14 NAPLES RD - BUILDING INSPECTION (2) i
The Commonwealth of Massachusetts CITY OF
YN
Board of Building Regulations and Standards� Massachusetts State Building Code, 780 CMR SALEM
Revised.Clot 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
Otte-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number. tA,A ted:
Building Official(Print ;une): Si' r Date
SECTION f:SITE FORMATION
1.1 Property A dress: 1.2 Assessors Nlap& Parcel Numbers
t
I.I a Is this an accepted street?yes ✓ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L a 40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone'?
Public Private❑ Check ifyes❑ Municipal2VIOn site disposal system ❑
SECTION2: PROPERTY OWNERSHIP''
2.1 wnerl of Record:
to OL4,1:
l ern `�a�t4l n n
4hme(Print) City,Slate,ZIP
I �[1%J2 (61 . �k OVA 213-VI .Cwl
No. mid Strect i Telephone Ernuil Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ I Existing Building Owner-Occupied epairs(s)ZO' Alteration(s) Addition�f
Demolition ❑ Accessory Bldg.
Number of Units Other ❑ Specify:
Brief Description of Proposed \Vork': ,
/{i1VCTy .f✓ "C P ?ti CZrrrr2 /)n" C4n ✓S'i9T9A
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and iNlaterials)
I. Bung $ , U o0 1, Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑-Standard City/'ru%vn Application Fee
Z d O ❑Total Project Cost (Item 6)x multiplier
3. Plumbing S ! 0 O U o ? Other Fees: S
d. Mcchanird (FIVAC) S List:
S. Nlcchanicat (Fire
Su pression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6. Tutal Project Cost: S 190 0 /DOb v" ❑ Paid in Full ❑Outstanding Balance Due:
-c 1649
w�4b d &A
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 3 _(
(,o* L W n S e J/`. License Number_�— Expiration Date
Name of CSL Holder
List CSL"type(see below)
�� l E �1f)L� c�
Nu.and Street "f la,.i.'. Description
iI ��f }� e ? D Unrestricted(Buildings a to 35,000 cu. it.)
n
! (!�- J�. Q Restricted 1&2 FamilyDwelling
Cityk u ,State,ZIP M Mason
ry
� hh ZD
Roofing Covering
.--v., �i�� Window and Siding
c. Solid Fuel l;uming Appliances
Insulation
Telc hone Email address .CC:n Demolition
5.2 Registered Home Improvement Contractor(HIC) / L/5 2S Z
IA4, 67 i 2r /11 a n' v t fI1C Registration Number Fspuuliun Date
FI1C Comp:u nine or Ifegistr: / nII
/
No. d Str t Email addre s
city/Town,State,ZIP Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(MIG.L.c. 152.g 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 .........r 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 4,,t 11 Gam,., Idea
t9 act on my behalf, in qll matters relative to work authorized by this building permit appcation.
(� d$'-
11c, &IAHn /V
Print Owner's Name(Electronic Signature) ate
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 and accurate to the best of ny k v edge and understanding.
Print Owner's or Authorized Agent' ;one(Flee truoi Signal e) Date
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 Flome Improvement Contractor(HIC)Program),will not have access to the arbitration
program or guaranty fund under iNLG.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov�oaa Information on the Construction Supervisor License can be found at w�ew.niass.uov:41.tM
2. When substantial work is planned,provide the information below:
'rota) floor area(sq. It.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. tl.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms q Number of half/baths
Type of heating system rs Number of decks/porches
Type of cooling system n /a Enclosed Open
r
3. "Total Project Square Footage"may be substituted for'Total Project Cost"
5" CITY OF SAL.EM, NLA sSACHUSETTS
• Bt=LNG DEPARTMENT
120 WASIANGTON STREET, 31D FLOOR
T EL (978) 745-9595
FAx(978) 740-9846
KIMBERt FY DRISCOLL
i44AYOR T1do:�L►S ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONNISSIONFR
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 111.5
Debris, and the provisions of NfGL c 40, S 54;
Building Permit# 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 MGL c
111, S 150A.
The debris will be transported by:
(name a1'hauler)
The debris will be disposed of in
i
(name of facility)
ff
(address of facility)
signature of permit applicant
date
!° CITY OF SaZr . -,\I, NAL SSACHUSETTS
BL:ILDING DEP-.RV,ff-1T
} 120 WASHINGTON STREET,3"a FLOOR
TEL (978) 745-9595
Fmx(978) 740--9846
KINfBF A f FY DRISCOLL THohiAS ST.PIERRE
IMAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDING CONLNIISSIONER
Workers' Cornftensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legibly
VaInC (Nosiness:Organizariun.'Individual): �ir'/./ l�lJ �ai�T/.�1G
Address: _-3_if c
City/State/Zip: 5 �,, iN1� D/,�O Phone #: '�- 2,&Q 2-O
Are you an employer?Check the appropriate box: '9 ype of project(required):
I.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).° have hired the sub-contractors
- 2.El am a sole proprietor or partner-
listed on the attached sheet.t 7 �Remodtling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers' comp.insurance. g. Building addition
[No worker comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their ME] Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑ Plumbing repairs or additions
myself. [No workers' comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13 ❑ Other
comp. insurance required.]
•Any applicant flat checks box Bl must also rill out the section twlow showing their worketa compensation policy in b mation.
+I lommwnen who submit this affidavit indicating they are doing all work and then him outside cammetom must submit a new arrdavit indicating such.
=(:,ouractors That check This boa mar attached an addiliorml abect showing aw mmce of the subaoNractors and their workers'comp.policy infomtation.
I out an employer that is providing workers'eumpensadon insurance for my employeest. Below is the policy mad job sits
information.
Insurance Company Name: A,f f r
Policy 4 or Self-inv. Lie. e: G lG =_31 c- $'.�,�,�r�J /1 Expiration Date: /➢�/r� ). /,/ _
Job Site Address: /TR4Z? G/- City/state/zip'—We LyL,j 20
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A ofNIGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to$230.00 a day against The violator. Be advised that a copy of this statement may be forwarded to the Office of
Invesligalions ofthc DIA for insurance coverage verification.
Ida hereby ceerttify�under doe paiyns and penalties/of perjury that the information provided above is true
,,and correct.
ll!It'IIIIfC' [// // �.wM Date: w�Z/ / S
Phone#� /Tor -ZZ,21 6 2®2
Official use atdy. Do nor write its tilts area,to be completed by city or town officlut
City or Town: _..__._.__.._ Permit/ License
Issuing Authority(circle one):
1. Board of health 2. Building Department 3.Cilyifnwn Clerk 4. Flectrical Inspector 5. Plumbing Inspector
6.Other ._____--
I Contact Person: _,_._. ...._.__......_ Phone I: