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28 MOONEY ROAD - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF '` r' Massachusetts State Building Code, 780 CMR SALEM `mow^' Revised Mar 2011 Building Permit Application To Construct, Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Ap ' d:' Building Official(Print NzGe) ignat Date SECTION 1: SITE INFORMATION 1.1 Proper y Address: 1.2 Assessors Map& Parcel Numbers gh' 0 L l a Is this an accepte street?yes no Map Number Parcel 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.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: _ Outside Flood Zone? Check if yes❑ Municipal❑ On site disposal system ❑ z SECTION 2: PROPERTY OWNERSHIP',, 2.1 Owner'of Recor� Print r�Name (Print) 'City,Stat, Zee, IP --�' No.and Street Telephone Email Address (,SECTION 3: DESCRIPTION OF PROPOSED WORK Z(check all that apply) , New Construction❑ Existing Building Owner-Occupied ' Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify: Brief Description of Pro d Wor z _ L Cie SECT[ON 4 ESTiMATED CONSTRUCTION COSTS K Y" timated Costs: Item Es Official Use Only ' Labor and Materials f ' r �. , 1. Building $ ©fI� al.' Building Permit Fee: $ Indicate how fee is-determined:' 2.Electrical $ 0 Standard City/Town Application Fee "❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ - 4.Mechanical (HVAC) $ List: ' t� 5.Mechanical (Fire Suppression) $ Total'All Fees:$ "- Check No. Check Amount: Cash Amount 6.Total Project Cost: $ _� � ❑Paid in Full ❑ Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) OPT,, / LL1'�f�fi' License Number Expiration Date Name of CSL Hal e ' List CSL Type(see below) N and Sheet ,• Type,, - ,,Descnpnon,- 29 `L� i/ D�a'ry U Unrestricted(Buildings u to 35,000 cu.ft �i 1 //1Y R Restricted l&2 Family Dwelling City]'own,State,ZIP M Mason ry RC Roofing Covering WS Window and Siding SF Solid Fuel Burning Appliances I Insulation Telephone Email address D Demolition 5. Registered Home Improvement Contractor(HIC) iS/r 9 Z HIC Registration Number Expiration Date Hlti Co pony Namo§HIC Registrant Name No.and Stre Email address City/Town,State,ZIP Telephone 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 4 ' 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. 1 �t /r 5 Print Owner's Name(Electrons I Signature) Date SECTION 7b:`OWNER`,OR'AUTHORIZED AGENT DECLARATION ' Aingbbelow,I h eby attest lrepaigs and penalties of perjury that all of the information ic tion ' and accurate to the b t of my knowledge and understanding. ' ri d ent's Name(Electronic Signature) Date 1NOTES: 1. An Owner who tains a building permit to do his/her awn work,or an owner who hires an unregistered contractorry (not registered in the Home Improvement Contractor(HIC)Program),will not 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,mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov!tips 2. When substantial work is planned,provide the information below: Total floor area(sq. ft.) (including garage, finished basement/attics,decks or porch) Gross living area(sq.ft.) Habitable 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 3. "Total Project Square Footage"may be substituted for"Total Project Cost" 3!4" anal W-18 W30 ill W-15 B-la Stove 30" B48 "0 ti15 W33 48{ 0" 15' 15"— aal 5} 18' 18' 30' 1 -I - an, ' Mal oy P,O#8443859 OF W8WL W3018 UTT 5W Ceding Height 98 314' T _ 4W318 3 1)Cusbmer wants to remove 1a2 6GAS-RANG 18 02FWf atfB162 theoldcabinalsainsiallnaw , v 2)Ctakmervrantstoaccess - - s- merat Pealnentil for atender. 13W 3)Cusmmerwants Ragouts 4)Custaomr W nt6 rJ9wT (not to telling) l• \ n I 2r Lv� ITT {L) � i To aB l!a M , \\ 6le here F TT (L) =s t 3"filly OW24' Tell /j � F'3302F'Wr SIITT Z4DISHW 3( j H OF _. {361 waUTT W3838BUTT 1 Pass th[o to {[I lre GoeM 2354�. i To 38' I 106�" 361 2ze'" w nil vv3o 1AW-24 Wtd W-24 71" All dimensions-Size designations This is an.original design and must Designed: 1113/2013 given are subject to verification on not be released or copied unless Printed: 11/23/2013 job site and adjustment to fit job applicable fee has been paid or job conditions. order placed. b02O72fr All Drawing#: 1 No Scale. 