80 MEMORIAL DR - BUILDING INSPECTION O
The C'omnwnweulih of Massachusetts -
i�`� Board of Building Regulations and Standards CI"I'Y OF
Massachusetts State Building Code, 780 CMR SALLM
Building Permit Application To Construct, Repair, Renovate Or D nolish a
One-or Ti vr-Firrnllc Du dllinp
This Section Forficial Use Onl
Building Permit Number Date Applied- _
_
lAiilJing 011icial(Prin(N;une) �� i
Sign re Date
SECTION 1:SITE INFORMATION
I PPrroperty Address: ]]�� 1.2 Assessors Alap& Parcel Numbers
L la Is this an accepted street?yes °� no Map NumM r Parcel Numhzr
1.3 Zoning Information: 1.4 Property Dimensions.
Zoning District Proposed idle Lot Area(Nq It) Frontage(Il)
1.5 Building Setbacks(R)
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 Lune?
Check if zsC1 Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP"
2.hl t tirpf Reygrd:
Na(in(e(Phnnt) i' Ia0 t[ �y .Sc(ZIP , 01770
�1 City.State.LIP
ra Mewoe� rd l>;)"Or— 9� 3Y2
Nu,and Street Telephone Found Address
SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Briz Description of Proposed Work': Xetv lu W S
< ct v <
SECTIO, J: ESTIMATED ONSTRUCTION COSTS
Item Estimated Costs:
U.abor and .Materials) Official Use Only
I. Building S I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical S ❑Standard CityiTown Application Fee
❑Total Project Cost' Item 6)x multiplier
j i. Plumbing g 1 1 — -----
_. Other Fees: S
4—me l aoicad III\':\(') S List:
5. .\Iceh;mic;d iFire {/�/j}_
Su prQiiion) S Tond :\Il Fces: S_ --_ - -- 1" `- -- -
Total Project Cost: S2 Check No. ---C'heck Am Count: - _-----_ ash Anunun:
S 000 ❑Paid in Full ❑Outstanding Bahuce Due:
„ a
SECTION 5: CONS1'RUCrION SERVICES
5.1 Construction Supervisor License(CSL) 25
F-\'C,� ao C-C-Z I) I iccwc Numli•r _ P pirutinn Uale
N attic of l'SI. I Io-Jcr
13 � a t- Iis1C51.1)pel+.ehelms) ---
cf' �iVv 3Tvc't\ '
----------�-----"-- --------”— 1'} Description
No. :II1J Strcct
� li Unrestricted( hilJins u' it)13.010 Co. 11.1; V- 91 / Itcslricl¢J IX'_ fumil Dlldlin
01%,ro%o.State../ P M1I %lasollry
RC Rlwlin C'o\crin
WS R'indo\v;md Siding
SF Solid Fuel Burning Appliances
1 Insulation
'I"cle lane Email address D Demolition
5.2 Registered lion a Improvement Cont�/ractor(HIC
tl�OGG� D lion
I \�-St+-kC-
I I I C C'ompan) Name or I IIC' Registrant me
�l Covti` tom. Sfvze�
�- No. I1J Street Email aJJnss
_( � ,( da: D l j S 97E Shy S�S9
City/Town.Start(ZIP "rele hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 15C(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........... 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 Owner's Nunte(Electronic Signature) Date
SECTION 7b: 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 accurate to the best of my knowledge and understanding.
Print Own`cr's or.\ulhorireJ,\gent'x N;une Ih.lcctronlc Signauuc) Date
NOTES:
I. :\n 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 no have access to the arbitration
program or guaranty fund under\I.G.L.c. I12A.Other important information on the HIC Program can be found at
m.n. �;o1 o,1.I Information on the Construction Supervisor License can be found at L�o\ Ip.
