26 MOFFATT RD - BUILDING INSPECTION (2) 4'
0 The Commonwealth of Massachusclls Town of
4 Board of Budding Regulations and Standards
Massachusetts State Budding Code, 780 CNIR, Ta edition Building Dept
Budding Permit Application To Construct, Repair. Renovate Or Demolish a ME"
One.or Tuo•Furmils Dnef6nd
This Section For Official Use Onl
Building Permit Num c Date Applied:
2/ZS>/o
Signature:
Buildt C tits t r IN ine of 8uddmge Dui
SECTION 1:SITE INFORMATION
1.1 P ny Addr 09� 1.2 Assesson Map i Psrcel Numbero
M Number Parcel Number
I.la Is this an ace teal street? ro no ":'
I..) Zoning Information. 1.4 Property Dimensions:
Zoning District Proposed Use
La Am Isq R) Frontage IR)
13 Building Setbacks III)
From Yard Side Yub Rene Yard
Required Provided Required Provided Required Provided
1.6 Wster Supply:(M.G.L c.40.654) 1.7 Flood Zoo@ Information: 1.8 Sawage Dbposal System:
Zone; _ Outside Flood Zone? Municipal O On site disposed system O
Public O Private O Cheek if
SECTION 2: PROPERTY OWNERSHIP'
2.1 Qw ltr^of R�esrd:
Name IPi :1 Address for Service:
G�k ��c5- 2 s�Sr
Sign Telephone
SECTION):DESCRIPTION OF PROPOSED WORK'(cheek AB that Apply)
New Consmtction O Existing Building O Owner-Occupied O 1 Repairds) O Alleration(s) O Addition O
Demolition O Accessory Bldg.O Number of Uniss_ Other O Spec,O:
Brief Description of Propose
Q Work
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OOlchal Use Only
Item Labor and Materials
I. Building S o I. Building Permit Fee: S Indicate how fes is determined:
O Standard CiryrTown Application Fee
2 Electrical S O Total Project Costal Item 6)x multiplier x
J Plumbing S 2. Other Fees: f
a. Mechanical IHVAC) f List:
J Mechanical (Fire S Total All Fees: f
Su tenon
Check No. _Check Amount: _ Cash Amount:_
is Total Project Cost S 5OG0 0 Pad in Full 0 Oubunding Balance Due
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) CS 7&&
L icenw Number Erpuuuon Dule
Neree ul l'SL-tl�Yg It.ml CSL Type live heluwl I
Address T)ON I Description
U I Unresutcted io1f,000fofl
R Restricted I&I Family Duelling
S sn.t� � M Ma Only
7 RC Resrdrnnal Reoftn Covering
w'
Telephone S Resldmnal Window and Siding
SF I Residential Solid Fuel Burning Appliance Installation
O 1 Residential Demolition
5.2 Registered Home Ire vemen Conti cloy(HIC)
HIC fompany Nam or HlCcl ytsP,tmt � Ag�x/ Ret{unanan Number
Adam,. !/ /
4 45;70�1 Expiration Deny
Sist wee Telephone
ZZ
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. ISL 1 2SC(6))
Workers Compensation Insurance affidavit must be completed and submined with this application. Failure to provide
this affidavit will result in the denial of the Issuance of the building permit.
SipW AM&vil Attached? Yes..........0 No...........0
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject properly hereby
aulhorias to act on my behalf,in all matters
relative to work authorized by this building permit application.
Si of Owner Date
SECTION 7b:OWNER'OR AUTHORIZED AGENT DECLARATION
so 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
Signature of Ow ulhorizcd Agent Date
Si under thf Palms 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
(Trot registered in the Home Improvement Contractor(HIC)Program),will gg have access to the arbitration
program or guaranty fiend under M.G.L c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing ICSL)can be found in 790 CMR Regulations 110 R6 and 110 RS,respectively.
2. When substantial work is planned,provide the information below
Total fiaore area(Sec. Fl.) (including garage,finished basement/ama,decks or porch)
Gross living area(Sq. Ft.) Habitable room count
.Number of fireplaces Number of bedrooms
.Number of bathrooms Number of half baths
Tvpe ofheating system Numberofdeckv porches
n PC uf,aohng system Enclo.ed Open
1 "Tool Protect $yuare Fuotagt"may he.uh,tituled for 'Total Project COst"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
\I`.n N 110 VI'A+I II\bl\1,V 11'N TO S•\I1'\1,%t.Ni.\I
l'FI:`17ti-71 'JiYs f.\x:9716740-7946
Construction Debris Disposal Affidavit
(required I'ur all demolition mid renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40,S 54;
is issued with the condition that the debris resulting from
Building Permit q
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. S 150A.
