7 PIONEER CIR - BUILDING INSPECTION (3) �238 � 30
The Commonwealth of Massachusetts RECEI EO
Board of Building Regulations and Standards 'NSPECTIONAL SERVMEQF
Massachusetts State Building Code, 780 CMR SALEM
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Building Permit Application To Construct,Repair,Renovate Or`Dyypp'��A a 3 � ��
One-or Two-Family Dwelling
,This Section For Official Use Only ,,.
Building Permit Number: Date Applied:
Building Official(Print Name) _ P „ , o ".Signature �,', :^ 5� _ .? ,Date r
SECTION 1: SITE INFORMATION
1.1 Pro erty Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes 'V no Map Number Parcel Number
1.3 Zoning Information: 1.4 Proper imensions:
.Sb�:1\hMk%)6 01 400 U
Zoning District Proposed Use Lot Area( q ft) Frontage(ft)
1.5 Building Setbacks(it)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
b 1211 , .
1.6 Water Supply: (M.G.L c.40,§54) 1.7. Floo ne Information: 1.8 Sewage Disposal System:
Zone: _ 'Outside Flood Zone?
Public Private❑ Check if yes❑ Municipal DI On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(P �`
nnt) City,State,ZIP
No.and Street Telephone - Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repai s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify:SNO XM i W 6' Tb 0 L
Brief Description of Proposed Work : 'T'
SECTION 4 ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials w
1.Building $ 'I_Building Permit Fee: $ : , Indicate how fee is determined:';
2. Electrical $ ❑Standard City/TownApplication Fee = x
❑.Total Project Cost'(Item 6)z multiplier """ x
3.Plumbing $ 2.-"
Other Fees
n
4.Mechanical (HVAC) $ List:V = °01
a. P c Y a . 1
5.Mechanical (Fire A"$ _
Suppression) Total All Fees $�•'_ � � '.,
6.Total Project Cost: $ 31� Check No 'Check Amount ` Cash Amount t
V ❑Paid in Full ❑ Outstanding Balance Due
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KtNtT, MUKAIN & 11VINAIV
REGISTERED LAND SURVEYORS NAME GERARDO AND LISA A. DOMINGUEZ to
75 HAMMOND STREET — FLOOR 2
WORCESTER, MA 01610-1723 LOCATION 7 PIONEER CIRCLE �
PHONE: 508-752-8885 co
FAX 508-752-8895 SALEM. MA I
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�w PuMaX me WIL�FNOF&NRE OFFSET 0 m NOT NECEsSAW ACCORATE.WOE.mum PLANS AM
NEalaRpmm ON s mom FROM VIDLAWF ENFORCEMENT
NOTED.1NB s Nmh DIED BY FEFN Nm/aR 11 YFRNr�1L COMM SWFIEY 6
$E AWJS C�GTOf6 ARE MATE WnN THE FNgi�F TNAr 7AEW9E ECflTOWtB owFmr eE aEI9BSEO.
THE aBMOIYIOII PROYM 6 ACCURATE AND TWa THE YUdURE-
I SI&t lXUaA6T LIXAM I RELATION To THE
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PIONEER
CIRCLE
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SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �
• Q Q3 n 6 C\�_.\ V.1 ` \ License Number Ex rati Da Ye
Name of CSC Holder
List CSL Type(see below)_ ��
No.an Street `-�_�-�• Type Description...,
d
. ` U Unrestricted
(Buildingsu cu.ft.
R Restricted l&2Far1 Dwelling
City/Town-,State,ZIP M Masonry
RC Roofing Coverin
WS Window and Siding
J SF Solid Fuel Burning Appliances
1 1 Insulation
Tele hone Email address D Demolition
5.2 yRegistered Home Impro ement Contractor(HIC) ` � i
1 l 1 �&-zs �C R C Registration Number xpir ion ate
o Na eor C strant Name
N6.3 tree[ `. Email address
City/Town,State, \ 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 th Issuance of the building permit.
Signed Affidavit Attached? Yes ..........No 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 D//ylet f j"I Z5
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's ame(Electronic tgnature) Oate
SECTION 7b:O R'OR AUTHORIZED AGENT DECLARATION r; ,
By en 'ng my name below,I hereby attest under the pains and penalties of perjury that all of the information
contained ' this application is true d accurate to the best of my knowledge and understanding.
Print Owner's or Authorize Agent's Name(Electronic Signature) ate
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
3D .mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/des
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"maybe substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass govldia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name(Business/orgmizationflndividual):
Address: g
City/State/Zip: \ % Pe one
Are you an employer?Check the appropriate box: _ Type of project(required):
I. I am a er with employer _Q_ 4. ❑ 1 am a.general contractor and I
P y * have hired the sub-contractors 6. ❑.New construction
employees(full and/or part-time). t 7. ❑Remodeling2.❑ I am a sole proprietor or partner- listed on the attached sheet
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any rapacity. workers'comp.insurance. g, ❑-Building addition
[No workers'comp.insurance S. ❑We are a corporation and its 10.0 Electrical repairs or additions
required-] officers have exercised their
I Elf am a homeowner doing all work right of exemption per MGL ]LEI Plumbing repairs or additions
myself.[No workers'comp. c.152,§1(4),and we have no 12.❑Roof epaus '
insurance required.]t employees.[No workers' 13Z]Oth
comp.insurance required.]
*Any applicant that checks box#1 most also fill out the section below slowing their workers'compensation policy information.
I Homeowners who submit this affidavit indicating they ate doing all work and then hire outside monitors must submit a new affidavit indicating such,
rContraciors that check this box must attached un additional shin showing the name of thesubconnaceors and their workers'comp.policy information
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information. A ^\
Insurance Company Name:'t1t., aC. S
Policy#or Self-ins.Lic.#:�l l� l 1 lot ot) Expiration Date:
t Job Site Address: 7 /� S
�\Q`(��iC� 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.$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$250.00 a day,against the violator. Be advised that a copy of this statement may be forwarded to the Office of
lnvestigaue of the DIA for insurance coverage verification.
Ida her rn unde h airu shies ofperjury that the information provided abov is and correct
Sign Date: 1
Phone#:
Ofeial use only. Do not write in this area,to be completed by city or town offeciai
City or Town: PermitiLicense#
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#•
3 ��ree'tt11 Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS 032472 .
Construction Supervisor
WENDELL W HOLMES _ ,p
23 DADANT DRNE -�sF;�
WILMINGTON MA 018ilF j
l/L— Expiration:
Commissioner 03107/2018
VRe �poma»tonme2[[/t o��LaJ4kr.J�aJedb - -
-` `QN' Office of ConsumenAffairs 8i_Business Regulation ? License or reglstcaEion,valid for mdmduhuse only
ME IMPROVEMENT CONTRACTOR - before the expiration date. Iffound return to:
egistration: :1'10127 Type:- -Office'of Consumer,Atfaimand Business Regulation. -
1O.Bsrk,Plaza-Suite.5170
xpirahon 1016/20]6- DBA�" + -
+ Boston,MA 021,%
HOLMES POOLS
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Wendell Holmes
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NON-DIVING POOL
4'-0;• 2' 20' -{2' 4'-0l' A-FRAME DETAIL DECK SUPPORT DETAIL
R2' I R2' SHORT BRACE
2' _a 2'� T4' A_FRAME
BRACE
4•
R4' PANEL PANEL
16' 12' +R6' R6'
LONGBRACE2, + + STAWE
NDRIZQITAL
SEE DETAEL-A BRACE
R2• R2' NOTES
I> DEPTH AND SHAPE OF POOL MEET MINIMUM STANDARDS
MANDATORY ROPE [IF THE INTERNATIONAL RESIDENTIAL CODE 2009 AG103.1
AND FLOAT 12 INCHES (ANSI/APSP-5) FOR RESIDENTIAL USE.
FROM SLOPE CHANGE 2)A MEANS OF EGRESS FOR BOTH THE DEEP END AND THE
SHALLOW END OF THE POOL MUST BE PROVIDED AS
REQUIRED BY ANSI/NSPI-5 SECTION-6.
FINISHED , PANEL 3) BUILDER TO PROVIDE A MEANS [IF EOUIPOTENTIAL BONDING
FINISHED DEPTH ?-4• 3'-6- ANEHEIGHT IN ACCORDANCE WITH NEC SECTION 680.
DEPTH 6'-6, -r 4)ALL A-FRAME BRACES WILL BE MOUNDED WITH A
MINIMUM OF (1) CUBIC FOOT OF CONCRETE, OR A 6-
POURED CONTINUOUS CONCRETE PERIMETER COLLAR.
5)'NO DIVING' LABELS TO BE INSTALLED AROUND PERIMETER
OF THE POOL.
-6k 6)ENTRAPMENT AVOIDANCE MUST BE INSTALLLED IN ACCORDANCE
2 INCHES SAND WITH ANSI/APSP-7.
OR VERMICULITE POOL PERIMETER: 83'-6 1/2'
POOL AREA: 447 SQFt
DETAIL-A VOLUME: 16,400 APPROX. GAL.
INTERNATIONAL SWIMMING POOLS NOTES SWIMMING POOLS ARE DANGEROUS WHEN USED IMPROPERLY. I N T E R P O O L
NEVER DIVE IN THE SHALLOW END OF ANY POOL. CONSULT WITH THE DIVING BOARD AND SLIDE
MANUFACTURER(S) AND THE ASSOCIATION 13F POOL AND SPA PROFESSIONALS (2111 EISENHOWER AVENUE 4-
ALEBANDRIA, VA 22314 (703-838-0083)PRIOR TO INSTALLING DIVING BOARDS AND/O( SLIDES ON —��, / L X 2
' 3 '
THIS POOL TO ENSURE THE POOL MEETS THE EQUIPMENT MANUFACTURERS MININUM STANDARDS FOR �p /� „J ROMAN
ALLOWABLE INSTALLATI@I OF THEIR PRGDUCT(S) ON THIS PGOL. INTERNATIONAL SWIMMING POOLS IS
NOT RESPONSIBLE FOR THE POOL'S INTERIER DETAIL. RATHER THE LINER MANUFACTURER MUST ENSURE 68Y
THE INTERIO( MEETS A P.S.P. AND AN S 1. STANDARDS IT IS THE RESPONSIBILITY OF POOL BUILDERS, 6' ATTACHES DATE: 04/06/16 SCALE: NONE
TOWN Or AND POOL OWNERS TO FOLLOW ALL SAFETY GUIDELINES OF THE AP.S.P., LOCAL TO STEP
ORDINANCES. AND EQUIPMENT MANUFACTURERS
DRAWN BY: P.T. ACADREF:SARM1632K
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