1 Massachusetts - Department of Public Safety ` Board of Building Regulations and Standards Construction Supervisor License CS-091696 ROBERT A BENJAMM -- 11 FERN COIJR'C �: MILFORD NH 03055�s y �r "0 Expiration Commissioner 06/20/201:5 i I ��a �ovuirniRuierz�(�, p/��r1��ic�euJeUJ (lice of Consumer A.fTaits&Business Regulation ME IMPROVEMENT CONTRACTOR glstration:-.S60-139 Type: 1EVIra. QM-61,25/20-4, Supplement I, KTM PROPERTIES;iLEGs, - BOB BENJAMIN - li 26 KENDALL POND RD: DERRY,NH 03038 Undersecretary J Preliminary Installation Estimate m.ivor roe v�.� 3484 KTM Pro erti" Joan t! re 1 74/2l2013 BreakdownCategory Cabinat Installation only 52,600.00 Custom work and molding Electrical,Plumping and Appliance Install Drywall Work!close off pass through 5400.o0 Customer Signature: / Date:71 7- I >. Ltd GC signature: Date:_ 11 ZzL2 The above signature does not commit either party to the sale of the above listed Items.The signature represents a full understanding of the price and scope of labor for the categories listed. Prices are subject to change based on the final design,layout of the kitchen,and unforseen conditions. This is only an estimate;a final price will be presented during the final Site Verification. Notes: This is a cabinet install only with closing off the pass through. If the customer wants pendant lights over the penninsula(2) Please allow for$475 in electrical work(customer supplies lights) 6/6 d A/ 009Z£52£ << 291LSL5£09 29L6825£09 NOM 2t:90 6Z-66-£60Z i CITY OF SM.Ebvf, iNL-kSSACHUSETTS BL'II.DLNG DEPARTNI NT \ 120 WASHNGTON STREET,3-FLOOR TEL_ (978) 745-9595 Flux(978) 740-9846 KINIBERLEY DRISCOLL MAYOR THolsw ST.Pmm DIRECTOR OF PUBLIC PROPERTY/BUILDINIG COMMSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Anplicant Information Please Print Le ibi V i Name(Busitx�s OrganizatioMndividual): City/State/Zip: Phone #: Are you an employer?Check the appropriate box: Type of project(required): I.T 1 am a employer with� 4• ❑ l am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.t 7. remodeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp,insurance. g, ❑ Building addition [No workers'comp. insurance 5. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself. [No workers'comp. C. 152, §1(4),and we have no 12.0 Roof repairs insurance required.]t employees.[No workers' 13,❑Other comp. insurance required.] 'Any applicant that chucks box MI must also GII out the section below showing then workers'compensation policy intormalion.r i lomcuwnen who submit this affidavit indicating they ate doing all work and then hire outside contractors most submit a new afndavil indicating such. -Contra non that check this box most attached an additional sheer showing the name of the sub-contractor and their workers'comp.policy information. I am an employer that is providing workers'compensation Insurance far my employees. Below Is the policy and Jab site information. Insurance Company #av)r� Policy#or SelGins.Lic.#: _)J� ��J Expiration Date: �4 /J —� Job Site Address:.�`1A11��Ie4,( i City/State/Zip: � Attach a copy of the workers'co ensatioo policy declaration page(showing the policy number and expiration date). Failure to secure coverage as required under Section25A of MGL c. 152 can lead to the imposition of criminal penalties of a 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. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. Ida hereby certify an r the pains ar enalties of perjury that the information providers above is true and correct. ('111M lure: ` Date: Phone#: /1) Official use only. Do not write in this area,to be completed by city or town official City or Town, Permitl.lcense# Issuing Authority(circle one): I. Board of Ilealth 2. Building Department 3.City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: _____ Phone#•