11 ORNE SQ - BUILDING INSPECTIONf �
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
'—' Y
Building Permit Number: ate Applied:
/ / /
Building Official(Print Name) Signature Date
IJ�^ SECTION 1:SITE INFORMATION
l — 1.1 Property A dress: 1.2 Assessors Map&Parcel Numbers
c, �/.� C 2
l.l a Is this an accepted street?yes L/no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(tt)
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: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal O On site disposal system ❑
Check ifyes❑
SECTION 2: PROPERTY OWNERSHIP[
2.1 Owner of Record:
!P a 6 —a
Name(Print) City,State,ZIP
11 ('11 / SC1yA46 g -
No.and Street e Tpho elene Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ I Alteration(s) ' Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: 1Z 1) ❑Paid in Full ❑Outstanding Balance Due:
yfot+,e t94/4ef—
SECTION 5: CONSTRUCTION SERVICES
5.1 onstruction Supervisor License(CSL)
�tC [) k, License Number Expiration Date
NameName of
<D�a_ Au +f
List CSL Type(see below)
2
No.and Street Type Description
,(y1,n ��� O Unrestricted(Buildings2 Fm u el ing cu.ft.
Cityffown,State,ZIP U� f/T M Masonry
I&2 Family Dwelling
RC Roofing Covering
WS Window and Siding
� ^�n ^�� SF Solid Fuel Burning Appliances
�� (3�
J(f% �FJ+ 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contactor(HIC) bWzl}S Zoe
HIC Registration Number Expiration Date
Co an N e or, C Registr e
Ll— M C o�C1, -c�pViZ� rPv19<t✓
N treet Email addr k
��ti� 47 0/X— ` PPS
City/Town,State,ZIP Telephone
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 Issuany6 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 GLl
to act on my behalf,in all matters relative to work authorized by this building permit application.
aM 64A `rx rl
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 hereby attest under the pains and penalties of perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
c1 ft �7 A -'Tki tJ""c / >-i,,rF- O-a)4)
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos
2. 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.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"
CITY OF SM EN1, 1NL�ss-kaius s
• BUII.DIING DEPART 61&NT
120 WASHIINGTON STREET, Yo FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
IQ%tBERLEY DRISCOLL
MAYOR T HOMAS ST.PIEUE
DIRECTOR OF PUBLIC PROPERTY/BUILDAVG CONfMISSIONER
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 will be transported by:
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit applicant
date
dcbriw(f.d[x:
r
CITY OF S�U.&NI NIASSACHLSETTS
• BUILDING DEPARTME:sT
v 130 WASHINGTON STREET,3ae FLOOR
dj TEL (SIN 745-9595
FAX(978) 740-9M
KI\IBERI Elf DRISCOLL
11ZAYOR THO"ST.PIE1"
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMMSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print 1,eejbIX
NaMe(Busim-swOrganizatiomindividuad):
Address: C"i-, �k(u--
City/State/Zip: �`S MIA- t---�lg 2.-4 Phone d: bO I
Are you an a ployer9 Check the appropriate box: Type of project(requireft
1.❑ 1 agod employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
ployces(full and/or par-time).' have hired the sub-contractars
2.CY1 am a sole proprietor or partner-
listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These subcontractors have il. ❑Demolition
working for me in any capacity, workers'comp.insuranm 9. Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its 10.❑Electrical airs or additions
required.) officers have exercised their
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.0 Roof repairs
insurance required.)f employees. [No workers' ME]Otha
comp.insurance requited.)
•Any applicant that checks box 9I most also fill out the section below showing their wo ne mt
rker'eompeatim policy infomlon.
*I lomeownen who submit this affidavn indicating they ate doing all wort and then hire outside contmeteta must submit a new affidavit indlcating such.
=Commetom that chmic this box must anachod an additional ahcet showing the nano of the sub.conuactms and their workers'comp.policy information.
I am an employer that is providing workers'compensadon Insurance jar my emplayeert Below Is the polley and fob site
information.
Insurance Company Name:
Policy#or Self-ins.Lie,M Expiration Date:
Job Site Address: 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 MGL 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 S250.00 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.
l do hereby crr jy and fire ns and naitle of erJury chit the informadon provided above Is true and correct
ate _ Dnte: CG l 2AZ�)(
a e�:
Ofriciat use only. Do nor write in this area,to be completed by city or town ofjiciaL
City or Town: PermidLicense#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person• Phone#: