9 PICKMAN RD - BUILDING INSPECTION (3) The Commonwealth of Massacht�Set�SE)VE� $
� ., , SERVICE CITY OF
Board of Building Regulatiol' a� tjlQdard� SALEM
q Massachusetts State Building e, 80 CMR pp q 3 Revised Shir 2011
Building Permit Application To Construct, Rep Mellish a
one-or Two-Fcunrly Dw Ing
J This Section For Official Use Onl
(5C Building Permit Number: Date Applied,>
CT'
' Building Official(Print Name). Signature : - Date
SECTION 1:SITE INFORMATION
1.1 Property Address: (7 1.2 Assessors Alap&Parcel Numbers
1.1 a Is this an acce ted street?y�es no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
"Coning District Propose)Use Lol Area(sq R) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provide) jSECTFON
Required Provided Required Provided
1.6 water Supply:(M.G.L c.40,§ 7 Flood Zone Information: 1.8 Sewage Disposal System:
one: Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ — Check if es❑
Z: PROPERTYO�VNERSHW
2.1 Ownert of Record:
RRAh swell ifn A 54Lk)9 ^4
jme(Print) City,State,ZI
9 101cKM4,A) RD 9756 86b 37.57
Nu.and Street Telephone Email Address
SECTION 3: DESCRIPT ON OF PROPOSED wORW(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ Altemtion(s) ❑ I Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other [3,'specify: R! ')-L4A)
Brief Description of Proposed Work':
AiULATE &72 ^ LU TN RLnWni CA11
SECTION 4:ESTUNIATED CONSTRUCTION COSTS
Icon Estimated Costs: Officiul Use Only
Labor and Materials)
1, Building 0-0 I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical $ ❑Total Project Costa(item 6)x multiplier x
). Plumbing S 2� QtherFees: S 7
4.Mechanical (FIVAC) S - List:
5. Mechanical (Fire S "total All Fees:S
Su reseion)
Check No._Check Amount: Cash Amount:
6. Total Project Cost: S a$-eKJ: 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) CS''/06258 /_31_17 t
®RAD PAA)OAf License Number Expiration Dale
Name of CSL Holder List CSL'rype(see below)
//1. &21 Type Description
No.:md Street -
U Unrestricted Ouildin a to 35,000 cu. 11.
1.!//} 18L 111,4- )hoo R Restricted l&2 F:unil Dwelling
City/1'awn,Slate,Z M Masonry
RC Rooling Covering
WS Window and Siding
' SF Solid Fuel Burning Appliances
1 I Insulation
Telephone Email address D I Demolition
5.2 Registered Home Improvement Contractor(HIC) /I�SOS A)-.24
< r'c�A L'OnJTRZ VA)6 60 HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street Email address
. 07riIP
Cit /town,State ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L C.I52.g 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........... 0
SECTION lap OWNER AUTHORIZATION.TO BE COMPLETED WHEN:
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERrvuT'
[,as Owner of the subject property,hereby authorize Si l CfF1 CO AJTI. CO.
t9 act on my be f,in all matters relative to work authorized by this building permit application.
�s,•�tvfii,�����n 4�/S
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.