The debris will be transported by: {)
� I`'� �(J N�J✓GI 1 Ian I�i
Itiame of hauler)
The debris will be disposed of in
G Mello
prame ut ace lty)
Gec/.,L / L
(address of facility)
uam Innnit applicant
date
s
Iola n,Ii I:,k
CITY OF S.1I.E.`I, AksSACHL;SETTS
BL'ILDLYG DEPART\IEINT
120 WASHIINGTON STREET, 3"'FLOOR
TEL (978) 745-9595
FAX(978) 7.10-9846
KI>IBERIEY DRlSCOLL
MAYORTHobLu ST.Fmm
DIRECTOR OF PLBLIC PROPERTY/flV a DLNG CONDBSSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/ElectriclanslPlumbers
Applicant Information / q / Please Print Le4ib1Y
Name (ausima Oratnirationln,bvtd&W)!
Address:
City/StatrJZip: Phone #:
,%re you as employer?Cheek the appropriate x: Type of project(required):
1.❑ I am a employer with 4.V11 I am a general contractor and 1 6. ❑New construction
omployces(full and/or part-time).* have hired the sub-contracmrs
2. I am a sole proprietor or partner- listed on the attached shceL : ?•remodeling
ship and have no employees These sub-contractor have I. Cl Demolition
workin for me in an capacity. worker'comp.insurance
g Y P ry• 9. ❑Building addition
[No workers'camp. insurance 5. We area corporation and its 10.❑Electrical repair or additions
required.] otTicen have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions
myself(No worker'comp. c. 152.§1(4),and we have no 12.0 Roof repairs
insurance required.)t employees.(No workep' 13.0 Other
comp.insurance required.)
Any applicant that checaa tten At must star fin was the section tslow showing their workem'ctnnpmraLat pulley infurmalloe.
'I Lvtwmvnen who rubout this anldsvit indicting they am doing all work and then him outside romans"must submit a raw anldsvil it hcWng sock
4%,ni>YOn that chuck this box rasa anachod an additio d sheers showing ds ause of dw sula a nrton and their wad"-come.policy infentuaos.
/am an employer that lr providfnif worker'compensation Insursarce for my employees, Below/s the paley arrd fob r/ter
information.
In..urrnce Company Name:
Policy #or Self-ins. Lie.#: Expiration Date:
Job Site Address: City/State/Zip:
Attack a copy of the workers'compentatloo policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL C. 152 an lead to the imposition of criminal penalties of■
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. lie advised that a copy of this statement maybe forwarded to the office of
Incealigatiuns of the DIA for insurance coverage vcriticativa
/do hereby Certify un r tb sns asrd penalties of perJury that the information provided above is true and carrel
Win•r t it -7 Q Data: _
OffiCial we dilly. Oa not tvrire in this area,to be completed by city or town ,fffeiUl
Ciry or Town: __ PcrmiUl.kcnse N
IAsuing Aulhurity (circle une):
I. Ituard of llealth 2. Building Department 3.City/town Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Cutllact Person: _ __. ___ Phone 4:
_� .l�P. �p9ItMI69dU:F,IG��/t. Ow��dJQf�(IJC�j
eu Office of Consumer:Affairs& Business Regulation
HOME IMPROVEMENT CONTRACTOR
Registration: 130441
Expiration: 3/9/2012 Tr# 292258
Type: Private Corporation
HORNE CONSTRUCTION CORP.
JEFFREY HORNE
156 BARE HILL RD.
BOXFORD, MA 01921 ° Undersecretary
*� Massachusetts- Department of Public Safel.
Board of Buildin_ Rc•_ilaliuns and Standard%
Construction Supervisor License
License: CS 71149
Restricted to: 00
JEFFREY S HORNE
156 BAREHILL RD .d!
BOXFORD, MA 01921
Expiration: 5/21/2011
( nuui.riiner Tr#: 15702