2 NICHOLS ST - BUILDING PERMIT APP $ 3
CK 3g ► 3
o The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
O ���� Massachusetts State Building Code,780 CMR SALEM
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:. Date P—Plliieed'-: i
Building Official(Print Name) '-Signature ri
SECTION 1: SITE INFORMATION I 9
IbPropet�Lrty 12 As M & Parcel Numbers ddress: . sessors Map arceumers r
of S S� -
1.1 a Is this an accepted street? es no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
r*m
N
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 ❑
SECTION 2: PROPERTY:OWNERSHIP'
2.1 Owner'of Reco
y-) Sa(.Q wi MA
N (Print) l �7ry�State,ZIPq
l l< S� �' 6` 9J- 11-100.2
No.and Street Telephone Email Address
" SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction ❑ Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I l0ther ❑ Specify:
Brief Description of Proposed Work': G U
SECTION 4:.ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: ,
Labor and Materials Official Use Only
I. Building $ 1. Building Permit-Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee -
❑Total Project Cost'(Item 6)x multiplier' x"
3. Plumbing $ 2. Other Fees: $ - - -
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
�� Check No. -Check Amount: 'Cash Amount: `
6.Total Project Cost: $ ❑Paid in Full , ❑ Outstanding Balance Due:
M T:�J it`imp '1'D 1A � M
V, AAI
SECTION 5: CONSTRUCTION-SERVICES
'r 5.1 Construction Supervisor License(CSL)
aal o �� ho! o �on t5
��� License Number Expiration Date
le
Name of CSL Holder
List CSL Type(see below)
No.and Street Type - Description,
U Unrestricted(Buildings up to 35.000 cu.ft.)
\ R Restricted 1&2 Family Dwelling
City/Town,Stale,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
3��-�3 SF Solid Fuel Burning Appliances
l— "J I 1Insulation
Telephone Email address D Demolition
5.2 Registered
�Home Improvement Contractor(HIC) r. /„ )L
2- o` Vdle HIC Registration Number Exdlir-adon Date
H 'C parry Name or HI�t,Regis r• ame
�3
o.and Street Email address
c(,.,I� MP
City/Town, Stsff,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 Issuan5p of the building permit.
Signed Affidavit Attached? Yes .......... N.—........ ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
o,OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize /2oiNe`l ok
to act on my behalf,in all matters relative to work authorized by this building permit application.
SJ-k Cow,I �o.J C)/ 1 �S
Print Owner's Name(Electronic Signature) Date
SECTION 7bi 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 my knowledge and understanding.
Print Owners or Authorized Agent's Name(Electronic Signature) Date
NOTES..a �.
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 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/dns
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"
CITY OF S�UE.Als N'-LuSACHUSETTS
t BL'u.DLNG DEPART TENT
• 130 WASHR3GTON STREET,3aa FLOOR
T EL (978) 745-9595
FAX(978)740-9846
KI%IBERLF-Y DRISCOLL
MAYOR TttontAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUUMM:G COhLLNUSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information pp y� Please Print Legibly
Name(Busim�Organizatiodlndividual):� C�
i7� 1 e �-
Address: -X ((5J'' )A/G-t c�l U S I /
City/State/Zip: i'l21 v ✓Cl�evw 61pbone tl:
Are you as employerY Check the appropriate box:
Type of project(required):
I.❑ 1 am a employer with 4. ❑ I 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. 7• ❑Remodeling
These
ship and have no employees L� sub-contractors have S. ❑Demolition
working for me in any capacity. orkers'comp. insurance. 9, ❑Building addition
[No workers comp.insurance S. We are a corporation and its 10 El Electrical repairs or additions
required.] officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.[No workers'camp. 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 chhucts bra d 1 most also rill out the serum below slowing their workers'compensarion policy inr'nmatio a,
1 I homeowners who submit this afAdavb indicating They ran doing all work and thw hire our,ide eanoncers most submit a trees affidavit imliwling etreh
'C,noractor,that check this has most attached an additional sheet showing the name of the sub ntnwtots and their workers'wrap.polity to adnit sug.
ch.
l am an employer that is prov•ding workers' 'ompens(attipo-n insarancefor my employees. Below is the policy and fob site
information.
�1C \N\
Insurance Company Name:.
"Policy 4 or Scif-ins.Lie.H__ 11 W c ���`��(�3 Expiration Dater
lob Sire Address: � 11V t C i 1 S City/State/Zip:_q' yn
Attach it copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can 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 may be forwarded to the Office of
Investigation+of the DIA for insurance coverage verification.
l do hereby certify trader
,,tlhe—pains and penalties of perjury that the information provided above is true and correct.
i m 1 ire• (J7 c, 1 1 clo �Q' 2��'Vt"('/0 Date
Phone It: �Soi )3(Ib — /Y J 1c .
Official use only. Do not write in this area,to be completed by city at town official
City or Town: Permit/1.1cense
Issuing Authority(circle one):
1. Board of Ileallh 2,Building Department 3.Cityrrown Clerk 4.Electrical Inspector S. Plumbing Inspector
6.Other
Contact Person: Phone$:
° CITY OF S4.UE.1\I, NUsSACHUSETTS
3t:R.Dl3NG DEPiRT\tEZNT
\ o 120 WiSHNGTON STREET, NO FLOOR
T EI- (978) 745-9595
FAX(978) 7.30-9846
KIIIBERLEY DRISCOLL
MAYOR T HoNiAs ST.P[ERRa
DIRECTOR OF Pl BLIC PROPERTY/BUUMLNG CONMaSSIONER
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 MGL 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:
L l . lde;-•ry�14 fZ—Scm S
(nam hauler)
The debris will be disposed of in :
C . Z. . ldc,(Vgu C� SJN-� S
(nam�of facility)
---� (address of facility) i
signature of permit applicant
date
debnsnil'Jac
zr�o,
H&R ROOFING AND SIDING CONTRACTORS Proposal
GALL: SOa-348-4348
PROPOSAL#
FREE ESTIMATES•FULLY INSURED
SHEET#
ONLY IN AMERICA 22 Years of Workmanship with references MA LICENSE#152206
All work 100%guaranteed in writing RI LICENSE#28442 DATE
PROPOSAL SUBMITTED TO: WORK TO BE SUBMITTED AT:
NAME: ADDRESS:
ADDRESS:
a Nci oI
PHONE: ARCHITECT:
H&R ROOFING AND SIDING CONTRACTORS
We hereby submit specifications and estimates for ROOFING COMMENT..
1. fiver house and shrubs with tarpaulins for their protection.
2. to existing roofing up to 2 Layers(Extra—$50.00 per layer per SO. Ff.over layers). A 0 Lr o ljf,eil 14 r,- Of IiL
3. nail all loose roof boards. hQ .)- xtp? . O fidQ
4. Re ce all rotten roof boards up to 50 sq.ft.no charge.$6.00 per sq.ft.thereafter.
5. install feet ice and water shield at all gutter edges,valleys and chi ey.
6. .'Install aluminum drip edges to all edges color hit, ❑Silver ❑Brown Ft.
7�C) lb.felt underlayment. llk_i, alf_A A4 '�' 1 M
8. &flash dormers and wall areas if any as necessary.
9. wave all valley if any.
10. stall new roof flanges on vent pipes.
11. L�fstall new roof shingles to all roofs on hous ARCH r 3TAB Color sq. ❑ Porch Roofs
12 fnstall new aluminum chimney step flashing.
13. Install new ridge vent to all peaks.
14. Clean all gutters.
15. If needs plywood after stripping rood it will be an extra charge at fa' arket price.
16. OPTIONS: ❑ Flat rubber roof ❑Soffit vents ew lead chimney flashing ❑Chimney rebuilt umpster
and Extras: ❑Garage ❑ Hurricane nailing ❑Skylight ❑ Fascia or soffit replacement ❑ Gutters
❑Bay roofs ❑CDX plywood ❑ Low slope ❑Material supplied by customer
All checks payable to H&R ROOFING SIDING CONTRACTORS—All dates are contingent upon adverse weather.
We take no responsibility for dust and debris in your attic.Please cover and/or remove valuables. Respectfully Submitted H&R ROOFING AND SIDING CONTRACTORS
Magnetic clean up for nails.All debris to be removed Fully licensed and Insured.All work warranted for
25 to 30 years.You may cancel agreement if a has been signed by a party thereto at a place other than Per H&R ROOFING AND SIDING CONTRACTORS
an address of the seller,which may be his main office,provided you notify the seller in writing at his man
office by ordinary mail posted by telegram sent,or by delivery not later than midnight of the third
business day following the signing of this agreement. NOTE—This proposal may be withdrawn by us if not accepted within 15 days.
TOTAL 9 ? ", J �-
YOU HAVE 72 HOURS TO CANCEL THIS PROPOSAL.AFTER 72 HOURS, DEPOSIT IS NON-REFUNDABLE.
Payment Plan Date: Acceptance of Proposal
OC?C
1/3 Deposit ;S ^ C) tjs The above prices,specifications,and conditions are satisfactory and are hereby accepted.You are
U authorized to do the work as specified. Payment will be made as outlined above.
1/3 Start
Customer Signatur
1/3 Completion
NO PERSONAL CHECKS Salesman Signature
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
C4 nWrrucrion Supen-ianr Specialn -
License: CSSL_101027
RONALDOSOLANO
16 North Street $ $ = •�
Fremtngham 7A ,17' -
Commissioner Expiration
12IM2015
l
�y\_Office of Consumer Affairs&Basiaess Regulation
ME IMPROVEMENT CONTRACTOR
istration: 152206 Type:
piration: M12016 DBA
Y
- H&R ROOFING
RONALDO SOLANO
763 WAVERLY ST g �2
FRAMINGHAM,MA 01702 —�—
Uader retary