39 NORTHEND AVE - BUILDING INSPECTION (4) 11
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The Commonwealth of Massachusetts
Board of Building Regulations and Standard RECEIVE OF
� ! Massachusetts State Building Code, 780 CQNSPECTIONAL ERYNkm
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate o t3UHs+q 151
One-or Two-Family Dwelling w�•
This Section For Official Use Only
Building Permit Number. Date Ap lied:
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.I a Is this an accepted street?yes_ no Map Number Parcel Numhcr
1.3 Zoning Information: 1.4 Prc,perty Dimensions:
Zoning District Pmlmscd Usc Lot Area(sq 11) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Require) Provided Required Provided
1.6 Water Supply:(M.O.L c.40,§54) 1.7 Flood "Lone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ zone: _ Outside Flood Zonc? Municipal ❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSFIIP'
2.1 Owneri of Re ord:
f�16 __
Name(Print)—,/ City,State,,rZ111
_3q /�f7/ � Ton G�i-V4" ?— _�J�1/ �..�i ���ee EJl�.—CPsrt
No.and Street "I"elephone d'niail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building DUO"
Owner-Occupied ❑ Rer.; i s) ❑ I :I: tioi(s) ❑ Addition ❑
Demolition Cl Accessory Bldg. ❑ Number of Units Other ❑ Specify:___
Brief Description of Proposed Work 2:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor,md Materials Official Use Only
1. Building S Oa I. Building Permit Fee: S Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'([tern 6)x multiplier_ x
3. Plumbing $ 2. Other Pees: $
4. M List:
(I IVAC) S List: �
5. Mechanical (Fire
Suppression) 5 Total All Fees: S_
Check No. check r\mount Cash Amount
6. Total Project Cost S /� d' --
/ �U ❑ Paid in Full ❑Outstanding Balance Duc:
�IJKe I`f M LS.l L—tFm sP I e,
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
i�tfRi?JA'/�*fans oS� 064
License Number Fspirat ion Date
Name of CSL Holder �p
r�,?r i�'s�„— IS List CSL'fype(see below) !�
No.and Street Type Description
'44 O��S_ S U Unrestricted(Buildings up to 35,000 cu. ft.)
Cityl1'own,State,"LIP R Restricted M2 FamilyDwelling
M Masonry
RC Roofing Covering
WS Window and Siding
SF' Solid Fuel Burning Appliances
7,9/-6t/0-S-177 �o���GlAtLtSJpuiiral� 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
_i7Sy7y
/7—�Zflb/LI //J JIJ3r 111C Registration Numtxx Expiration Date
I IIC Company Name or I IIC Registra t Name /e
( J� rr71"l- SJ �ar3p� /`RAOL7SiA aY� Cm"
No.and Street
Email address
city/'town,State,ZIP` Icle hone
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
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, as Owner of the subject property, hereby authorize ✓ � L''-
to act on my behalf,in all matters relative to work authorized by this building permit application.
�T b L- _ (� -/�-/y/
Print Ownu s Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under a pains and penalties of perjury that all of the information
cont3inct iinn this application is true and accurate h best o ny knowledge and understanding.
. uthorPrint Owners.:.AzdA Name(Electronic Signature) 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 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
wwwLuass.eov/oca Information on the Construction Supervisor License can be found at www.nmss.eov/dos
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. R.) Habitable room count
Number of fireplaces_--_ Number of bedrooms
Number of bathrooms _ Number of half/baths
Type of healing 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:1LzNf2 >tiL1SS:ICHUSETTS
lJI;tLDLNGDEPAR-MENT
120
_0 WASHLNGTON S-nF T, }O FLOOR
4 l�r�EL (973) 745-9595
!Q.%u3ERI PY DIUSCOLL F•%-X(973) 7d-9344
NLAYO L
r-1o3L13 ST.Plcgltg
DIRECTOR OF PUBLIC PROPERTY/sE:UZLNG COSLN1,SSIONER
Construction Debris Disposal Afttdavit
(required ter all demolition and renovation work)
In accordance with the sixdi edition of the State Building Coda, 730 CUR section It 1.5
Debris, mid the provisions of I1MGL c 40, 3 54;
Building Permit l# is issued with the condition that the debris
properlylicensed resulting m
this work shall be disposed of in a censed waste disposal Fro
facility as defined by ,ng r c
S 150A.
The debris will be transported by:
n S
(name fhaulcr)
The debris will be disposed otin
- (naula of taaility)
-`-- (:Dress of�ilcilit%1
L J
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CITY OF SAL.EM, NLNSSACHL'SETI-S
( BUILDING DEPARTSLE.NT
120 WASHLNGTON STREET, 3as FLOOR
TEL (978) 745-9595
F.ir(978) 740-9846
K).\IBERLEY DRISCOLL
�LiYOR THaMAs ST.PIE13AE
DIRECTOR OF PUBLIC PROPERTY/BUILDING COXLMISSIONER
Worlcers' Cmnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print t e ihly
Vililll.' (nusinussOrgvliratiamindividu,ll): �P✓* )"P fIA.fG�T
Address: / 7Z/ wrEST .ST.
City/State/Zip: l�EPFrJro //4 Phone #: . 7PI-6 7 �
Arc you an employer!Check the appropriate box: 'type of project(required):
1.❑ 1 am a employer with 4. ❑ 1 alto a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).• have hired the sub-contractors
2.�ans a sole proprietor or partner- listed on the attached sheet. t 7. ❑Remodeling
ship and have no employees These sub-contractors have B. ❑ Demolition
working liar me in any capacity. workers'camp. insurance. 9. ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs or additions
myself. (No workers'cump. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers'
comp.insurance required.] 13.❑ Other
•Any upplicml nut checks but AI most also rill out the section beluw thawing their workers'compensation policy infiomadon.
'I lumeowm"who w1voil this amdivit indicating ihry ate doing all work and then hire Outside contractors most sohmil a new afl?davit indi=ing such.
('n tmiors thin check this box most anachcvl an additional nhwl showing the mane of the subaonlncton and their workers'comp.policy information.
I unt an employer that is providing workers'conspensallon insurance jar my employees. BLIoly Is the poUcy and fob silo
information. yJ/
Insurance Company Name:
/A, �I�r r
Policy 4 or Self-ills. Lie. Jl: V�e- 19
' �Z— Expiration Dale:_
Job Site AdJresS: 3e Abr/-4aeyo &r City/State/Zip: S� A44-
AtWch a copy of the workers'compensation pulley declaratlon page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine 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 aline
nr up to SM.00 a day against the violalor. Ile advised that a copy of this Statement may be forwarded to the Office of
lo%c stlgutiont of the DIA for Insurance coverage verification.
/do irdreby cerri a or the poi and pen altics u rrjury that the nrfunnuliun pro eider/above is true and correct
CX
si-viiturr Data:
Phtme 1 7JL/-�4rd
Official use only. Do not wthe im this area,to be completed by city or town ofpcinf
City nr'fuwn: —._.. — ilermitli.Icensc#
Lssuing Authority(circle one): - -- _— --- --
L Board of Ilealth 2. Iuilding Ilepartuteut J.chylrown Clerk 4. Electrical Inspector S. Plumbing Inspector
6.Other
Contact 1'crson:_ _--__-- Phone tt: