64 MEMORIAL DR - BUILDING INSPECTION (2) T6 - jet -ads
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
• �_ ( Revised Mar 201l
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 Applied:
Building Official(Print Name) Signature Dale
SECTION 1: SITE INFORMATION
1.1 Pro ertyJdress: of 1.2 Assessors Map& Parcel Numbers
c O
L la Is this an accepted street?yes-_ no Map Number Parcel Number
1.3 Zoning Information: IA Property Dimensions:
Zoning District Proposed Use Lot Area(sq 11) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Itear Yard
Required Provided Required Provided Required Provided
Lfi Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside flood`Lone?
Public❑ Private 11 Check if yes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERS"IP'
2.1 Owner'of Record: eS
Name(Print) City,Statc,ZIP
GH �Frmtr��al �f 1��' 'Sl$`O`fS�i
No.and Street 'rclephone 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_ I Other ❑ Specify:
Brie kiD es
o Proposed Work':_ ti( ro. - „e y+el
f ¢ •-b
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:
'. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $ /
4. Mechanical (IIVAC) $ List
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No.__Check Amount: Cash Amount:
(. "Total Project Cost: $ 3,rj CJ0 ❑ Paid in Full ❑Outstanding Balance Due:
5l2- l ) N a o c�,vrnr�e^
r
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
_[ e ylL I I zre r 06 License Number Expiration Date
Name of CSI,11 Ider
1 List CSL"type(see below)
No.and Street
�,, I Q�r Type Description
C) 17?� U Unrestricted(Buildings u to 35,000 cu.ft.
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 lnsulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) ,
vy Ly—oo
rr- e.R`T Cv.C.'?%Z"` HIC Registra ion Number Expiration Date
HIC onipaik Naq�c or IIIC Re�isirant Name
htct rtltr �o a<1 (.J2r"zoo+
N an Stet Email address
City/Town Srtate,ZIP T'elc hone
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
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 Owner's Name(Electronic Signature) Date
SECTION 7b:OWNER' 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 is true and accurate to the best of my knowledge and understanding.
Print Ownei s or Aut prized Agent's Name(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 toot 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.niass.gov/oca Information on the Construction Supervisor License can be found at www.niass.eov/dos
2. When substantial work is planned,provide the information below:
Total floor area(sq. 11.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) I-labitable 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_
;. "Total Project Square Footage"may be substituted for"fond Project Cost"
i�
('`(^ram/ /,�! , r �, � ( ` ` Lt T C �'+��+7^�+
1 'y. Li 1 1 i 0 Sig�zm� LY 4�1 &. CH Us E s
?.r � BI:ILDLNrl DEP.IR-MENT
120 WASHLNGTON STREET, 3'0 FLOOR
'" °' TtL (973) 745-9595
F.ALv(973) 7.10-9M
IuNIaFIuEY Dtuscou
Nbkyoa Tt-tosLAS ST.PIERAs
DIRECTOR OF PUBLIC PROPERTY/3UILDLNG CO\L%QSSIONE I
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, xid tie provisions of tNIGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be l I I, S ISOA. disposed of in a properly licensed waste disposal facility as defined by %,IGL c
The debris will be transported by:
y 1/ ff
y (1.4et'P 7� � IC
(nanta of hauler)
The debris will be disposed of in :
(narneoFFacility) —�
(address of racility)
si.guature orpermit applicant
Luc
GG77C-- ,
Omce`6fte - +o
E Aat!aGon OVE 6Eq "iOR -
L EI hon' 7/1412014 7,
RA CANS - DBA YPe: _
TRt7CT101�&MASONRY
LgONEL PEREIRq -
ANDOVER El
PEASODY,MA OlggO ,
4
butler
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Super,isor
License: CS401147
LEONELPEREIR,p
21 MONTCLAIRjtOAD t
WEST NEWBURV MAC 01985 _
y
Expiration
Commissioner, 09/07/2014
J
° CITY OF SAL.ENI, %LNSSACHUSETTS
BUILDING D EPA RT%IE.NT
3 4 �,Er 51 120 WASHLNGTON STREET, Sara FLOOR_
deO TEL (978) 745-9595
Eta(978) 740-9846
KIMBERLEY DRISCOLL
,7LALYOR T HORLILS ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BUR.Di\G CONNISSIONER
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbera
Applicant Information I Please Print Legibly
Name(Business Organization'IndividunlY rf t t :d® tj A-e /1
Address: '21 Zo/ '}(x lair nd
City/State/Zip:L /P5� t1f'Aybvr,, 1U¢. PhoneM: ri7�-05 �- C7/7
1Are to an employer!Check the appropriate box: Type of project(required):
.U I am a employer with ( 4. ❑ I am a general contractor and 1 6. ❑New construction
empinyees(full and/or part-time).* have hired the sub-
contractors
2.❑ lam a sole proprietor or partner- listed on the attached sheet. i 7. ❑ Remodeling
ship 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. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ I ran a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself. [No workers'comp. C. 152, gl(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13.❑ Other
comp. insurance required.)
•,any uppiwant their checks box 01 must also Mimi the section below showing their work,;W eompensaiiun policy inti,rmariun. -
'I Lenwswtxrx who suh,nit this atflrlavit indicating they:ne doing all work and then hire outside contractors rnmt suhmil a new aRWavit indicting such.
$'nmmuton shut check this box mmt attached an additiywl.heel shuwin the mm�e of the sub<onoaeton and their wnrk• 'a sra comp,policy infutmation.
l unt on eutplayer that is providing workers'cunspeasadan Lrsurance for my employees. Bdluw is the pulley and Job site
information.
Insurance Company Name: tee{✓¢
Policy A or Sclf-itvr. Lic. fl: �, GkL"6 ' _�{t{/q 123 31 - I Expiration Date: �'/S
Job Site Address: ccy /vI C�I'h P vr�1'.r+— a, City/State/Zip: , ,, _ cll,^-)o
Attach a copy of the workers'compensation policy declaratlon page(showing the policy number and expiration date).
Fuiluru to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a -
fine up to S1,500 00 undlor one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
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
Investigwions of llie DIA for insurance coverage verification.
t du lmreby certify wide the pains and penuities of perjury that the information provided above i.v true and correct.
Sip'n lore 7 2 Date: 'rl 7-1 e4
Phone
Of ciul use only. Do not write in this area, tube conrpletetl by city ur town a/J1clu1
Ciro or Town: .__ Permit/Mceme p -
L+suing Authurify (circle one):
1. Board of lleallh 2. lluilding Ilepartutcat .1.Citylruwn Clerk 4. Electrical Inspector 5. Plumbing In.tpeetor
6.Other
Cuntael Person: Phone ft: