161 NORTH ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
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: Vate Applied:
�iy,.q a3
Building Official(Print Name) Signatu D�(e.
7 SECTION 1: SITE INFORMATION
LIP roperty Address:t� 1.2 Assessors Map&Parcel Numbers
�(p 1 al` r ST.
1.1a 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(ft)
1.5 Building Setbacks(It)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
6 Water ply:(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Dis sal System:
.Zone: _ Outside Flood Zone
r �
Public Private❑ Check if yes❑ Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
�12rkCt / e4A- 1 �,44A•u �Si Gw� ✓Y(l�. O1SZG
Name(Print) I City,State,ZIP
1, 1 Vo'g-t 14 z)T. G 7YS G 33
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) lif Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work : & .4M R t ( Ce i r1 i r L C
e� A�,d / Cyu - I l i tz 2- 6 rH I
CPl f mec ni (b 15 , ? P(� 'mn.r u s /✓1-y Q uE e.,,�c f/1e.9
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only r
Labor and Materials
1.Building $ f 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ /� j uj ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ e 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 43Dr c_f�/0 ❑Paid in Full ❑ Outstanding Balance Due:
17�5
r"ti�^
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) -1Z7�
�1 rn4��
�-j� -ram License Number Expo ion Dale
Name of C�r
5 List CSL Type(see below)
No.and Street Tye Description
G jC C 9 Unrestricted2 Family
(Buildings u el ing cu.ft.
/O l R Restricted 1&2 Famil Dwelling
Cityfrown,State,ZIP M Mason
ry
RC Roofing Covering,
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email a dress -fell D Demolition
5.�egistered Home I provement Contractor(HIC) /7 qZ Z
HIC Registration Number Expiration Date
MC Company Name or}}IC Registrant N e
psi /
No.and-,Street Email address
Ci /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 f 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
1,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.
_u /,-) i
Print wner's Name(Electronic Signature) fD to
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering m e below,I hereby attest under the pains and penalties of perjury that all of the information
coma m thi pplication is and accurate to the best of my knowledge and understanding.
' 12
Print Owner's or Authorized Agent's Name(Elo6tronic Signature) Date
NOTES:
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(MC)Program),will not have access to the arbitration
program?r guaranty fund under M.G.L. c. 142A.Other important information on the HIC Program can be found at
www.mass. ovg /oca Information on the Construction Supervisor License can be found at www.mass.eov/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"
t CITY OF S.U.E:NI, 2AXSSACHLSETTS
/ BUILDING DEPART%IENT
d• 130 WASHINGTON STREET,3'a FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
KI.\BERLEY DRISCOLL
MAYOR THoNtAs ST.PiERn
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONMIISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
ADPlicant Information Please Print Leeibly
Name(Busimss;OrganizatioNlndividual): 16w c IrP� H�_� r iP✓li�L C ix l)k
T
Address: � r f � F,,- o/583
City/State/Zip: (11 / J3 2 Phone #:r/1222 �/) 5 ` yy✓L/
Are you an employer?Cheek the appropriate box: Type of project(required):
1. am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New nstruction
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• emodeling
ship and have no employees - These subcontractors have S. ❑ Demolition
workingfor me in an capacity. workers' comp. insurance.
Y9. ❑ Building addition
(No workers'comp. insurance S. ❑ We are a corporation and its 10.❑ Electrical repairs or additions
required.) officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself.[No workers' comp. C. 152,91(4),and we have no 12.❑Roof repairs
insurance required.)t employees. [No workers' 13 ❑Other
comp. insurance required.]
Any applicant that checks box#I most also fill out the section below showing their workers'compensation policy information.
I Inmcown rs who submit this affidavit indicating they am doing all work and then hire outside contractors most submit a new affidavit indicating such.
:Contmion that check this box most anachat an additional sheet showing the name of the subeontractas and their workers'comp.policy information.
I am an employer that is providing workers'compensation Insurance jar my employees. Below Is the policy and Job site
information.
insurance Company dame: // /� q�
Policy#or Self-ins. Liic.M 6 / Qz co 57��/(¢ U Expiration Date: � C
Job Site Address: /K Z el6 C5/ Ciry/State/Zip: /i/ ,
Artach 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 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 he forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby • t/fy under a pains and ra t1 s of perjasy that the information provided above is true and correct.
�m t lr Date: /Z e) l�
Phone#:
Official use only. Do not write in this area,to be completed by city or town aJrchd
City or Town: Permit/I.icense#
Issuing Authority(circle one):
1. Board of health 2. Building Department 3.Cilyffown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other,
Contact Person: Phone#:
CITY OF SM E:INI, XWSACHUSETTS
BUILDING DEPARTMENT
130
WASHINGTON STREET, 3w FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
Kl.\fBERIBY DRISCOLL
MAYOR THows ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUILDIAIG CONMSSIO,ER
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:
(name of hauler)
The debris will be disposed of in
(name of facility))
(address of facility)
signature of permit applicant
y
date
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