87 MOFFATT RD - BUILDING INSPECTION (2) CP
The Commonwealth of Massachusetts
�. Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 Cb[R SALEM
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Sectior'iForOfficial UseOnl
Building Permit Number:.. Qate Applied;
Building Officia Print Name) .. g atura;. . Data
SECTION l:SITE INFOMAITON.
/ IA Property Addres :� 41.4
,2 assessor Map 3c Parcel Numbers
x �jfn
!/ l.la Is this an accepted street?yes noap Number Parcel Number
1.3 Zoning Information: Property Dimensions:
Z.S-40Zoning Disuict Proposed Use ot Area(sq It) Frontage(i
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:
Zone: Outside Flood Zone?
Public 121� Private❑" — Check if esRl blunicipalOn site disposal system ❑
SECTION2 PROPERTB'UWNERSRMP "
2.1 Ownert of Record:
S•-1-Q a6,e to L c1 L e r I S S r m MA ®f g '7
Noma(Print City,State,ZIP
/ \ No.and Street Telephone 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. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work': '2
SECTION 4: ESTIbWTED CONSTRUCTION COSTS
Item Estimated Costs: OfRelal Use Only...
Labor and Materials
1. Building S I..Buildlhg PennitFee.5 ' Didicdtehow fee is determined:
3. Electrical
❑Standard.citylfuwn Application Fee.
$
❑'Total.ProjectCost .(Item.b)xmultiplier x
3. Plumbing S 2. Other Feast
1. M-chanical (IIVAQ 3 List:
i. Mechanical (Fira $
5n� ressimt) _ "lbtal :111 Fees:$_
- Check No. . Check Amount: Cash Amnon:
f ntal Project Cost: S yf j00V f7 I'ai,l in I-nll ❑Oatstandim, [Balm co I)ua:
• r r
N VICES
SECTION 5: CONS'fRUC'l'IOt SERVICES
5.1 Construction Supervisor License(CSL)
License Number Expiration Dane
Name of CSL I lold.1
List CSL'rype(See beluw)
No.and Street rype Description
U Unrestricted Duildin s u to)5,000 oil tt.
R Restricted 1&2 Famil Dwenin
City/Town,State,ZIP �I \lasonr
RC Ruutin Cuverin
WS Window and Sidin,
SF Solid Fuel I)urning a\ppliunces
[ Insulation
1'ele hone Email address D Demolitions
5.2 Registered Home Improvement Contrnctor(HIC)
FIIC Registration Number Expiration Date
I IIC Company Name or I IIC Registrant Narne
No.and Street Email address
City/Town,State 'LIP tale 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 Nnme(Electronic Signature) Dote
SF.CTtON 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name bel w, I hereby attest under the pains and penalties of perjury that all of the information
containe ' th'• app 'ca is true and accurate to the best ofmy knowledge and understanding.
S fie•, et-a— 3
I lit wi is u r\u o rted:\gent's Name(Elegy tunic Signature) ate
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
progrtun or guaranty fund under M.U.L. c. 1.12A. Other important information on the FIIC Program can be found at
owwan;us.uuv%oca Information on the Construction Supervisor License can be found at rvww.mass.eov dL
2. When substantial work is planned,provide the information below:
Total floor area(sq. 11.) __. —(including garage, finished basemendettics, decks or porch)
tho;i living area(sy. ft.) _ Ifabitable room count _
Nnntberoftirepl.tees_-.--.------- Number of bedrooms
Number otbadirooms __ Number ofhaitb:uhs -- - ----___ _
I vpe of hc.uing.iy;lcur _ —— --_-- Number of deck.;parihce -- _ --__—
ftpuofcaoling ;y;tcnr Enclosed _-- !tpcn ---__—,
t I,Ird PIn ].:t Syu it I:oorj,c-in.rY he ;i ib;titut.,d row" I ,t.d Prow:( Co X'
CITY OF S.u-&NvI
PUBLIC PROPERTY
DEPAR'T,�IENT
WA rurvw.
VA�Oe
r b iaar►.cfd snaa��M V..saow wm Ot f'0
T'ti.f"L7t17Sf! •VAX f'L7a47ey
HOMEOWNER LICENSE EXEMMO►V
Pine. Trial
Du. /3
Job Laeados R r7 ✓V!o � Salrsy n7
Home Owner Address G,-►,
Home Owner Telephone
PMUM Mailing Addrew Sr4r,.,
The current exempdon out"Homeowners"was extended to include owner ocaupiad
dwellings of two Units or teas ad to allow such homeowners to engage ao for
hire who don not possm a Bcenso provided that the owner acts as superviao l
individual DER NMON OP HOMOWMM
Pawns) who owne Al pereel otlaad on which hddhe rtxidca or tateride to reWde, an
which there It. or is intended to ben, a one or my lhmily dwelling. attached or detached t
swxftwm acceswry to such use and/or/arm strucnwm A person who comtructainore
than one home in a Me year period shall not be considaed a homeowner. Such
"homeowner"shall submit to the Building 0ificial,on a form acceptable to the Building
Permit that hdshe be responsible for all such wort performed under the Building
The undersigned "homeowner"ueumes responsibility for compliance with the State
Building Code and other applicable bylaws usd reguladona
The undersigned "homeowna"certifies thu he/she undentands the City of Salens
Buiidin D
g eD artntrnt rtunimum inspection pn'7ee+dura and r uirsmrnb an
.vill com i w c9 d the he/shs
D Y with said procedures atsd it rn
HONfEOWYERS SIG.!ArL,"
VPROVAL OF BUILDGYG ViSPECTOR
See other side far state coda
1
CITY0FS.ILEm, A-ks5:1C
HUSETTS
i BL•ILDLYG DEPAITUENT
-4 120 WASHNGTON STREET, 1 FLOOR
TEL (979) 745-9595
F.UX(973) 7.10-9345
(<!J[DE3LcY D2ISCOLL
AA.Y03. -J1lOAU ST.PIEAM
❑IXECTOR OF PULIC PROPERTY/Stanva COSLmlSS1ON ER
Construction Debris Disposal Atttdavit
(required tar all demolition Luid renovation work)
In accordance with tha sixth edition of the State Building Coda, 730 CIbIR section 111.5
Debris, and the provisions of 1MGL a 40, S 54;
Building Permit A is issued with the condition
spos that
the
this woredebris work shall bresult in disposed et to a ro erl liven tng from
P P Y licensed waste
disp
osal fawlt
l l I, S I SOA. tY as defined by NIGL c
The debris will be transported by.-
The debris will be disposed of in :
(lddress ur'fa�ilil/)
l
ynamr Ij( omit applicant
- 3 '3
Otte
N/F LORING
REALTY TRUST
o�x
OT 12 LOT 11
co 12,540 S.F. oa
LOT '13 N
a,
1 rpP oS e�
a 17- Deck 1es
1 RY
DWELLING
87 mciflF t, al
Sa�e�. MA
n
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O QQ
26.52 R 73.48
OFF AT T R o AD
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9 JOHNS. G i
T� LAUR<:TANI m t
4'� �93M1311 y LOCATION OFSTRUCTURN)
�P. BASED ON LINES OF OCCU�'AT10ry
ONLY. A MORE ACCURATE LOOA11ON
WILL REQUIRE AN IN%TRUMEW
SURVEY �
SCALE; 1' m 40'
f I