\Then substantial work is planned, provide the information below:
Total floor area(sq. ft.) _ (including garage. finished basement attics,decks or porch)
Gross li\-ing area(sq. It.) _ Habitable room count
Number of fireplaces _.. - ----- "- - Numberofbcdrooms
Numhcrofbathrooms _ Nnnberofh:dfbalhs
1\pe ufheating s)slcm Number of'Jecks, porches
I\Ile Ofc,'01416 IN"tell' _ ..... .._ I,Ilcloset) _. .. - _.t)Pen
1, "Zonal Project Square Footage-ma\ he subitltutcd fir, l'otalProject(ost-
N9assachusctts- Dcp:utmcnt of Public Safct�
Board of Building Rc_ulatinns and Standards
Construction Supervisor License
License: CS 25924
RICHARD T ROCCIO AWL
43 CORNING ST
BEVERLY, MA 01915
Expiration: 8/6/2013
('ouua i,,w,wr Tr#: 20584
Office of Consumer Affairs and tiusines Iat1�Pd
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
a_
. Registration: 107114
s_-- Type: individual
Expiration: 7/29/2012 Tr# 299645
ROCCIO BUILDING & REMODELING
Richard Roccio
43 CORNING STREET --
BEVERLY, MA 01951 -
f
Update Address and return card.Mark reason for change.
DaS-cat 0 eOM-04iO4-G101216 i. Address ❑ Renewal Employment ❑ Lost Card
t Control No: 3 3 3 4 3 ;
THE COMMONWEALTH OF MASSACHUSETTS
- DEPARTMENT OF LABOR
DIVISION OF IOCCUPATIONAL SAFETY
19 STANIFORD STREET,BOSTON, MASSACHUSETTS 02114
LEAD-SAFE RENOVATION CONTRA LICENSE
R4CCIO BUILDING AND REMODELING
43 CORNING STREET
BEVERLY MA 01915
LICENSE: LR000086 EXPIRES: Sunday,October 18,2015
IN ACCORDANCE WITH M.G.L. C. 111, § 19713(b) AND 454 CMR 22.04,THIS LICENSE IS ISSUED BY
THE MASSACHUSETTS DIV. OF OCCUPATIONAL SAFETY TO THE CONTRACTOR ABOVE FOR THE
PURPOSE OF ENGAGING IN LEAD-SAFE RENOVATION AND MODERATE-RISK,DELEADING WORK.
THIS LICENSE IS VALID FOR A PERIOD OF FIVE(5)YEARS.
THIS LICENSE MUST BE MAINTAINED BY THE CONTRACTOR IN ACCORDANCE WITH M.G.L. C.
I 11, § 197B(b)(2)AND 454 WHEN ENGAGED
I WORK.
RENOVATION AND
MODERATE-RISK
HEATHER . ROWE,ACTING COMMISSIONER .
ii
Prinad on Recycled Poper
CITY OF S,V[. Nfl AASSACHUSETTS
f3t.ILOLYG DEP.IRT\tENT
120 W.ISHLYGTON STREaT, ya FtooR
ILL (978) 745-9595
F.kX(978) 1#984d
K1J®FJtLEY DRLSCOLL
MAYOR THo.�us ST.PMA"
DIRECTOR or PLBUc pnoPExTY/ecRALVG Co% "USSIO.
ER
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 I 1 I.5 .
Debris, and the provisions of MGL a 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
11 work shall be disposed
1 11, S I SOA. of in a properly licensed waste disposal facility as defined by MGL c
The debris will be transported by:
(name of haul
The debris will be disposed of in
�U Sbry
" (n'ame of facdily) .
