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23 MOFFATT RD - BUILDING INSPECTION (3) t The Commonwealth of Massachusetts CITY OF 4 Board of Building Regulations and Standards Building Code, 730 CLN Massachusetts State SALEM �) jl Revised rLfnr 2011 ^� a Building Permit Application To Construct, Repair, Renovate Or Demolish a ! I One-or Tavo-Family Divelling This Sechon,For'Officia siOnly ' Building Permit Number: PPlied Building Official(Print Name) g ure . Date - SECTION 1:SIT FORMATION 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers 1.1 a Is this an accepted street?yes I� no Map Number Parce!Number 1.3 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.O.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑ Check if yes❑ SECTION 2: PROPERTY OWNERSfi 2.y. Ownert of Rec rd: CS�or�e RJtKcsioc�, ��cis Name(Print) t� City,State,ZIP B No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction ❑ Existing Building❑ 1 Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ her ❑ Specify:tr/Q,nand Brief Description of Proposed Work': SECTION 4: ESTINIATED CONSTRUCTION COSTS- Item Estimated Costs: . Official Use Only% Labor and Materials 1. Building $ Ov PJ I Budding Permit Fee $ Indicaie how fee is determined: ❑Standard.City/Town Application Fee 2. Electrical $ i - ❑Total Project Cost ,(Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: .$ � 4. Mechanical (liv.\C) $ List �� V 5. i\lechanical (Fire $ Su ression) _ _ Total:\II Fees: S — Check No. Check Amount: Cash :\mount. fi. fatal Prnjcct Cult $ G' !(dam.a 0 Paid in Fulf ❑ Outstanding 11;tlance Due:_..---_--- 'n'tC�.Q� t SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSI,) � y Id!-��3l— __ License Number E.epi auotn Date Name of CSL l folder List CSL Type(see below) 141d 1rpf 2oE7--S7— jRC pe Description No. and Street - U Unrestricted Duildin gs u to 35.000 cu. ft. _L (7 R Restricted I&2 Famil Dwellin City Fotvn, Siute, `LIP I[ blasonr Raofn CovcrinS Window and Sidin SF Solid Fuel Burning Appliances 7�( �iS512t( [ Insulation Telephone Email address D Demolition 5.2 Registered Hone Improvement Contractor(111C) /Y( -)�6 r 1 - n.,T4ttldR.tii iblt S;IE2. 1+ 1/ FI[C Registration Number Expiration Date [[IIC Company Name or I11C Registra k`nt Name No. and Street Entail address City7Town,S ate, ZIP Telephone SECTION 6: WORKERS' COINIPENSATION 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 [, 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 7SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION containedin e below, I hereby attest under the pains and penalties of perjury that all of the information plication is true and accurate to the best of my knowledge and understanding.hontcd:\gene's Name(Electronic Signature) Date NOTES: 1. 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 W the arbitration program or guaranty find under M.G.L. c. I42A. Other important information on the HIC Program can be found at www.tnass.,m6xa Information on the Construction Supervisor License can be found at tvww.mass.,�o�dpz 2. When substantial work is planned,provide the information below: Total floor area(sq. rt.)__ _ _(including garage, finished basement/attics,decks or porch) Gross living area (sq. tit Habitable room Count NuntberoFtiraplaces,-.—_-- _ Nuntberofbedratms --- —--------- Number of bathrooms Number of halubaths Cope of heating system - --.. .--- _— _.--- Number of decks/porches ----_--___ -- I)pe of cooling syucm ---__--- Enclosed_—_ _-- _ -_Upcn —- --_--- S. `fot.tl Project Squire FooLl"''c" ntay be rub;tituted t)l I ,t.11 Projcct Ca t" ° CITY OF S:U EM Albs kCH[:S ETTS a. BUILDING DEPART"t>:rT t )� 120 W."HLIIGTON STREET, 3'a FLOOZ TEL (978) 745-9595 RuX(978) 740-9846 Kl.N[BFRf Ey DRISCOLL THoatAsST.PtERxB MAYOR DIRECCO A OF PUBLIC PRO PEATY/BC[IDING CO\NISS[ON ER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aiinllcant lnformatinn Please Print Leeib[r Name(Businxys•O(yiniraliamIndividual): ( A.) AM t AVIAe-..M' ja Address: t UPlLc�n� S city/state/zip:_T'0- MA nl S-v�4 Phone M: 7e�/ S 5 5a 1Z 14 FC11 you an employer?Cheek the appropriateboat Type of project(required):i am a employer with 4• El 1 am a general contractor and 1 6. ❑New constructionemployees(Nil and/or part-time).• have hired the sub-contractor I am a sole proprictar or partner- listed on the attached.sheet t �• ❑Remodeling ship and hava no employees These sub-contractors have a. 0 Demolition working fur me In any .eapaciry. workers'camp.insurance. 9. 0 Ouilding addition (No workers'camp.insurance S. 0 We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.0 1 ran a homeowner doing all work right of exemption per MGL i I.0 Plum .ing repairs or additions myself.(No workers'cump. c. 152,)1(4),and we have no 12. aof repairs insurance required.) t employees.(No workers' comp.insurance required.) 13.0 Other •Any uppllcanl dW 0IM14t hex 01 must also 1111 uld the uuliuo below showing their"lush'mmpamadun pulley inlbrmadon. 'I hMwuW ft"who rulmdl 1h1s affidavit indicating they an doing all work and thea him mnide contrectors must submit a new antdovil indicting tuck lcontmeton that chick this box must anwhud an addidunol ehst showing the tome of the mb:eentraetors and Chair Workers'ramp policy infotmadan. f am an employer that/s provldlnir ivorkes'compeasadon Insurance jar my aunpluyeex Belaw is the polley and Job site injannarlom insurance Company Name: /J./Z -1—S Policy A or Sclf--itu. Lic,d: C, > Expiration Data: T / —/ Job SiteAddress:62-3---�&&M�'r Pei Ci1y/St2WJZip: 4z1,/a,,_ t/ysa (yei')a .%Itach A copy of the workers'compensation policy declar266111 page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of s tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of STOP WORK ORDER and a lino of up to SM.00 a day against the violator. Re advised that a copy of this statement may bat f-urwarded to the Ohics of Investigations of the DIA far insurance coverage verilicaliurt. I du bdreby cepil,fy under die pulps and pdnu/des u/per/ury thut tkt abuse is true uud carnet. ii:nuure: Jv/ ✓i gala: / rT/ Ifinne r!• �fd/ �5 ri �� � o1jiciul axe surly. Do oat write in thlr urrrp to be completed by city ar lawn nIJIciad I I Citynr'fuwn: __ ._ Nrrnl0.lccnse# Iasuiug,\ulhurily(circle one): 1. Board of Iteallh !. Ruildlnq Depirtmeot I.Cilyrfown Clerk 4. Electrical inspector 5. Plunihing Otapeetor 6. other ('witact i'erson: _I I i`5Pr .Y CITY OF Siv.EI,t, UuSACHUSETTs ©ULDLNG DEP.IR'IILENT 120 WASHLNGTON STREET, 3'O Room T'EL (978) 745-9595 :CI..Nc3&U-SY DRISCOLL Rux(978) 7-10-9345 .bL3YOli T1l05N3 ST.PtERRB DIRECTOR OF Pta3LIC PROP ERTY/KU-DLYG C0\L\lt5SIOJiER Construction Debris Disposal Affidavit (required for all demolition and renovation work) in accordance with the sixth edition of the State Building Code, 780 CNIR section I 11.5 Debris, and the provisions of i'YiGL a 40, S 54; Building Permit k 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 1WGL c l 11, S I50A. The debris will be transported by: (name of hauler) The debris will be disposed of in : (name of racitily) (�ddress or'rhailily) �W - signatuc ufpermitappiicant �/-ou -'�)of3 Talc -- rr Page No. of Pages 1II WM, TRAHANT JR. CONSTRUCTION. INC. 4TH GENERATION ROOFING 215 Verona Street LYNN, MASSACHUSETTS 01904 H.I. LIC. #141778 (781) 599-1211 • (781) 844-4551 • FAX: (781) 581-0855 PHO DATE LO OSP OPOSAL SUBMITTED TO STREET n 2 f1 JOB NAME / f n l ' CITY,STATE and ZIP CODE C JOB LOCATION it We hereby submit specifications and estimates for: We hereby submit specifications and estimates for: SHINGLE ROOF FLAT/RUBBER ROOF Str entire roof L Sweep entire root clean V Replace any bad boards up to 100 linear feet ❑ Strip entire roof - - CoW I'-AAT---Rt�S 671 Inst ice and water barrier first three feet up roof ED Mechanically fasten down ISO board insulation _ -- ---- stall ice and water barrier in all valleys and along dormers E7 Install 060 Rubber Roofing on entire roof n -— - — — -- — I(stall 151b felt paper on remainder of roof ❑ Install metal flashing around perimeter of building telnstall eight inch drip edge L1 i }� C-1 Flash chimney(s), pipe(s) and walls) ❑ Install ridge vent ❑ Edge caulk all seams V1 Ffash or re-flash chimney(s) 'Nsfpl(_NEL 1 r7!3P F1 Install new copper center drain h'I Install new pipe flanges ❑ Other: k install year shingle E-1 et#ter Fl Clean up all debris ❑ gutters a Instll tters and downspouts g . - - - ❑ Labor and materials guaranteed 100/% for five years I ❑ Install trim coil Install new fascia boards J11 L ( rryie - "-jt---o,»_ _- -__ _ C ❑ Install new rake boards FJ Install sky light(s) -/ - - -- - y�,/ //1 r- Ll Oth r CC7v�, L' -t GI�rr2y_ i,^t �l( � (� t ` f ! <ik� � IN vf Cie up all debris La or and materials guaranteed 100% for five years All shingle roofs are nailed by hand. 3(lc flrtipti hereby to furnish material and labor — complete in accordance with above specifications, for the sum of: e, rz 1-Yvi/) l��L1 r2 f7�1{1� lQ.�.E� Total Price($_ /pp yo o c) "IFdOU ARE HAVING YOUR ROOF STRIPPEDr PLEASE COVER ALL VALUABLES IN ATTIT, A wic HAVE NO CONTROL OVER DEBRIS THAT PAY FALL THROUGH ROOF BOARDS.` w All material is guaranteed to be as specified. All work to be completed in a workmanlike manner according to standard practices. Any alteration or deviation from above specifica- AUthori]_ed tions involving extra costs will he executed only upon written orders, and will become an Signaturs, extra charge over and above the estimate. All agreements contingent now, strikes C r accidents or delays beyond our control. Owner to carry fire, tampon. and other necessary insurance.Our workers are fully covered by Workmman's compensation Insurance. rxiep'fit1TCP. of 11ropint-Tjf—The above prices, specifications and conditions are satisfactory and are hereby accepted.You are authorized to SignatureX X i w `:.. do the work as specified. Payment will be made as outlined above. Date of Acceptance. Signatm' -"' P Flen:e nal yeuow copy m.,ho�e arnr,ss. -