185 NORTH ST - BUILDING INSPECTION (2) �J 4( ) I 3 o r- L-I
The Commonwealth of Massachusetts
VE,
Board of Building Regulations and StandardsCI'i Y OF
Massachusetts State Building Code, 730 CMR SALEM
Revised Mar?01/
Building Permit Application trust, Repair, Renovate Or Demolish a
One- T1vo- ntily Dwelling
This Secu n For Official Use Only .
Building Permit Number: Date Applied: ) 0 Z3
�o
Building Otticiul(Print Name). Signature- Dide
SECTION 1:SITE INFORMATION
LI Property Address: s 1.2 Assessors Map&Parcel Numbers
I.l 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 Ill Frontage(11)
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: LS Sewage Disposal System:
Zone: _ Outside Flood Zone?
Public CI Private❑ Check ifyes❑ Municipal❑ On site Disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owncrt of Rcc d:yJ�
pa•• t 0 �o'kt'�,IC Sys c o� 4 � 7Z
R7me(Print) City,State,ZIP
l6 10. rt 7c, — RW , z&L ? sr9 F'6 y/ dave
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Wo '
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building S V a7U O 1. Building Permit Fee:S Indicate how fee is determined:
Electrical S ❑.Standard City/Town Application Fee2. "
O G 0 ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing 5 v' p O 2. Other Fees: S
4. Mechanical (FIVAC) S List:
5. Mechanical (Fire '
,�
Su �ression) total All Fees:S
Check No. Check Amount: Cash Amount:
C. Total Pro
Ject Cost: .S p� si e ❑Paid in Full ❑Outstanding Balance Due:
Zo /
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supe or License(CSL) CS-' 03 1 1 & I 3 (-) ( � I'
�� License Number Expiration Da,
Nante of CSL Huller
List CSL'fype(see below)
Type Description: .
No.:ntd Street
Q 1_ (� U Unrestricted(Buildings u to 35,000 cu. It.)
II �a ✓6 `{ 0&4 R Restricted 1&2 Family Dwelling
City/1'Ovn,State,ZIP ki Masonry
RC Roofing Covering
lVS Window and Siding
_ /�� (( "� >>,,W fI � '• SF Solid Fuel Burning Appliances
COM ED `tt yll I Insulation
'felt hone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
IiIC Company Name or HIC Registrant Name -
No.and Street Email address
City/Town, State,ZIP Telephone
SECTION 6:WORKERS'CONIPENSATION 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
1,as Owner of the subject property,hereby authorize
t4 act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b:0WNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest tinder the pains and penalties of perjury that all of the information
co M I cation it e and accurate to the best of my knowledge and understanding.
Print Owner's or torized Agent's Name(Electronic Signature) Date
NOTES:
I. A.V1wncr 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 und
er der M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.eov4 cr Information on the Construction Supervisor License can be found at wtew.mass.uov/dns
�. 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. It) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms Number of half/baths
Type of heating system Number of decks/porches
'fypeofcoolingsystem Enclosed Open
3. "Total Project Square Fooatge"may be substituted for"'Fatal Project Cost"
t Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supen'isor
License' CS-032181
MICHAEL E ROS);N
23 LEBLANC DR=42kii
WESTPEABODY Expirations-
0311712014
Commissioner %
CITY OF SM EM NWSACHUSETTS
Bt:=NG DEP.Afti'mENT
+ 130 %V.isiiLNGTON STREET, 3'1O FLOOR
L TEL (978) 745-9595
F.tiY(978) 740-9844
KimBERLEY DRISCOLL
NLALYOR THOSLiS ST.PI^eRRB
DIRECTOR OF PUBLIC PttOPERTY/3UMI)LNG CONNISSION 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 1 11.5
Debris, and the provisions of NIGL c 40, S 54;
Building Permit f# 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 iMGL c
111, S 150A.
The debris will be transported by:
ti
I V tiw P
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature permit applicant
/o a s 3
dart