20 ORIENT WAY - BUILDING INSPECTION (3) \ j / _� - --- fhe Cuntntuntvcahlt ul'��1;usarhwclls
( I ' a I1uard ul'Iluilding Regulations and SI.indards ( I I'1'OF
,
s 1V Mas.sa:huscits Sate Building CuJc, SO CNIR
a '.. lret r„.d v„r_nlf
Building Permit Application To Construct, Repair. Rcnuv:ae Or Demolish a
(Are-firrllw-Flultill. Duellrtrq
1-his Section Fur Otlieial se Only
Building Permit Number: I Bate:\ plied:
Iluilding 011icial(Print Mune) .tiigttalu Ou c
SECTION I:SITE INFORIIIATIO
rop�s(y AtlJresp 1.2 Assessors %Ie & c Number
I.la Is this an accepted street?yel no Map Number Parcel Number
I.J Zoning Informations 1.4 Property D nslons:
Lining District Proposed(Ise Lot Area Isq 11) FronWga(II)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Requimf Provided Required Provided
1.6 Water Supply:IM.G.I.e.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Pricatu O Zone: _ Outside Flood Zone? Municipal On slla disposal System.
O Check If yesO
SECTION]: PROPERTY OWNERSHIP'
wnairs of Record nA
N;unc 'm) (my.Stale,ZIP
Nu.:mJ S relephune Finail Address
SECTION J: DIESCAIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 E.risting Building O Owner-Occupied O Repalrs(s) C! I Alteratlants) ❑ Addition O
Demolition O Accessory Bldg.Cl Number of Units Other O .Specie
\ D f Des (pti of P o e \Vor
X t
SECTION J: ESTLNATED CONSTRUCTION COSTS
IICIn Estimated Costs: Olilclal Use On1
ILahor and Itlateriah) Y
I. Buddintl S I. Building Permit Fee: S Indicate how Ice is determined:
'. FIVclrical S O Standard City:Tusvn Application Fee
❑Total Project Cost'I(tens 6)v multiplier
t I'lunihing S '. Other Fees: S_ — -- -
J. Nlcchanic.d ill\ \('I S List:
11cih.mi"ll IPre
/X\ Su .vc,ilonl S rotas \II Fccs: S
('Ilk: \u. __( haA.\mount: l'.I�h \m.nun:
Total I'rnject Cad S — ❑ P.tiJ in Full
❑Oulst:uldinq B.d.mce Doc:
v V "yAby-ke 66612(�
SE("PIONS: ('I)Ntil'Rll('f ION SERVI('F.0
S.I ('unslructionSupenis iceuie(['S1.1 --- -
-- ---
�� >. I lceuee Numher I'\plr;ni�m Dole
1 ��//✓✓�� "�... -
N.une Ill iI I�LJJer � .1l'SI. I'%Pe hs
f>Pe Deicviptiun
No.-,old Free
1( Ite'tricled IS?I/^' /n1 (I (4lrestricicJ IIIudJin ill lu 1S,I111J cu. ILI
P .unit Dealin
V v \k \I Slawm
NC Roulin Coscrin
14'S N'indow.utdSidin
SF Solid Fuel lhtming.\ppliwtccs
I Inwluliun
l'ac hone ! I n1ail udJresi D Dcmolitiun
S.2 Registered Ilome Improvement Contractor(HIC)
IIIC Iteg(alrutiun NuntM:r livpiruliuu Uale
I IIC II N•une or I IIC Itegislrunt Nunes
(imai)address
Nu.wtJ street
Ci /Town. State ZIP rele one
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.Lc. 152.1 25CM)
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this atfidavit will result in the denial of the Issuance of the building permit.
Signed Affidavit Attached? Yes .......... t] No...........Cl
SECTION 7st OWNER AUTHORIZATION TO 8E 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.
Print Uwuer's Native(Electronic Signature)
Dula
SECTION 7b: OWNERt OR AUTIIORIZED AGENT DECLARATION
By entering Illy name below.I hereby attest wider the pains and penalties of perjury that all of the information
\/ conUi his lica tr nd accurate to the best of my knowledge and understandingg. _
((��``jj Data
/ I'rinl „neisar:\uthnnred,\hem sNenwlhlecuunly\Ignalun)
vo'rEs:
I. .\n O\stier who obtains a building permit to do hither own work.or an owner who hires in unregistered conuaclor
I not registered in the Hume Improvement Contractur(HIC) Program).will no have access to the arbitration
program or guaranty land under.M.G.L.c. IJ_'.i. Other important information on the HIC Program can be found at
nl.h, '�;o, -% I information on the Construction Supervisor License can be found at 1,,,,, Ill.1— ,,a 'ill'
\\hen iubilanlial work is planned, provide the information below:
I
our . t.l - _—__.._Iincluding garage, tinisheJ basement allies.Jerks or porch)
fugal (lr area Icy area I . l l --_, Habitable ruuni cuunt
Grusi l
\unlher of hedrooms
\unlheroYlireplaces .. ... _ .. --- \umher kit h;dfhalIti
\wllherolhathroolui -
I wollwmillgi),tem NumheralJeeki porches
1�I,v ofI uololg .�,WIII
I'nau,cJ I)pen
1 "I LII I'ro lc'zt Sll oare l'o,iI we 111.'% he ,Ilh,t I It It cJ lPr I ulal l'rujeO Co,t•
1 �
CITY OF SALEN111, N'LAISSACHUSETTS
BUILDING DEPARTJIENT
p e 120 WASHOVGTON STREET, 3'o FLOOR
TEL (978) 745-9595
F.kx(978) 740-9846
KjN(BEjU FY DRISCOLL
VL.%YOR THOMAs ST.Pt> RRE
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO%,WISSIONER
Workers' Compensation .insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aritilicant Information I I Please Print Legibly
Name(BusinvysiOrganization/individual):
,T�M Z
Address:
City/ tate/Zip: AA AV- Phone N: 7
Ar you an employer?Check the appropriate bust: 'Cype.of p feet(required):
i. 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑ ew construction
employees(full and/or part have hired the subcontractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. 7• Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demo(' 'on
working for me in any capacity. workers'comp. insurance. 9• ❑Builltinz addition
[No worker'' comp.insurance 5. ❑ We are a corporation and its
required.] officers have exercised their to.❑ ' ectrical repairs or additions
3.ElI am a homeowner doing all work right of exemption per MGL I I. Plumbing repairs or additions
myself. [No workers'comp. c. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.]t employees.LN'o workers'
comp. insurance required.] 13.❑Other
•Any applicant[I=chcroks box nt must also rill out tho section below showing their wotkea'compensation policy information.
I tomeowners who submit this affidavit indicating they am doing all work and then hire outside contractors most submit a txw affidavit indicting such.
Comrm:turs that check this box most attached an additionel sheet showing the name of the sub•erintracton and thew workerr'ramp.paltry infomution.
I am on employer that is providing workers'compensatlon insurance for my employees. Below Is fire policy and Jab site
informal/on.
Insurance Company Name. r 1� G/2
Policy#or Se)(=nu. Lic, q: `' <--7 ` J Expiration Date:_ _
Job Site Address: za City/State/Zip:
,mach a copy of the workers'compensation policy 4laratlan 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 4 STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Offee of
Investigwions of the DtA for insurance coverage verification.
I do hereby c un err nd peirnitles of perjury Drat tliee injormatlotr prov(d dab o �]/is I correct
St„n.litlfe't
Phone
Official use only. Do not write in flux urea,to be completed by city or town ofJlejul
City or'rown: _,_ Permit/License
Issuing Authority(circle one):
1. Board of health 2.Building Department 3.Citylfown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other,--
Contact Person: Phone#:
CITY OF SM.F-M, NL-1SSACHUSETTS
BUILDING DEP:IR—M&NT
130 WASHNGTON STREET, 3° FLOOR
TEL (978) 745-9595
Fnx(978) 740-9846
KIJt3E1tLEY DRISCOLL
MAYOR THO�LiS ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSLMISSIONER
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 ili be transported by:
Coh �c /-
(name of hauler)
The debris will be disposed of in :
(name of facility)
S L-j Q/n7 N N 7
(a dress of facility) -
d .
signature of permit applicant
date
dcbi;saifd�x