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1 OAK ST - BUILDING INSPECTION (3) The Cumttionwealtlt o t assachusetts Buard of Building Regulations and Standards CITY OF 1\ Ij tbfassachusetts State Building Code, 130 CMR SALEM Building Permit Application To Construct, Repair, Renovate Or Demolish a Reviszd tlfev 2011 One-or Two-Family Dwelling This Sect' tori U ril Building Permit Number Date, lied Building Official(Print Niaia) $ignat Data SECTION is SITE IWFO2WUTION. Ll Property Address 1.1 Assessors bfap&Parcel Numbers I a�Srn l.la Is this an accepted street? es no bfap Number Parcel Number 1.3 Zuninglnformation: 1.4 Property Dimensions: Zoning District Proposed Use Lot Area(sq Il) Frontage(it) 1.3 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Required Provided Required Provided 1.6 Water Supply:(M.O.L c.40,§14) 1.7 Flood Zone Informations 1.3 Sewage Disposal System: Public C3Private 13' Zone: _ Outside Flood Zone? Check ifes❑ Municipal 13 On site disposal system ❑ 3E`GTIONZ; PIiOPERTId-OW(VERSHD?i 2.1 Owner'of Rocard: kition (Pr nt) City,State,ZIP' CdAI /�� 4.1,41 ' ��?331-�9s7 Cd Street elephono Emai AddressSECTION 3: DESCRIPTION OF PROPOSED WORK 61lackallthat apply) onstruction❑ Existing Buildin ❑ OwOied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑❑ Accessory Bldg. Cl NumberofUnits_ Other ❑ Specify: Brief Description of Propose SVark a SECTION 4: ESTIyLATEDCONSTRUCTION COSTS- Rein Estimated Costs: OfRcial Use Onl Labor and,Materials y' .. I. Building $ I. Building Permit Fee:S Indicate hoti7derermined. r. Ffcctrical y ❑Slandard.City/rows Application Fee O Total Project Costs(Item 6).e multiplier 1. PlumbingS � Other Ftes: .Si;t:i'ofal All Pces: S � i hackN0. CltcckAutuuut:I'uh.tl Project ( 'nit ) `{ QOD Ij 1'.t l in Pall 0 tlat;t ldim� Ilal:tnca 1 srcrlON 5: co;Ns,I-RUCTION SERVICES 5.1 Cunstnretion supervisor License(CSL) O-J% — tz �rii PFF _ License Number Gepiratiun D11 N,una of CSL ITolder List CSL rype(teebelow) ✓/. N �/� —C' 10–L j� —/7 GW��� ra Dascriptiun No. and street ©l G ! U Unrestricted 2 F; n s u to 35,000 Co. tt. /� f R Restricted ISc2F;unil asonr Dwelliu City/ruwn, State,vp iVl M RC RU01111otLa Covering WS \Vinduw and sidillLE �7 b7 Ca V/J� SF Solid Foal Flurning Appli;mces 1 v� s� `� 1 Insulation 1'cle hmta Email address D Demolition 5.2 Registered Hone Improvement Contractor(HIC) MC Reaistration Number Expiration Date I11 Company Name or ItIC M1011mm Nmne "' �/� Email address No.and Street Ci /Town State 'ZIP Tele hone SECTION 6: WORKERS$COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 9 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'permiL Signed Affidavit Attached? Yes .......... No...,......,C SECTION 7a:OWNER AUTHORSZATIONTO DE COdIPLEIII E13 WHEN OWNER'S AGENT OR CONTILIC`n APPLIES FOR BUILDING PERhIIT (, as Owner of the subject property,hereby authorise �G iou to act on my behalf, in all matters relative to to v�thorized by this building permit application. L�1� Dnro Print Uwneff Name(Electronw Slanatura) SECTION 7h: UWNERt OR AUTHORIZED:\GENT DECLARATION By entering my name below, I hereby attest under the pains at penalties of perjury that all of the information contained in this application is true a urat knowledge and understandm . -7 . _ 'Date Print U�oner';ar Authurind:\gcntb N,una(Electrum:Signa(or) NOTES: I. ;\n Owner who obtains a building psoric to do his/her own work,ur.ln owner who hires an unregistered contractor (nut registered in dw Houle Improvement Contractor(HIC)Program), will nn have access to the arbitration program or guaranty find under M.O.L.c. 142A. Other important information on the II Program can be round at s w oras. fry%ora Intunn:ation on the Cunstntction Supervisor License can ba found at uww.url>...% ylLl 2. 1Vhan substanti;tl swrk is planned,provide the infurmatiun belu",' a finished baso nanr/attics,daels or arch) I'otal lluorarea(;q. ltJ __----- —(includinggi g , p iro;; livinyarc:a(';y. tt.l flabiGtblannnneount _ \Iwnhcratb,uh --_ rnnnls --- --- Vuud ur of ILIIE cal is - --_ --- I - _ - — \'I IIIIbN Uf I6;� I'Irilu; I-,.I+a of 11..wnl; iya�ln - -- - I nelo:cd 11PQJ1 _ .. � t '.I, I II I'r„L .t � �u u,. P �(.I;�, ul.ly I+a alh,tunl:,l t,a .. I ,t.11 irl,t•t ('n l- - CITY OF SALE1ms L1L36SACHUSETTS BUILDINGDEPk&T11MNT . 120 WASHINGTON STREET, 3"FLOOR TEL (978) 745-9595. Fmc(978) 740-9846 KINfB Rf RYDRISCOLl. 'I�.IOnNSST.FIERRB MAYOR DIRECTOR OF PUBLIC PROPERTY/HIaIDING COSL\135SIONER Workers' Compensation insurance Affidavit: Builders/Contractor.9/Electricians/Piumbers Applicant infirrmation Please Print Le ibl Name(Busine;&Crg,nizati°rvIndividual): G G J\1 Address:... 1,gogmh f cifA U 01g7OPhone li: 97� !� Seo2� City/Statc/Zip: ,k you an employer?Check the appropriate box: 'type of project(required): I.1i1 1 am a employer with 4. 0 1 am a general contractor and 1 6. 0 New construction ff employees(full and/or part-time).* have hired the subwontractms 2.0 1 ata a sour proprietor or partner- listed on the attached sheep 1 7. 0 Remodeling ship and have no employees These sub-contractors have g. 0 Demolition working,fur ma in any capacity. /workers'comp.insurance. 9. Building addition [No workers'comp:insurance 5. area corporation and its. required.] Officers have exercised their 10.0 Electrical repairs or additions J.0 1 am a homeowner doing all work right oPaxemptitm per MGL 11.0 Plumbing repairs or additions myself.[No workers'comp. c. 152;$1(4),9d we havr no 1 Z,0 Roof repairs insurance required.)t employees:[No workers'. 1J.❑Other comp,.insurancercquircd,j . -Any applicant ihu checks bmf Bl most also 1111 out the sectim below showing their wmkeis'compenwiao policy inlesmalrom I I r,weuwnens who submit this affidavit indicting ihcy are doing all work and then bin outside com nctcn must submit a new alydavit indicting such. :Cuntracturt that check ibis box meet anachod an addidunalshsad showing the name of(hesubeontrutent and theft works s'ccmp,policy inibemoaun. I am an employer that is provfdlrrR workers'compensaNan hisarancefor my employees- Below is rhe policy and fob site infernrarlam `99 ( ,, Insurance Company Name: U /� Policy u ur Sclf-stir.Lic,t/: Dk) �r— 2 OUII a C� J ):'rcpiration Date: Zo ,,7,f ` lob Site Address: / © City/State/Zip:� -MAI 01 /q/t/.-7� Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A ofblGL c. 152 can lead to the imposition of criminal penalties of a tine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line of up to 5250.00 a day against the violator. -13e advised that a copy of this statement may be forwarded to the OI'lice of Investigations of 0te DIA for insurance coverage veriticaliun. I do hereby certify ander the pains and penalties of pdrfary that the inforlrratlart provided above is true and correct. Sienature' Daro Phoned; Official ase only. Do not write in this arra,to be completed by city or town offlcl"I City or Town: Permit/License fl _ Lssuing Authority(circle one): 1, board of 1[MO 2. Building Department J.Citylfown Clerk 4, Electrical inspector 5. Plumbing inspector 6.Other Contact Persons . Phone#: l CITY OF SVa%1,, MAS&kCHUSETTS BUILD ,NG DEPARTn1HNT . aj - . , 3 • 120 WASHINGTON STREET, 3a`FLOOR - b TEL (978) 745-9595 Fmc(978) 740-9846 K%,BERt EY DRISCOII- MAYOR THontAs ST.P>FxRa DIRECTOR OF PUBLIC PROPERTY/BUILDING CO\LUISSIONER Workers' Cmnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant information Please Print Le ibl Nanic(nusiiws&Orpnization/individual): e— G /ot/ Address: © /� City/State/Zip:G _M40 IT70 Phone#: 9M 740 ,s t Are you an employer?Check the appropriate box: 'typo of project(required): I �] I am a employer with (9 4. �] 1 am a general contractor and 1 6. El Now construction employees(full-and/or part-time).* have hired the sub-contractor 2.❑ lain a sole proprietor or partner- listed on the attached sheet.l 7. ❑Remodeling ,hip and have no employees These sub-contractors have S. ❑ Demolition working,for me in any capacity. workers'comp.insurance, 0. Building addition (No workers'comp.insurance 5. We area corporation and iti. required.). offtcerd have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions myself.[No workers'comp. c. 152;§I(4);andwe have no i 2,Q Roof repairs insurance required.)t employees.[No workers comp:,insurance requited,), 13.0 Other,. ;Any applicam that cheeps box it I must also 1111 uui tho sectioa below showing their workers'compensattoo polfuy infummtfon I hvnauwnaia who submit this aenclavit indicating ihry are doing oil work and theta hke 01114 econlmaoni must submit a new afildavil indicating such. lCuntmcturs that cheek this box onto attached an mWidunal sheet showing tho narno of the nttieonbactam and thoWwurkan`comp.pulley infennnaon. fain un-employer fbatis provfding workers'compensation lltlYrance for my employees* Below tx fire policy and Job site h1fornradom ,� insurance Company Name: pA fX QXO Policy 4 or Scif-ins. Lic. d:_OIU rr�r-i W/rte "�x'pi, tion Date: Job Site Address: / City/State/Zip._ "—� Attack 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 NIGL 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 fine of up to 5250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the Office of Investigations uftlte DIA for insurance coverage verification. /do hereby certoy under the pants and penakles of perjury that the btfarmuNan provided above is true and correct I Sicnnturo: Date- Phone A• OJJic ial use Only, Do not iwite Lr this area,to be completed by city or town afliclal. Cityorlbwn: Permit/f.kenseis _ issuing Authority(circle one): L Board of health 2. nuildlnl Department 3.Cityffmvn Clerk J. Electrical Inspector 5. Plumbing Inspector 6.Other ConfactPcrson: . Phonal!: t CITY OF S.1LE, qtr, >bL,iss:wHttsEri-s `} t7t ttncrc Der.�RTat>?.vr � 4 l'0 j'U13Ht.VGTOV STtE&fj 3 FLOO,t IAC- (973) M-9595 <1su7E,U RY DRISCOLL F+x(979) 7•14-9344 ,bL�Yq;i t�tas6�sSr.Ptsang 1)(Mcrcit UP PCAL(c PROPERTY/3L mavC Co.%aussic.N g a Construction Debris Disposal Afttdavit (required for all dcmalition and renuvetion work) in accardanca with the sixth edition afthe state Building Coda, 730 C�1&IR sectian I i t.3 Ocbris, vtd the Pravhiuns uetWQL c 40, 3 54; ©Wilding Permit 4 this work shall i9 issued with the condition that the dcbrfs resulting from be dispused of in a PrcPcrly licensed waste disposal facility as daHncd by ,LIGE e It ►, s Isn�. 1'110 debris will be truspartcd by; //CSG (roma ut'ha lar) The tlQbrij will be dispasnd ot'in (iddress ur,raciLt�� 1,A ipt�iuru urparmit.ipplir.tnt