19 PATRIOT LN - BUILDING INSPECTION The Commonwealth of Massachusetts
° Board of Building Regulations and Standards RECEIVEDq� CITY OF
Massachusetts State Building Code, 780 CMR INSPECTIONAL Y deff,r 2011
Building Permit Application To Construct,Repair,Renovate Or.Demolish a
One-or Two-Family Dwelling 14 A 11: 00
This Section For Official Use Only
Building Permit Number: Date App 'e : '
L 7 /G
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
1.1 Property, ddress: 1.2 Assessors Map&Parcel Numbers
�Q r7J LiyG
'I.l a Is this an accepted street?yeses no Map Number Parcel Number
1.3 Zoning information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
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? MunicipaLb On site disposal system ❑
Check if yeslk�
SECTION 2: PROPERTY OWNERSHIP'
21 Owner of,$$ecord•11, t� r� , �
�m J `l.11rls flrr .IICr� 'IADt SGLI ;f11 Ml1
Name(Print) City,State,ZIP
lR a4r1a4 L0e_1 �2- �d ,�APIsf�Irrx�, co►Y,
No.and Street T e Email A dress
SECTION 3: DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work2: RJ'm o✓6 ,#i J W T(Jl3 24- T,zT�
c/L
i
o0
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 0(go,.. 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 $ d•� 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5.Mechanical (Fire Suppression)
$ Total All Fees: $
Check No., Check Amount: Cash Amount:
6.Total Project Cost: S 3000, / ❑Paid in Full ❑Outstanding Balance Due:
rL-Lv,�(5 Se-T'�V qb 15 Fl,�axxN-' S-1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construe ton Supervisor License(CSL)
Sco7F �-e(�/�S�evJ` 7- 3-l�
License Number Ex Expiration Date
Name of CSL Holder f /
List CSL'I'ype(see below) C/L.
No.and Street I\ I` Description
Ow
t�, f w� ( �7� U Unrestricted(Buildings u to 35,000 cu.ft.
/ n / R Restricted I&2 Family Dwelling
City w ,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
r SF Solid Fuel Burning Appliances
9 -330� Scot e� ��7a� I Insulation
Tele hone Finail address t ,<0 D Demolition
5.2 Registered Home Improvement Cont act J or(H IC) /.�100�/7
/ ' � �/� n /
/a./ r /l/ern /e.,,-/e ///r10: C Registration Number Expiration Date
HIC Company�e or HIC Registr�ame� HI
No.and Str t Email address I/
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 Issuance of the building permit.
Signed Affidavit Attached? Yes .......... �r No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I,as Owner of the subject property,hereby authorize_/-a'L,2n � Lr-/
to act on my behalf,in all matters relative to work authorized by this building permit applicat o .
ns Inc C�i I ' .___.
Print Owner's Name(Electronic Sign a
ature) Date
SECTION 7b:OWNER'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 wledge and understanding.
A/'7/, 2 -)^ 2 _/ S`
Print Owner's or Authorized Agent's (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. I42A.Other important information on the HIC Program can be found at
16 .mass.eov/oca Information on the Construction Supervisor License can be found at www mass.eov/dgs
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 S�U.ENN N-L-1SSACHLSEM
• BUILDING DEPARTMENT
a l'_'O WASHiNGTON STREET,P FLOOR
arj T L (978)745-9595
FAX(978)740-9846
KIJiBMEY DRISCOLL
1r1AYOR T1iOMAS ST.PIERR6 DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CO.NLMDSSIONER
Workers' Compensation insurance Affidavit: Builders]Contractors/Eleetricians/Plumbers
Applicant Information Please Print Legibly
Value(Busims Organization/individual):
Address: ! 3 //Jo/-r c
City/State/Zip: Sc ( urn D/S w Phone N: J 7
Are an employer?Cheek the appropriate box: Type of project(required):
I 1 am a employer with� 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7.JR Remodeling
ship and have no employees These sub-contractors have S. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. Building addition
(No workers'comp.insurance 5. [1 We are a corporation and its
required.] officers have exercised then 10.❑Electrical repairs or additions
3.❑ 1 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.[No workers' 13 ❑Other
comp.insurance required.]
;Any applicant that thetas boa sl must also till out the section below showing their workers'compensation policy infumtation.
'I Inmeuwtsas w1w submit this affidavit indicating they an:doing all work and then hire outside contmenots most submit a new affidavit indicating such
=commoton that Bieck this box must attached an additional sheet showing the name of the sub�coatracWts and their wotkers'comp.policy information.
i um an employer that is providing workers'compensadon insurance for my employees. Below is the policy and fob site
information.
Insurance Company Name: G-�oT�j' ? —J >41,
Policy Nor Self-ins.Lice.N: WL �—'���3 L3139--aO Expiration Date:�r
Job Site Address: / I �fl�j ITS 419AJL% City/State/2ip: 1_=,7
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 S 1,500.00 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 or the DIA for insurance coverage verification.
i der hereby certify under t e pains andpenathilp of perfary that the information provided above 1s true and correct.
Sienmure• q Date' ;.—
7 e L -Jy
Phone#: / 7Y' 7/V' 07
Official use only Do not write in this area,to be completed by city or town offieiaL
City or Town: Permit/License N
Issuing Authority(circle one):
1. Board of Ilealth 2.Building Department 3.Cilyffown Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other,
Contact Person: Phone N:
f
CITY OF SALEM) NWSACHL'SETrs
BL'ILDMG DEPIRT\MNT
p 120 WASHNGTON STREET,3m FLOOR
T EL (978) 745-9595
Fnx(978) 740-9846
1C1\1BERLEY DRISCOLL
MAYOR T Ho.%.A3 ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BC7LDI%G CMMUSSIONER
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:
/ a
(name of hauler)
The
debris will be disposed of in
/: /
(name of facility)
(address of facility)
r v
signature of p mit applicant
'/ `/yy
date
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