O 9 � /s
Print Owner' or Authorized Agent's Name(Electronic 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(HIC) Program),will no have access to the arbitration
program or guaranty fund under 1I.G.L.c. I42A.Other important information on the HIC Program can be found at
www.nnSS. •oL �O Information on the Construction Supervisor License can be found at www.mass._ov'dns
2. When substantial work is planned,provide the information below:
'total floor area(sq. R.) 'r .(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"nay be substituted for"Total Project Cost"
0 2tsarins
Tke Commonwealth fM etts
Department of Industrial Accidents
Office oflnvesiigations ,
600 Washington SYred
Boston,MA 02111
www mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A Pliant o 'Mation Please Print Le 1
pP Inf �v
Name(BusineesickpairstionAndividua0: S'R ftj /'niti?�AL'72i11.f La
Address: 374 UaryA and S r
City/Statemp: Phone m X 17 M- A*/q
Are on an employer?Check the appropriate box: Type of project(required):
1.[1I am a employer with A _ 4. ❑ I am a general contractor and I 6. Q New construction
cavloyees(full and/or part timc).' have hired the sub-conuacrora
7. Remodelin
2.❑ I arrt a sole proprietor or Partner,- listed on the attached sheet t ❑ 8
ship and have no employees . These sub-contractors have 8. Q Dernolition
working forme in any capacity. workers'comp.insurance. 9. Q Budding addition
5. We are a corporation and its
o workea co a ❑ tporati
re cap.insurance 10.Q Electrical ropers or additions
required.] officers have exercised 01e'v
3_❑ I am a homeowner doing all work right of exemption's MGL ]I.[]Plumbing repairs or additions
myself.[No workers'comp. a 152,§1(4),and we have no 12Q Roof repairs
insurance required.]t employees.[No workers
13.❑Other
comp.imsuranee required.]
'Any aWimntasa ehsta box 01 an-also an out&a section below showing their wastes'omnpe®uoa Policy infmmetioa
t Hmoenw em who shhbmit this affidavit"aft limy ere doing as week end tbmk Imo outside mnbscmrs maetsobadt a new affidavit iodicatug such.
teonbutms that cheek this box ant steehedin eddtieoel sheet showing the nsme of the sob•mubnema endtheb wmkms'Comp.policy iMo®stion.
y ant an m7loyar that it providing workers'compensation insurance for myrmployea. Below it the policy and job do
infannason.
Insurance Company Name: ZYyem h/11tMeAhl
Policy#or Self-ins.Lic.# V B'a2Edti"�5 � '/� Expiration Datc
Job Site Address: J- hC/Cp1w )tj, Cityninvaip: YfUAr At#
Attach a copy of the Workers'compensation policy declaration page(showing the policy number and expiration date -
Failure to seam coverage as required under Section 25A of MOL c� 152 can lead to the imposition of criminal penalties of a
fine up to$1,500.00 and/or onemyear imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of 0 to 9250.00 a day against the violator. Be advised that a copy of this state tent may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
do heraby certify under theeissr ns and penalties ofpedury that die information provideed above is true and correm
Sismam �hn: 1[..4 Date:
Phone#
Official use only. Do not write in llsir area,no be completed by dry or town of%dd
City or Town: Permit/Lic'ense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Clty/rown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other -
ContactPerson ' Phone#:
Cnngtmcwm Supenimr
:_-s_ CS-10"m
BMDIZYDAMDFF
15 MARIOM ROAD
weldMA OMM
UnreswiMd Bmtldin=of any uwgMWwhich
corium kwftn 35,0*cubm Seat(991ta3)of
cndmd space.
Failure to a ament edition of the Massachusetts
StateBu"%c de iscawe for revocationofthisIk we.
Far OPS ti iatar nob vwt www.Mm.Gov/OPS
Office of Consumer Affairs and Business Regulation
10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 110505
Type: Supplement Card
Expiration: 1 02 01201 6
STICCA CONTRACTING CO
BRADLEY DANOFF
376 WASHINGTON ST
MALDEN, MA 02148
Update Address and return card.Mark reason for change.
!--I Address ; Renewal [ 1 EmPloymcut 1_.I Lost Card
SCA f 0 soseoe 11 . ..
-rzt yt!IHM!!N!!t vl�irJ+r'� IIlUAt.�MH�!
Office of Consumer Affairs&Business"laden License or registration valid for individul use only
before the expiration date. If found return to:
` GNOME IMPROVEMENT CONTRACTOR
r office of Consumer Affairs and Business Regulation
Reglahadon: 110505 Type: to Park Playa-Suite 5170
Expiration: 10R02016 Supplement Card Boston,MA 02116
STICCA CONTRACTING CO
BRADLEY DANOFF
376 WASHINGTON ST g'-`— -- _ _
MALDEN,MA 02148 Usden ftary Not valid without signature
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