard Side Yurds Rear Yard
Required Provided Required Provided Required Provided
1.61Yater Supply:(M.G.I.c.JU,§!a) 1.7 Flood Zone Informadom 1.3 Sewage DIs oral System:
—/ Zone: _ UuuiJe FloadLyatf?
Publle C3 Pr(wle O Check if esO' Municipal On site disposal system O
SECTION2: PROPERTY OWNERSHIP'
2.1 Ownerl of Record:
art 17' AK sA)frn /,( 0)91/)
N;uttnl�arllPrint) City.Stale,ZIP
-1 1 Y)70WIt i"I'/11I /7f'7(a7"3 d�'$� �e'16,710 `koyy-/C/l7
Nu.and Street relephone Flnall Address
SECTION]: DESCRIPT19N OF PROPOSED WORKS(check all that apply)
New Construction❑ Existing Building arl Owner-Occupied ❑ 1 Repairs(s) O 1 Alteratlon(s) O Addition O
Demolition O Accessory Bldg.O 1 Number of Units_ Other O Spccily:
Br Dacripti nofProposed Work%
SECTION J: ESTIMATED CONSTRUCTION COSTS
Inem Estimated Costs: Ofllelul Use Only
I l.abur and Materiels( y
1. Building S IIr)0 I. Building Permit Fee: S Indicate how fee is determined:
2. Ilcctrical S0. O Standard City+Ton Application Fee
)V l7 Tutal Project C'ostl al llem 6).1 multiplier .x
1. 1'lunihiny S / Or 6 1 2. Other Fees: S
-I. MMI.mical ill\ \(': S List:
Cu rrrassionn S rorll .\Il Fces: S
('heck \'o. Cheek:\Iumuu: C'a ih \oonmt:
n Illlul Project Cosh 1 ❑ Paid in Full C3 Outstanding Ilalmce Due:
r
SEX"PION S: CONS'I'R(,("rION SERVICES
!IA Constructions Supervisor License IC'SL)
I—I --
a \pirltiou Rile
N.ulle oft.'9(. Ilulder _. Ilsll'Sl. I\pe(See
hclua).__._
__ _ --.---..__ .._-- - -- -- --- 1)pe Deicrlption
N. ,u,J Street ..-----.
(I 11,000c11. It.l
R Rc,trieted IA2 Pamil D+,ellin
M \laean
RC Rmitin Unerin
W'S W'indow,utdSidin
.SF Solid fuel Ilurning Appliances
1 Insulation
1'ele hone fnloiladdre,.r U Demolition
5,2 Registered Ilume Improvement Contractor(HIC)
IIIC'Registration Number livpintlion Umc
I IIC Compao) Name or IIIC I(cgistrum Name
No.and Street Flnuil address
City/Town,State ZIP T¢le hone
SECTION 61 WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. 152.1 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..........C No...........O
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 behalf,in all matters relative to work authorized by this building permit application.
Print ONsner's Nwne(Electronic Signature) Dula
SECTION Its.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.
Print Ow wr'n ur:\uthorired,\gcnt'.r Nunw Ilfleetrunie Sign;mucl Dual
NOTES:
I. An Owner who obtains a building permit to do his her own %vork,or an owner who hires an unregistered contractor
(nut registered in the Hone Improvement Contractor(HIC) Program).will no have access to the arbitration
program or Suaranty fund under.I.G.L.c. 11?A. Other inipunant information on the HIC Program can be Il and at
Information on the Construction Supervisor License can be found at
2. \\'hen substantial,wrk is planned,provide the infurmation below:
rota) dour arcs(sy. R.l - ____.._I including garage, finished basement attics,decks or porch)
cin,i;Iiv ing area I sy. t1.1 .._.._ _... . Habitable ruum count _ .. ...
\umberul'lircpIaces .. .. ._ .. �_ Number ol'hedroants
\mnherol'hathrrwns . . Numberul'h:dl'hulhs
I)pe(it he.uing ,):tein Numherol'Jeeks, parches
1,
f1 pC 0f ePp1111g i1-i1tOt I�ncluKd ..( en
1. "I', lal I'r„jecl S,iu;rre PoatagC"nlir) be•uhstitutcd fur"Total I'mjcct C'oit"
CITY OF S.V-&Nf, AkSSACF-i(:SETTS
t3t.uacvG DEp.�xntEvt
I_'0 U7.liHfNGTON STRFgr, jiO FLOO1l
rEL 97
l g1743.959!
KIMBERI RY OKMOLL FAX(973) 74&9&W
S1AY01t 1110.►w ST.PrlU4
1)"SaOa OP pL aUc PR0P!llTY/8l•p p0jC G01C{IfSJ(O V EA
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition orthe State Building Code, 790 CMR section 1 11.1
Debris, and the provisions of MGL o 40. 3 34;
Il19uil or permit// is issued with the condition that the debris resulting from
1 work shay)be disposed of in a properly licensed waste disposal racili
111, $ I JOA. P P Y
ry as defined by,blGL c
The debris will be transported by:
(n+ma ul'haular)
no debris wi 11 be disposed of in
(narn o rxaily) . ...... _
I Jdre�i ar Q, �,ly)
❑In"rule orpermil ippliunf
CITY 01 Si�U-M, NWSACHUSETTS
1 BUILDING DEPARTMENT
120 WASHNGTON STREET, 3o'FLOUR
� ,,•.
C)� � TEL (978) 745.9595
Rifix(973) 710.9846
!U\l B ERL EY D RISCOLL
L�Yo t TTiONUS ST.PIEARI3 DIRECTUR Of PCOLIC PROPERTY/3UHDrNG CONNISSIONER
Workers' Compensation Insurance AI'Itdavit: Builders/Contractorv/Electrician+/Plumbers
\nnlleant Informatinn Ptcase Print Leaihiv
VlllmclOmitx,.t,Urganuatinnlmtividu.dl:� T . "ICCw� ��' 'V+-V
p o
City/State/Zip: (It.. 011)`� Phone* '76- -t� ^�
Are you an employer!Check the appropriate bolt Type of prnjeet(required):
1.❑ I am a employer with 4. q 1 am a gunural contractor and 1 5. ]New construction
employees(Rill and/or part-tima).a have hired the sub-conhracbrs
2.0 lain a cola proprietor or partner- listed off the attached+hurt.t 7. ( Remodeling
ship and have no employees These sub-contractors have a. ( Demolition
working for me in any capacity. workers'comp, insurance. 9. IJ Building addition
(No workers:comp.insurance 3. 0 We are a corporation and its
rcyuircJ.( officers have exercised their
10.0 Electrical repairs or additions
3.0 lain a homeowner doing all work right of uxemplion per MGL I I.0 Plumbing repairs or additions
myself.(No workers'camp. C. 152,4I(4),and we have no 12.0 Roof repairs
insurance required.)I dmployecs.LNo workers' 13.0 Other
comp. insurance rcquin d.)
-A,1Y�pPlham dw vhwka but tl mul alias Moot Ihv wa9iva buluw.howing tMir coolie'compnWlun policy inM1ummton,
'I I,vacuwlwra wha,uhmil Ihis alildnvit indicating they In doing all wills Ind Ihen hiro uunide rontnetan mur Along arm anldavil indi"ing.uk
To.inwten that chi<k ibis box meal 4112ch d in WJUiumJ.hml.hawing the nwna orthe mtIoani acton and their workM'comp.policy InWmutlo s.
fain un rarpluyer rhutJs pruvldlnX workers'cumpruradun hisurancejar my employees, @eluw is rho pollq and fob site
in�oruralnn, N, ^/
In H1rance Company Valne:
Policy 4 ur Self-itu. Liv. 0 t--Z �S�j Q Expiration Data:
Job Sire Address: ( oils ,lYl )-�Yd/� Cityislate/2ip.
Attaeb a copy of the worker'compensation policy declaration page(showing The policy number and ezplra fins data).
Flllura to wcuru cuvernga as squired under.Suction 21A of vl0L a. 132 can lead to the imposition of criminal penalties of s
rir.c up to 11,500.00 ond/ur rote-year imprimnmcnt as well as civil penalties in the form of a STOP WORK ORDER and a line
of up to S230.00 I day against the violator. Ile advised that a copy of this statcmrnl may bat furwardcd to the Office of
lavc,ligat rem of the MA I'ar insurance coverage vcriticalion.
!da lrrrrby rrrri�y unJt h ins nJ pro ,i�par%u tut the i ijuraludon pruvidej a vvil it True wid earrecC
Cj
Of icial"ate anly. Oa nnI wrist in this area, (a bt curupleled by city ur fawn a//Trial Ili
Ciry or I'n,vn:_ PermiriLiccme 4
I„uin;Authority (circle fine): —._. -..__ ...
1. L'oard u(IIcallh 2. lNildlmy I)elmitlne it I. ('ilyrfoun Clerk T, Electrical htry)cctor i• I'lumhin4 Inlpecfor
6. Oilmr ----- ---- ..