7-9 PLYMOUTH ST - BUILDING INSPECTION cow
The Commonwealth of Massachusetts
uh,
Board of Building Regulations and Standards CITY OF
SALEbI
Massachusetts State Building Code, 780 CMR
Revised,Liar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Tivo-Family Dwelling
This Section For Official Use Only
Building Permit Number: bat lied` g-C>
t3'..ldmg.Ot6cial(Print Name) Sign ore - Date
SECTION 1:'SITEINFORn fATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
—ij-9 OlVfhas k ST-
I.la Is this an accepted street?yes ✓ no 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(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? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2. Ownern of Record:
Rhine(Printl City,State,ZIP
�-5 D�ymo�r'+ ST S6/ 30g 5�38
No.mid tnt`c� ' 'Celephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied [3Repairs(s) ❑ Alteration(s) ElAddition Cl
Demolition ❑ Accessory Bldg. ❑ Number of Units Other city: S'iR1?� C Ad Qz�
Brief Description of Proposed Work 2: 5 R� P00P t K e iC.aop
C-5 nee K1 .
SECTION 4: ESTIMATED CONSTRUCTION COSTS'
Estimated Costs:
Item - Official Use Only'
Labor and Materials)
I. Building $ 00 O-0 I. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Feed':
2. Electrical $
❑Totals Project.Cost'(item 6)x multiplier x
3. Plumbing S 2. Other Fees: $
4. Mechanical (FIVAC) $ List: - - �`�
5. iNlechanical (Fire
Total All Fees: $
Suppression)
Check No. Check Amount: Cash Amount:
6. Total Project Cost $ I G,q p, of 0 Paid in Full 0 Outstanding Balance Due:
t 1
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
--1-6mot ^3r�
f>_ 9 r��S n `tr'" An&C License Number Expiration Date
Nmne oFCSL rn Flolder ��77�
No.and Sueet
List CSL Type(see below) t1
rot \/'C�n'"— e Type Description:-_
U Unrestricted(Buildings tip to 35,000 cu. ft.)
[—✓/JN /Y1/! n1cloy R Restricted 1&2 Family Dwelling
CiC�own,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidim,
SF Solid Fuel Burning Appliances
nblSTi4 tarn I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/�/Y /U/))B
w) r 1 I t M `�-"RAAX 4 u- ty 2 CON9I- tr l FI C Registration Number Expiration Date
FIIC Company Name or HIC Registrant Name
').1Cyelonca 5T
N and Street Email address
y ir1A iFo ��1545 /�f1
Cit /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 .......... 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 (`_�[5
t9 act on my behalf, in all matters relative to work authorized by his building permit application.
� -l3'a�1y
Print Owner's Nmne(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.
1A d) A/ti ` RANANT [11'l3'aory
Print Owner's 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 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
soww.rnass.cov:'oca Information on the Construction Supervisor License can be found at www.mass.aov/cIps,
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"
1 j
CITY OF S.U.Etip, NYL-kSSACHUSETTS
• BUILDING DEPARTNtEINT
• 130 WASHIINGTON STREET, 3'O FLOOR
T EL (978) 745-9595
FAxx(978) 740-9846
KINtBpRT F.Y DRISCOLL
MAYORT'HOstAs ST.PtERR&
DIRECTOR OF PUBLIC PROPERTY/BurLDD4G COWMISSIONER
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:
`y l.�t 11"am "�2au�atVT
(name of hauler)
The debris will be disposed of in
(name of facility) —y
(address of facility)
atnre of permit applicant
C3 • �3-aot3
date
IjUbnijtf d'X
�! CITY OF SMZL%I, iAxsscImusMS
BUILDING DEPART.IENT
120 WASHINGTON STREET, 3sa FLOOR
' TEL (978)745-9595.
F.LX(978)740-9846
KIJIBERI.SY DRISCOL L TtiORL1S ST.PiERRB
MAYOR
DIRECTOR OF PUBLIC PROPERTY/BUILDCVG CON12MISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant information Please Print Legibly
Ntune (Busii%4sOrganizatiamindividual): ✓s) I ��t(-Y*�`{(2A{1/3 � 3fZ CCYLS�/�ucfrJ✓\
Address: 7—
City/Sratc/zip:L,lyA, .Aj mA lollrn4 Phone* Zt 5'r9 !a //
Are yo n employer?Check the appropriate box: Type of project(required):
1.21 am a employer with 102 4, 0 I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the subcontractorx
2.0 lain a sole proprietor or partner- listed on the attached sheet 1 7. ❑Remodeling
ship and have no employees These subcontractors have 3. ❑Demolition
working.fur me in any capacity. workers'comp.insurance. 9. El Building addition
[No workers'comp.insurance 5.1] We are a corporation and its
officers have exercised their 10.❑Electrical repairs of additions
required.]. - . . ..
3.0 1 am a homeowner doing all work right of exempdurl per MGL 11.0 Plumbing repairs or additions
myself.(No workers'comp. c.,152;§1(4y,and we have no 12.C'Raof repairs
insurance required.]t employees.LNO workers, 13.0 Other
sump.insurance rcquircd.].
•Any appikam that chwim boa e 1 must also fill out tha section below showing their waken'campensatlao pulley information.
I Lmm:uwn ns who submit this affidavit indicating they an doing all wort[and than him mtiids commca ns most submit anew aQldavil indicating auch
:Contractors Ihat check this box most anaehod an sddilionsl shml showing Iho name of the su"atraebn and Ihab'workers'camp,put icy inlrxmanm.
i am airentployer that Is providing)vorkerr'compensation hisarance for my empluyem Below/s the policy and fah slte
infarmaliam ^
Insurance Company Name: (/�,J A
ee�o -a Policy lJurSrif-itts.Lic.H: tPSS9Va S13 y Expiration Date:— /a v5_ yi3 -
Job Site Address: /'e( plyr wfR S/ City/State/zip: �/e!2:3,/nA tn/9,)o
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to sccury coverage as required under Section 25A of MOL c. 152 can lead to the imposition of criminal penalties of a
tint up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
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 of the DiA f°r insurance cnvcraga verification.
/do hereby certify underr tthhatt pp/ules aid penolrfes of per/ury that the iufonnurlat provided above is true and correct
-Ii" I �f—sa-z-EI�1/yA.ti� Data'
Phone A: Op/ SS9 /d-14
D/Jlcial use ady. Do not write in this area,as be canrpleted by city or town nfJkluL
Cityor,ruwn: Permil/f.leense
fssuing Authurity(circle one):
I. Board of hearth 2. 13uildinti Department I Cityffown Clerk a. Electrical Inspector 5. Plumbing lnapeetor
6.Other
Contact Person: - —_ Phone#:
L