6 PATTON ROAD - BPA-10-695 REROOF The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Ili Massachusetts State Building Code, 780 CMR, T°edition OF SALEM
Revised January
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1. 2008
On - r Two-Family Dwelling
Tb6 Secti For tcial Use Only
Building Permit Nun)ber: ate Applied:
Signature:
Building Commissioner/Inspecto of u in Date -
S C 1 N I.SITE INFORMATION
1.1 Property Address: V 1.2 Assessors Map& Parcel Numbers
4L-/7—,v A .5 T
I.la Is this an accepted street?yes_ n✓ o Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(It)
1.5 Building Setbacks III)
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❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ownert of Record:
p02Rr6 ,( qm7 Ile
Name(Print) Address for Service:
Sob- 9 ?0 _,37-0
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Ofllcial Use Only
Labor and Materials
1. Building S 6�pJt y 1. Building Permit Fee:S Indicate how fee is determined:
�. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire $Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6. Total Project Cost: S �5 po r 0 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
(Y /�ti
e✓�4e ,pl License Number Es'pi/ratiunDute
Name of CSL-IIoIJer n List C'SL Type(see below) (/
7 Z TC 17 Gf� T lC f. Description
Address U nrnresuicted u to 35,000 Cu.Ft.
R Restricted 1&2 Famil Dwelling
Signat M Mason Only
RC Residential RoofingCovering
cphon WS Residential Window and Sidinit
SF Residential Solid Fuel Burning Appliance Installation
7 O / / D Residential Demolition
5.2 Registered HOW mprovement ontra tor(HIC)
P 4 '_ (Y YNoJ vn f
HIC Companyor HIC Registrant Nume Registration Number
Addres �/)Y-91 Expiration Date
Signature Telephone
SE ON 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 .......... No...........O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
i , 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.
Signature of Owner Date
SECTION 71b:OWNEW OR AUTHORIZED AGENT DECLARATION
a o lam-/ i N J j ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
jbehal �f ner or Authorized Agent Date
erthe ainsand naltirsof 'u
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(HIC)Program),will Mo 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 I IO.R6 and 110.115,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"
CITY OF S.U.E.N1q AtLkSSACHUSETTS
13L DLVG DEPARTMENT
120 WASHOiGTON STREET. r FLOOR
TEL (978)745.9S95
FAx(978) 140-959
KIJ®ERLEY DRISCOLL
Ary
MAYORTtiobw 11R ST.P� t
DIREcroaOPP LICPROPERTY/gcILDLNGCOWNUSSIONER
Workers' Compensation Insurance Affidavit Guilders/ContractonlElectricianslPlumben
karillcant Infarmalloto
Plesse Print Legibly
VaITle ltlurinerrartaml rarionlnLridusl): r�l—
Address: /t/1 Ti 4 !!'LY X l IK..0 '
city/state/zip: S�LP, i /1 P Phone 0. �! S
Are yaw an employer!Cheep the appropriate boa: Type of project(required):
1.❑ I am a unployer with e. Q 1 No a Sinteral contractor and 1
employee(full and/or put-time).• have hired the saab�cerrractors b ❑Now construction
2.❑ 1 am a solo proprietor or partner- listed an the ansched shett i y Q Remotlding
.hip and have no employee Theta sudcontreetms have tl. Q rlemotition
working for me in any capacity. workers'comp.inaumism, 9. Q Duikling addition
I No workers'comp. insurance 3.)4 We am a corporal"04 in 10.❑Electrical repair or additions
required.) onion have exercised their
3.Q 1 am a homeowner doing all work right of exemption per MOL I I.Q Plumbing repairs or additions
myself.(No worker'tomµ c. 132.41(41 aid we haw no 1241toof repair
insurance required.)t ampknyae.(No worksm' t),Q Other
comp.insurance requited)
•Any appua.m ti dw.haat n aw be air tea tttn the unnas below showing tadr war..'amps ..�n parry i tatrtnalae.
'I Lwraaw t
w sobs submit ad@ adlaYrk idtody trey am Join oil work and ilia hie oath awaraera.in"athak a new artldmw Minaity ark
t'.rtuaran the 'buch ttda ban toss ad=%"as 3"tiad ohm"wine da talc e(ese aAawarraraaa sea tbtr warhw.'taan7.paliry fatrrnrWs
/into an ampkyer that hi provldbr;w rbers'compotaradan/aaematn jar a)raplarysaa &IM it lim policy ender r/er
inform,Ato
In.surrnce Company Name:
Policy e w Self-ins.Lie.p: Expiration Darr.
Job Sire Address: City/Stae/Zip
Attach a copy of the workers'compensation policy derlerathea pop(showing the policy number and expiration dare)6
FFailum to secure covemp L required under Section 23A of MGL a.132 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment,as wall as civil penalties is the form of a STOP WORK ORDER and a tine
Of up to S230.00,a day apinrl the violator. lie adviwxl that a copy of this slatemem may be forwarded to the Office of
Inv.altymiuns of ilia DIA for insurance covcrap vcriticalica.
/do hereby cerii/y er rho nas and Pena/Nee ojpef/uty that the information provided ubove is true end correaa
vrtt cl - i S- ys ? `)
of lcid we out/yL Do tea write in thin afro,to be,utwp/erd by city of tewn 04 la-Ad
City or fuvn: Yrrmit/LlcanuM__,
luuing Aulhurtly (circle one):
I. Iluard ur HeA lk 2. Nuildtntt Deparlmcni J. City/town Clerk b. Electrical lorpeclor S. Plumbing Inspector
6.Other
l .riser ret,on: _ Phones:
Wit, 1
CITY OF SALEM
6 0 PUBLIC PROPRERTY
DEPARTMENT
.1111: Mlfl "Mlr.'II
NI .u'N 11C�'.,•111.\L.,IV�I'Mkl'7 f'SA1I\I, M.1•"r 111 J I,•.1'I'.
1'FI:v;t•N}•li9S �I°,x:Y7tl•;aa'1:NU
Construction Debris Disposal Affidavit
(required fur all demolition grid 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 q is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be transported by:
A10 r-tti �-r .160 CAI r n
(name of hauler)
The debris will be disposed or in
(name of as Ity
(o,klrins ul'1'acdity)
seat a nl permit applicam
0
date
I•I•a.dl•:•r