55 MEMORIAL DR - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR,7°edition OF SALEM
Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or o-Family Dwelling
1.`\ s S ion For O ial Use Only
Y \ Building Permit Numb r:/� ate Applied:
Signature:
Building ommissio /tnspect r dings Date
S TION 1: SITE INFORMATION _
1.1 Property Address: c� 1.2 Assessors Map&Parcel Numbers
S5 M.e�n'a� 1�c.
L la Is this an accepted street?yes 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❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP`
2.1 Owner'of RecoFd.
iYI t—o a. e 1 `�c 2ss ss m a(
Name(PrintY Address for Service:
97F 7-fS oa8'4
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK"(check all that apply)
New Construction❑ Existing Building So Owner-Occupied FT Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work": Rkq�q R O®sic
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ ,3-]a25. 00 1. Building Permit Fee:$ Indicate how fee is determined:
2 Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: Cz
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 37a 5.00 ❑Paid in Full ❑Outstanding Balance Due:
V vv,-d U U Yl civie CJc,(- O-L
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) O 6
a� c� License Number Expiration Date
Name of C L-Holder eXn / List CSL Type(see below) tJ
Address MDResidentiall
Description
lion
Unrestricted( to 35,000 Cu.Ft.
" Restricted 1&2 FamilyDwelling
Si �j e MasonryOnly
/ 7A ..7 3 5- 0 SS 57 Residential RoofingCovering
Telephone _: t' ,., Residential Window and Siding
Residential Solid Fuel Burnin Appliance Installation
Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Company Name or HIC Registrant Name Registration Number
Address
Expiration Date .
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NLGAL r— 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
I,' ' 1 Ct,�c-cl c�-.C'e. ��20 5 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.
Signal=of Owner Date
---c- SECTION 7b:1OWNEW OR AUTHORIZED AGENT DECLARATION
I, J t 29 , c1 ,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
GcJ _ i t- lS to
Signature 9POwner or Authorized Agent Date
(Signed dfider the pains and penalties of ) _
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I O.R6 and I I O.RS,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 count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of haWbaths
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"
c �
i CITY OF S.UI•E`15 iN'LkSSACHUSETTS
BunmLNG DEP.mmstEN�,T
120 W ssHLNGTON STREET.3i0 FLAOR
TEL (978) 745-9595
FAX(978) 740-9946
g1.%fBFRr RY DRISCOLL
MAYOR ' THOMAS ST.PfERRE
DIRECTOR OF PCBuc PROPERTY/BL'IIDING comasstoNER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 790 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 debriss�w�ill be transported by:
m
(name of hauler)
The
l debris will be disposed(o�f' in : I
}yo4Sl��—�CcY1�2f" S t�trl
(name of facility)
address of facility)
signature of permit applicant
date
dcbrivtf Joe
J
CITY OF S.u.&N1, NL s kcHusET rs
BLanwG DEPAR-MLNT
• 120 WASHINGTON STREET,Yo FLOOR
�j TEL (978) 745-9595
FAX(978)740-9946
KINIBERLEY DRISCOIl
MAYORTHOMAS S7.P1FRRs
DIRECTOR OF PUBLIC PROPERTY/BCIIDLNG COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders!Contractors/Eleetricians/Plumbera
Anaticant Information \ —�> Please Print Ledbly
Name lBusiness.organirariotvindiviNdy.-7'
Address: U` C.0 55 fAVQ
City/State/Zip: 15 l tem MA of q7O Phone #: 1'79 - 7 3 S- 0 3 57
Are you an employer'!Check the appropriate box: Type of project(required):
1.Jd 1 am a employer with ;Z 4. 0 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contnt tors
2.❑ 1 am a sole proprietor or partner listed on the attached sheet: 7. ❑Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
(No workers comp. insurance 5. 0 We are a corporation and its 10.❑Electrical repairs or additions
required.] officers have exercised their
3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions
myself.(No workers'comp. e. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees. [No workers' 13.0 Other
camp_insurance required.!
Any appliaal fiat encore box r1 must ako GO out the sectioC below showing their waken'compensation policy information.
t 1 ronxommot who submit this aflidavh indicating they ate doing all wodr and then hire outside CCneffiOn mug submit a new attldavit indicating such.
:Contmeeon that check this boo[mtwt anachod an additional duct showing the Came of caw sabwmractom and their warkas'comp.policy into anoatm.
I am an employer that is providing workers'compensation insurance for my employees Below is the pddley and fob site
information.
Insurance Company dame: `W1 ockex-5 Con p t (1S ,�(Qvl O� I r I H
Policy N or Self-ins.Lic.M\rJ C eZ' 31 5 ' 37 7,2 j Sl, 01 o Expiration Date., y' 9-a a/I '
Job Site Address: 5 5 M e,rvlo r 'g City/State/Zip: S4 (4442 /77a /J/r/70
Attach a copy of the workers'compensation potlry 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
fine up to S 1,500.00 and/or one-year imprisomtten,as well as civil penalties in the form of a STOP WORK ORDER and a Itt=
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations or the DIA for insurance coverage verification.
I do hereby ce/nl�f under dke pains a'nnd milks of perjory time the Lrformadon provided above Is true and Correct
Sienatuse: f y t/V• C,l�l.�f/ Dow, l/- I S=/ 0
Phone : 77E - 735- O3S7
nl — _
Okrad use only. Do not write In this areaq to be completed by city of town official
City or Town: Permit/License q
Issuing Authority(circle one):
I.Board of]Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone q: