22-24 PARK ST - BUILDING INSPECTION (3) The Commonwealth of Massachusetts RECEIY s Regulations 5
P a Board of Building Re ons and S $ERYIC
p� � �pg�+,fiCTIUNAI CITY OF
Massachusetts State Building Code, 780 CMR SALEM
II: 3evised Mar 2011
Building Permit Application To Construct, Repair, Re."JAM o is t a
One-or 7ivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date pplied:
Building Official(Print Name) Signature vDate
SECTION 1:SITE INFORMATION
1.1 Property A$dress: 1.2 Assessors tYlap& Parcel Numbers
77 ZY Iwr-Y 54- Iln. k- $i I _
I.1 a Is this an accepted street?yes_V_ no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Diwensions:
Zoning District Proposed Use Lot Arca(sq It) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
___T s I ttl2tE
Required Provided Required Pravidul
1.6 Water Supply:(NLG.L,c. .10,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check iryes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWN ERSIIIP'
2.1 Owneri of Record:
_
None(Print) City,Slate,ZIP
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK2(check II that apply)
New Construction ❑ Existing Building Q' Owner-Occupi�10IRcpairs(s) Altera[ion(s) ❑ Addition ❑
Demolition ❑ AccessoryBldg. ❑ Number of UniOther ❑ Specify:
Brief Description of proposed \York'':__,1?e r%c+ J-�
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 15 pop I. Building Pennit Fee: $_ Indicate how fee is determined:
2. Electrical $ ❑Standard CitylTown Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S ?. Other Fees:
4. Mechanical TIVAC) $ List:
5. Mechanical (Fire
Su ression) $ Total All Fees: $
Check No. _Check Amount: _Cash Amount
6.Total Project Cost: $ l5� 6-to 0 Paid in Full ❑Outstanding Balance Due:
r
t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(M)
i �5-1-37clt 01 Zv Lois
License Number F,xp ration Date
Name of CS illolder. �
" fn '* List CSI,'f see below Lq re 57fls`t-t_Z
No.and Street 'rype Description
ale U ffi,n
d 'In dinM35.00O)Citylfown,State,ZIFI&2 FaamiM RC overinWS d SidinS. Buming A
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC) i 7.71(�
// G I�15
I1IC Registration Number Es rat' n Date
f IIC Gnnp:vay Name or I IIC Registrant Name
No.and Street S41rM D raN Email
l address
City/Town,State,ZIP Tele hone
SECTION 6: WORKERS' CONIPENSATION 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
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 Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, I 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.
r _
-30 /y
Punt w is or Authorized Agents Name(Flectronic 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(FIIC) Program), will not have access to the arbitration
program or guaranty fund tinder M.G.L. c. 142A.Other important information on the HIC Program can be found at
www.nmss.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dns
2. When substantial work is planned, provide the information below:
Total floor area(sq. 11.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. 11.) 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 —_-
3. "Total Project Square Footage"may be substituted for`Total Project Cost"
CITY OF SM-E 2 L%C1SS:ICHUSETTS
BCILOLNG DEP.IRTJLGNT
1e Yr t 120
_0 V(/.13HLYGTOV STZEET, }O FLOOR
Ttl- (979) 745-9595
KENMERLEY DRISCOLL FAX(973) 740-984S
NLAYO;'t
T'rtOSLL4$T,PIc.Rtl$
DaELTOR OF PUBLIC PROP ERTY/aCtLDLNG CO\L11ISSIONER
Construction Debris Disposal Af'fldavit
(required for all demolition and renovation work)
In accordance with the sixdi edition of the State Building Code, 750 C,fR
Debris, ruid die provisions Of tMOL e 40, S 54; section l 11.5
Building Permit # is issued with the condition that the debris resultin fm
g m
this work shall be disposed ot'in a prope
l S ISOA. rly licensed waste disposal racility as defined by b9OL c
ll,
The debris will be transported by:
y
("Inu: urliaulcr)
The debris will be disposed OF in
(name of(]cdity) -
r 111111y)
i
siynumro u(perant applicant
-----
Q-1-Y OF S.`l '%[, 21vL1SS.ICHUSE7--S
BUILDING DEPART\tL\T
3 3v" tl 120 WASHINGTON STREET, 3'r'FLOOR
T EL (978) 745-9595
F.ke(978) 740-98-16
KIMBERLEY DRISCOLL
A-kyOR THOSfAS ST.PlERRH
DIRECTOR OF PUBLIC PROPERTY/BCII.DING COMMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electrlcians/Plumherg
Applicant Information Please Print 1 of ibl_y
VeI11C (Nosiness(Jrganiralion,lndividu:d):�v,�TZ�s'�C. t's"'�
Address: -
Cily/State/Zip: lem Jl 0070 Phonehl: `176 -6ti9-f 3
Are you un employer!Check thesppropriate bus: FOEMI
7or
ired):
1.❑ I am a employer with - 4• ❑ I am a general contractor and 1n
�ntployees(full and/or part-time).• have hired the sub-contractors
2 I am a sole proprietor or partnur- listed on the attached.rhect, t
.hip and have no employees These sub-contractors have CO]
working for me in any capacity. workers'comp. insurance. n
(No workers'camp. insurance 5. ❑ We are a corporation and i6s
required.) officers have exercised their or additions
3.❑ I am a homcuwner 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. [No workers' 13.❑ Olhcr
comp. insurance required,]
'Any applicant Hour checks box rI must also fill out the scu un below showing tbeir wudtco'cumperumiun pulicy imbrmarlun.
'I Inmo ewoors who suhmit this a01(trivir indicating they are doing all work mtd then hire outside cuntracton most sohmit a new aMdavit indicating such.
$'antrwmn ihut chuck this box most Machu)in nddiliwul.hun showing the name of the subrunrncturs and their workers'camp.policy information.
I our an employer that hr providing n'orkert'cumptasutlon insurance for my employees. Dehola Is the policy and fob site
iu�uurulinn. y-
Insurance Company Name: 'uvwc�C.rCe tT"C. r .
Policy it or Self-iris. Lic. 0: M a 6J Z--,__ Expiration Datc:
Job Site Addrr:ss: ZZ-2 t-I 'PafL t) City/Stale/Zip:
Attach a copy of lice o-orkers' campensutlon policy declaration page(showing the policy number and expiration date).
Failurt:to secure coverage as required under.Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties ofa
line up to S 1,500.00 and/or One-year imprisnnmmill,as well as civil penalties in(he form of a STOP WORE(ORDER and a lino
of up to S230.00 a day against file violator. He advised that a cagy of This statement may be forwarded to the 011ice of
Inve>ligatiuns ol'the OIA for insurance coverage verification.
I du hereby certify under the paint arrd penalties u/perjury that the hi/oranutlaa provided ubuve ix true and correct
^t none' i / 1)ntet 1' /U
k 0 4
01 icial use ardy. Do oat write in this area,to be completed by city or town n/Jir•iur!
City or Town Permit/f.lcentc.a
Issuing Atilhurily (circle one): -- -- _— „_-- - ---
1. Board uI'llealth 2. Iktilding Ilepartun•nt .1.Cityfrnwu Clerk 1. Electrical Iuspcctur S. Pf lolbing Inspcclur
6. Other
C'u n1sU I urat n: