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1 ORCHARD TER - BUILDING INSPECTION (2) c � 2 a -7 Z, The Commonwealth oftblassachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 730 CfvIR SALEM P Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised Mar20lf One-or Ttva-Family Dwelling This Section For Official Use Only. Building Permit Number: Dai dC 1. L Il2Z Building Ot}icial(PontN:une), SECTION I:SITE INFORtNIAT10N " 1.1 Property Address: -J - I rlk6.d I cr�4 C c LI Assessors blip g parcel Numbers I.la Is this an accepted street?yes x: no _ Map Number Parcel Numbcr 1,3 Zoning Information: La Property Dimensions: Zoning District Proposed Ua�—' Lot Arca(sq tt) Frontage(R) 1.5 Building Setbacks(ft) Front Yard Side Yards Provided Re Require) Provided Rear Yard Required Require Provide) 1.6 JVater Supply:(M.O.L a 40,§54) 1.7 Flood Zone Information; LS Sewage Disposal System: Public❑ Private El Zone: _ Outside Flood Zone? Check ifyes❑ Municipal❑ On site disposal system ❑ OwncrofRecorSECTION 2: PROPERTY4OWNERSHIPt 2. t � d: t V i rJ Ujry y tj VringI ,,(P A%- City State,ZIP _fiC✓/- fn �+ No Strict 7 7L ga (.,G14 Telephone — — SECTIOEmail Address N 3: DESCRIPTION OF PROPOSED WORK'(check all that"apply) New Construction❑ Existing Building)? Owner-Occupied Repairs(s) ❑ Alteration Demolition s Addition ❑ ❑ Accessory Bldg.—0Number of Units Brief Description OfPr —r /Other ❑ Specify: lkit /Vow, TJ SECTION a: ESTLHATED CONSTRUCTION COSTS Item Estimated Costs: Labor and i\laterials Official Use Only I. Building $ S rOO I. Building permit Fee:$ Indicate how fee is determined: 2. Electrical $ �0 Cl Standard City/Town Application Fee 3. Plumbing ❑Total Project Costa(Item 6)x multiplier ,x 2. Other Fees: $ d. Mechanical (FIVAC) $ List: 5. \lechmiical (Fire Su ression) $ 'total r\II Fces:$ 6. Tutsi Project Cost: $ Check No. Check— Amount rQO ❑ Paid in Full —Cash Amount:__ Cl Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 03(5.1 Construction Supervisor License(CSL) X= License Numbcr Expiration Date nn�tr'r' •u% �'I,t�JS JName ot'CSL H(ldu/cr List CSL Type(see below)__�- . '3 L 'type ' Description No.and Street _ U Unrestricted Buildin s u to 35,000 cu. ft.) p ,�� S R Restricted 1&2 Famil Dwellin W � ry lam/1 I NI Mason Citylrown, Iatc,ZIP ILC Roofin Covering WS Window and Sidin �i5 e I V i I SF Solid Fuel Burning Appliances 1 Insulation —� QS76-Vgc?C-3 jj,/�in Email address CCLD Demolition ` Tcic lune /5�.2 Registered Home Improvement Contractor(HIC HIC Registration Number xpirution Date r �..r� enc �r �c L-6 -e a-, I IIC Camp;laY Name or HIC Registrant Name ry 1 S/ .i Sl lit 1z 1 f71 Email address No.ndStreet nA/�- �d-I�� � S 3 u 'Iele hone Ci /Town,State ZIP N INSURANCE AFFIDAVIT(M.G.L.C. 152.§ 25C( SECTION 6:WORKERS'CONIPENSATIO itted with this application. Failure to provide Workers Compensation Insurance affidavit must be completed and subm this affidavit will result in the denial of the issuance of the building permit. Signed Affidavit Attached? Yes .......... 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 permit application. tg act on my behalf,in all matters relative to work authorized by this building p ! ! �l/- A Date Prin[Owner's Nmne(Elecrromc Signature) SECTION 7ti:OWNERt OR AUTHORIZED AGENT DECLARATION By entering my name below,l hereby attest under the pains and penalties of perjury that all of the information contained in this application is true and accu late to the best of my knowledge and understanding. f 3 Date L-/ Print Owner's ar Authorized Agent's Name Lice tc Signature) NOTES: I. An Owner who obtains a building permit to do his/her own work,or an ol'In'titshaveta cess toires an the arbitration (not registered in the Home Improvement Contractor(NIC) Program), program or guaranty fund under ivLG.L.c. Id2A.Oilier important information on the HIC Program can be found at a,h,,, �,s,cov:'oea Information on the Construction Supervisor License can be Found at www mass.'sov��IL 2, When substantial work is planned,provide the information inglgarage finished basement/attics,decks or porch) Total floor area(sq. tt•) Habitable room count Gross living area(sq. ft.) Number of bedrooms Number of fireplaces Number of half/baths Number of bathrooms Number of decks/porches Type of heating system Enclosed-_Open fype of cooling system } Ibtal Project Square Footage"stay be substituted for`Total Project Cost" Page# of pages \r ProSubmitted To ,,f„� C04\1 � Job Na 9 Job# o al i vdr✓— rl Yi C04 Ad ress i- Job Locations, / �� �a`rc� �efrrnCC / _ e%' Date 1 ' Date of Plans Phone# (,� Fax# or- Architect We/r,h�ere/ebbyy..submit specifications ad estimates for: cel JULw --1'�>odr -- - #tis I�� --- — ——-- — _----- ----=--- — --- UC 1 C!r co V z.V c_- We propose hereby to fur ish material and labor —complete in accordance with the above specifications for the sum of: $ 1[ Dollars with payments to be made as follows: Any alteration or deviation from above specifications involving extra costs will Respectfully be executed only upon written order,and will become an extra charge over and Submitted above the estimate.All agreements contingent upon strikes,accidents,or delays beyond our control. Note—this proposal may be withdrawn by us if not accepted within days. CArceptance of JJropofsal The above prices,specifications and conditions are satisfactory and are hereby accepted. You are authorized to do the work as specified. Signature Payments will be made as outlined above. Date of Acceptance ` 3 Signature NC3819 '12 � N c� C r f /J lN'7 W E4, 1 I CITY OF SM1 E1 f, tiL�SS.ICHUSEITS q '' 13ULLDLNG DEPARnL&NT 120 WASHNGTON STREET, 3'FLOOIt TEL (978) 735-9595 KimmRL EY DRISCOLL F.Lx(978) 740-9844 ;NLAYOR Tkosw ST.Pmrts DIRECTOR OF PUBLIC PR0PERTY/8UIIDD;G COSOfISSIONER 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 It 1.5 Debris, and die 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 MGL c I 11, S 150A. The debris will be transsported( by: (name of hauler) The debris will be disposed ot'in (name of facility) GV t�e i ' M/ - (address of facility) si,nature ofpermit applicant — CITY OF SzU.EM, NLkSSACHLSETTS BUILDING DEPARTMENT 'H 413• 120 WASHINGTON STREET, 3su FLOOR TEL (978) 745-9595 FA.r(978) 740-9W KI\fBERLFY DRISCOLL MAYOR T mOMAs ST.PIERRE DIRECTOR OF PUBLIC PROPERTY/BUILDLVG CO\LMISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Nalnc (13usimess Organ 1m 1zaliiu /l mlividual): 1,5-t Address: / St Mn 3 2 d City/State/Zip{ ✓2 J ✓I 6t34f Phone 9:6�? "( �/ Are you an employer?Check the appropriate box: 'rype of project(required): I, ..am a employer with 1! 4• ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).' have hired the sub-contractors 2.❑ lama sole proprietor or partner- listed on the attached sheet.t ?• Et- modeling ship and have no employees These sub-contractors have 8. ❑ Demolition working for me in any capacity. workers'comp. insurance. y. ❑ Building addition INo 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 11.0 Plumbing repairs or additions myself. [No workers' comp, C. 152, §1(4),and we have no 12.❑ Roof repairs - insurance required.] t employees. [No workers' sump. insurance required.] 13.E:1 Other -Any upph[eat iliac checks box plmost also fit um the section below showing their worken'compensation policy inhumation. 'I lomeuwm"who submit this afficlnvit indicating ihcy am doing all work and then hire outside contactors mint submit a new arLdavil indicting such. Cumraewa thul chuck this box mint attached an addi loroll sheet showing dho name ofthe sub�ccmaeton and(heir workers'camp.policy information. 1 um on eutployer that is providing workers'compensation bnsuruncefor my employees. Below!s rhe policy and fob site hifonrraion. L Insurance Company Valne: S Uvl "l__.__ `S S 0 r4i G('.. Policy 4 or Self-ins. Lic. H:Ac S ,u joq�'_". !7/j•' Expiration Date:. Gl / Y C� le Job Site Address:I JCL4,� Tt­rA"Q- City/State/Zip: Attach 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',VfGL c. 152 can lead to the imposition of criminal penalties of a fine up to 51,500:00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up m 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigations of the DIA for insurance coverage verification. I do hereby cervi under die his and penalties of perjury that the information provided abovemrd correct 5jo3tore' Dale' Id-4713 Phonel_e t/ S3�I qo2Cla-- Official use only. Do not write M this area,to be completed by city or town offletal City nr'I'uwn: ----Per mit[License# ------_._--_.. .- Issuiog Aulhurhy(circle enc): 1. Board of Ifealth 2. Building Department 1.City(rutvn Clerk 3. Fleetrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone [ ! A- 5 ✓�+e 'r0omvmae of Consumer Affairs&B "Ines"RegulationE IMPROVEMENT CONTRACTOR Type:istratlon �t171919 Corporation-vahon 5!112014ME COMFORT I<�C t { HICOS rti h -S Rf) ,A 02152.,t,_.(� Undersecretaryr. 4 1 Massachusetts -Department of Public Safety Regulations and Standards !- Board of Building Reg �r Construction Supervisor .t License: CS-103884 MATTHEW 3 to s 34 PEBBLE AVENUEa - WinthropAlA 02152 ���i� , ''��. �� ���•� Expiration 0810112015 Commissioner c��z lz /73 The Commonwealth of Massachusetts • _ jtlg Board of Building Regulations and Standards CITY �j Massachusetts State Building Code,780 CMR,7`^edition OF SALEM Revised January Building Permit Application To Construct,Repair,Renovate Or Demolish a 1,2008 One-or Two-Family Dwelling fihls,Sec i9#t. t�Ii ial`, only Btti in N' ber s; atepNe . ,Signature Jwf BwldiggCominissionel>;nsp'ectoPoEBibl'i"}m '' ,,,'( - - 1.1 Property . PiAdd . ress: / ( 1.2 Assessors Map&Parcel Numbers c S 1.1 a is this an accepted street?yes o_ Map Number Parcel Number 1.3 Zoning Information; 1.4 Property Dimensions: Zoning District, .Proposed Use .Lot Area(sq ft) - Frontage(ft) - 1.$ 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 13On site disposal system ❑ 77 77,77 ECTION2 �jz® s>I>P' 2.1 Owne�rlofRe rd: 1�pt /q? LU. r o Name(Print) -- Address for Service: - y , k sisz Signature - - Telephone SECTIaN 3 T)E C1tIIiT,IQ1it eck a113hat apply) New Construction❑ Existing Building.❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition 17 Demolition ❑ Accessory Bldg. 13 Number of Units Other ❑ Specify: Brief Description of Proposed Work : "V SECTION 4: ESTIMATED,'GOIYSTRUi'1[ONCOSTS' Item Estimated Costs ' Labor and Materials) = . O"f$cial1Jse-OnI 1.Building $ t Buil m_g„Ferttltt Feo,'$ Indicate bow fee is determined: 2.Electrical $ ?5tatrdard't "Ov, wn Application.Fee 47 TotdaC"c�t0l's (Item i�Yc mul(iplier x 3.Plumbing $ 2.fiOtHf $e§ 4.Mechanical (HVAC) $ t 5.Mechanical (Fire $ Suppression) pf8)All'F�es $ > 'Ch6tk No k ChicAmount: Cash Amount: 6.Total Project Cost: $ 4i (� I Paid m Full .117 Outstanding Balance.Due: .SECTTQN 5�'��Q1V9�`tiU;, :..13y ^'�E1tYIC!'S v- 5.1 Licensed Construction (CSL) —7 14C77:? MiC, /aP L License Number Expiration Date Name of CSL-Holder _ q List CSL Type(see below) y Address .� j n U Unrestricted u to 35,000 Cu.Ft. A � .�-- R Restricted 1&2 Family Dwelling Signature M Maso Out RC Residential Roofin Coverm Telephone WS. Residential Window and Sidin SF Residential Solid Fuel Burning AP liance Installation D Residential Demolition 5.2 Re isteFe H el tprovement Contra gt r m 6�-y E_ ^I T Registration Number HIC Cogtgen Name or C Reg nt ne Address ! 7 j 7k,7 F�-�IZ Expiration Date Signature ,Y / Telephone77"", 777777 U' S,ECTIOIV,w6.', WORTCERS'COMpENSATT0D1 IN�UIINCE AFI IDAYIT.(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. "At i NEIf A1C) HI�ItI_A QNi'Eb$E;C F, L b WIIEN UWit1ER'SAGENT.ORGf1N>ItACTURAPPT�S OA'Bi7IL ?1PERMLT. as Owner of the subject property hereby I, to act on.my behalf,in all matters authorize relative to work authorized by this building permit application. LIA L. Si nature of Owner Date SEL'"!'•IO)V 7b QWNER�5� �4UF�2� .�� ��kG,F�1`�I1E�LARATION : , as Owner or Authorized Agent hereby declare that the statements and informatio on the foregoing application are true and accurate,to the best of my knowledge and behalf. l Print Name ///SLA / )JA Signature of Owner or Authorized Date (Signed under the inns and penalties of a ju 1. An Owner who obtains a budding 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 and Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 110.R5,respectively. 2. -When substantial work is planned,provide the information below: Total floors 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"