(add fsoYf'�ciLty) -
� ynanrrc ofpermit Epp cant
r dfe
:rhlr vl(!.ti
CITY'OF SALEM
PUBLIC PROPRERTY
i° DEPARTMENT
Mf I Y'n114,.'1
N 111 yr
1.^\Vn1/u.�,;iu.�irsel ' ielFu• Mn .u.ui u i nJ177:
11+1, Y7�.?livi'IS � f 1.r v)a•?tC•'MM
Workers' Compensation Insurunce :\lnilavit: 3ullderyCuntracture/Eleeirlc)ane/1"lumbers
\ t Illcrnt In unnatio
PI • .� Inn le�1;1171{:I Iluvl lc.r OraanlratimV Ind,v lduul l: 'hl
�Jdrrss:
City,Slaw,%ir•
I'hone ilk
.\ry 14141411.mployer?Check the approprlule boa:
J cmpluyur with 4, Q 1 ;utl a dcncral eonlraelor and I LyM otproJvcr(required):
Linysclf
ycvx-(lull and/or parl•iimt),r have hired the soh-i:unuuwrs rr' ❑new cunatrucuun
tulo prnpricmr ar pannvr• lialcd on the anachcd..heel �. ❑RelnaidiR�
nd have no wnpluycve 7heae eubeonrrsetors haw
g Air mu in an ca acil . w rkere'coin , m d. ❑ 1)emolirion
Y P Y o p If ce.nrkers'sump, insurance J ❑ We are a empontion anJ iq q ❑ Oudding aJJitiun
J J Orlcers have vccreiavvl(heir 10•❑Elecrriea!repairsor additions
humor>lvnvr doing all workrighto/v.ecmption per hICIL 1 L❑Plumbing rcpuira or aJJitinne
(Ko workcre'comp' e. li2, I(4),anJ wt hnvo no
e rcyuired.f r einployccn.(Ko workers' 12•0 Ruufrepaire
comfr. Insursncercyuirc•J.J 13•QUtber
•.11q.ggalcua IEIn chcb I>w AI mW, rill uu,I
'I Mswn,wr,rn yM111yi„1il lllio amJova iMl M w.11un lwluw dyrine'Awr s'u,il'it. n, sasi _
ka,ine 4164+,o Juine all wyA girl Ihq AW ywai,M euernnyrs Tnr'/.u'Iw1Y „ow a1R40vil iMlu,lin r
T•M,cwun IEY 1Msa IAe Eon nnW mahM an adJUlvrW.Boni 1Auwina IM nosy dIti luevsnr•11fly1a and Ilrn 4yrlele' d kl•/ors un anuployer thuf Ir prvldJlnd rverAert'rulnpenrnr/ae Lr.rurnnce�w/ny ern u, 'I"lyy'nlbrm,wiy�
inlurarathna p/�ee.R Bdulr/a tAiPu/ley and/u1 aih
Insurance Company Vaine:�__
I'nlicy if ur Svlr-ins. Lic.rs: —
�—" E�pirauon Data:
Jub Sits Address: -
.1RacA IIcu Cily'slaidiLip:
Py erlhe workers'cmnpvnratlun pnlivy deeiarutlun page(showing rho policy number and eaplraHun dote),
Pa(lurc to secure caserade as required Wider Sccuun 5,% ul SIGL c. 132 Can lead to nice nn
line up(a$I.Stla,(In and/ut ua w a civil lwnalllus in the Lunn yl'a STUP WUR
potinian oreriininal penalties ors
leop fit S250 00 a day Iduinat(lie vi-Altor. lit advl.a•d thin i vupy of this.dulemcnl may be l6rward¢d to theK ORDER
„1 E ORDERand a fine
hn c.vl�an'nu ul';hv MA for nlvivw• a a1vcN�c 1 ei Ilivaluat.
/Ju/rrrrhy,vrri/Y run/er Nit pninr and pen,dNer vfprr/riry char the iu unnyr/oe
/ p"Y"rerl ybuve is true and cameo
I'I'1 1: ' I la1L
1
I!//leiu/uiI wily, du„nI Irrire lit fhi.r urru, to Ar ru,nyh•aJ Dy c/ry of town a/�IfiuL
r Ily or I''llvn: _
1 - YcnninrLlhme e 1Haln1( .tYlhgflly lClrClO nlle1:
1 f Ile.11ih !. Ilwhhm: I) il h ' 7cfric.11 Inv Icv(ur ?,
Plunluind Iaspcclor6 )Uhr o1u C'fork 4. l
I
l'•al.,a 1',nun:
I
information and Instructions
as••. .every VI in the service of another under,illy conlrict of hire.
�LusacBuselts General .Lin��P`furs is Jeliludres all eny)lo)en to provide wurkeri compensahon tor their eulplayee+.
I'unu.Lu la Inl+ Nalul a.
;.press or ImpI1cJ. oral or wrlllen.' orahun ur uthet legal entity,or any two or more
to.vnpfupar is Jctin tJ Si"an individual, pairtnenhlp..IssaelUlWn.:°rD
lit In .m loyees. However the
't the Guegomg engaged m a lame enlerynse,and includin{the legal rcpreseuutives of�JeceaseJ employer•oft e
ecelver ter uvatee ul,ot indivf the
idual, pasenenhlp, assoctauoa or other legal enaty,emp e g ' D
a Persons
w do tnaintanuncd,cun+truction Jm�nt be wormed such
be an employer.
caner r a table 0 house Navin{not mare than three apaMnenu and who resides therein or the occupant dwelling
.Iwelling housd of anothet who employ. pa
or ,,n the Grounds or building appurtenant thereto shall not because of each employment
\li.L chaplet 152. d'-1C(6) also states this"IV $law or local licensing ageaey shag withhold the Issuancereq an
uired,
renewut of a license or permit to updraft a holiness or to construct
witlh the Insurances overagedings IN the lrequr ed,
Applies oho has not produc+d acceptable+videace of cump of iu political subdivisions+hall
ppliesnully, �IGL chapter l S_', i-'SCll)gates"Neither the conunonwcahh not my
enur into any contract for the perfomant!�ntedbla theic ork u tilt 1{citable yvidanla ter can)pliy)ce w ith the insuronca
requirements of this chapter have been p'
Applicant checking the boxes that apply to your situation and'if
ellsation affidavit eoet+Daaalyhone number(s)Along with their cenifieate(s)of
Plcasa iili out the workers' cump narteb),adding, 1' D LLP)with no employees other than the
necessary supply suDD1Y sub.contrwCoccsl
worker' comptnay on be
submitted to the Department Of Industrial
ustrial
instill once, Limited Liability Cmnpanics(LLCI or Limited Liability partnerships ps
membhave
er or patellar, are not required a to carry
employeas,a policy is required. ter advised that this affidavit nayortmcnt of
licatian far the ponnit or Iicanat is being requested, nol the l),p
\ccidenu far confirmation of insurance th eo coverage 11 bt sur law ter tiff yuugod tan required to obtain affidavit workers'should
ho routmed to the city or town that the apD uastioas regarding the
Industrial,\ecidanu, Should You baud any 4
compensation policy,please call the *anyandnt at Ih ranter listed below. Self•instareJ companies should enur the
self-insurance license number oa the a orapriate line.
.try or'rowe Officials
Plensc he sure that the affidavit is cmnplete and printed legibly. The Department has provided u spuaa h this Ottom
t cant
of Memo:
be juvlt far you to lilt out in the event the 1111ce of Investigations has to contact YOU regarding the applicant.
licutions in any given year, need only submit one affidavit indicating c`rreur
PI It* if cam to till in tol pttout in cmise number which will be used oa a reference nulnbcr. In addition,an u
hat must submit tnultipld pannio'lical>ye app r town nay be; rovidcJ w the
policy information I if necessary) and under"Jab Sta AJlmpv the applicant+haul le i writs"all locutions o (' Y
tawny."A copy of the ut7lJuvit that has had^ofticislly star^elm is ud or t Iieensasked by�lA nowty�affidavit Oust he tilled nut each
applicant as proof that a valid affidavit is on file for icon P ennit not related to any business ter commereinl venture
year. Where a hums owner or citizen is obtaining a license or p
tie. ,1 .lug Il 4 hui st permit lit burn leaves cteI +aid person is VOT required to wmplau this uffida a haw,a,y 4uesuons,
IIc ,>�lice la lnveragatlun+ ,vuuld like W think )'uu ill aJv:utea for youf caap+falp)11 and shuulJ y
hlcase du not hcsimtc to gtvc us s call.
the t):p.lrunenl'e addles, tcicphuna and rax number.
The COMMonwealth of Massachusetts
Depazvaent of Industrial Accidents
On11ee of lovatigadons
600 Wuh+ngton Street
Boston, MA 02111
('el. 4617.721Fu00 cxt 611406o71a977 MASSAFE
www.mass.&ov/dia