45 PRINCE ST - BUILDING INSPECTION (2) `f
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
0 Massachusetts State Building Code, 780 CMR SALEM
Revised,blur 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For Official Use Only
Building Permit Number: a Ap ied:
r / 2
G J
Building OtTicial(Printt N•. e . tgnat ate
SECTION I-SITE INFORNIATION
L�S rtyyAdddres� C S / r 1.2 Assessors Nlap&Parcel Numbers
s o Ma Number Parcel Number
1 a,ls thf an accepted street. es no P
1.3 Zoning Information- 1.4 Property Dimensions:
Zoning Dtstrict 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 Su :(M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal stem:
Public Private❑ Zuite: Outside Flood Zone'?Check if yes[] Municipal On site disposal system El
SFCTION2- PROPERTY OWNERSHIP`
2.1 Owner'of Record:
�me(Print) City,State,ZIP
`No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction❑ 1 Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Rropos j I A 5 0 !y J
0 F T141 1Z c IJC
SECTION 4: ESTIiNIATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials) Official Use Only
1. Building $ q i , w I. Building Permit Fee:$ Indicate how fee is determined:
�. Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: $
4. 'Mechanical (FIVAC) $ List: .
5. Mechanical (Fire $
Suppression) Total All Fees:S
Check No. Check Amount: Cash Amount:
6. Total Project cost. $ 3 -
0 Paid in Full ❑Outstanding Balance Due:
blet ec-,
r IF
SECTION 5: CONSTRUCTION SERVICES
5.11 Construction Supervisor License(CSL)
l
5 ` D 7 7 .s 65 License Number Espir on D
�7c4ttFof CSL Ilolder
�f o pr vJ jkm L, ` List CSL Type(see below) (0 .S
� ZAu �l �� r S / '
No.and Street Type- -0escription -
vN U Unrestricted(Buildings Up to 35,000 cu. ft.)
R Restricted 1&2 Family Dwelling
city/fownr State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
_ SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
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 ..........❑ No........... ❑
SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize
t9 act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information
con am d ' this applilcati�on is true and accurate to the best of my knowledge and understanding. 7
00%"icrl orvAtithorized Agent's Name(Electronic Signature) ate
J crt r,3 M u L ,ci �j 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 NI.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov'oc,, Information on the Construction Supervisor License can be found at www.mass.stov!dns
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"
Y
CITY OF Sa71.L'M, N'L'LSSACHUSETTS
y BUILDING DFP1RT\[F—NT
•� '"r'tl'c r�; 120 WASHINGTON STREET, 3ce FLOOR
TEL (978) 745-9595
Eta(978) 744-9W
i,JNtBERLEY DRISCOLL
�I iYOlt THomAS ST.PIERRE
DIRECTOR Of PUBLIC PROPERTY/BUILDING CONNISSIONER
Yorkers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumber9
Applicant Information Please Print Legibly
Naine (I)usinessorganiratiom Individual): V v �t' &J /✓l l/�-- CJ Va"�
s
Address: g
City/State/Zip: O� Phoneit:,ZC/ 0y
,kre.you an employer?Check the appropriate box: Type of project(required):- .
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
era "ees(full and/or part-time).* have hired the subcontractors
2. am a sole proprietor or partner- listed on the attached sheet.t �• ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers' comp. insurance. 9. Building addition
[No workers' comp, insurance 5. ❑ We are a corporation and its
required) officers have exercised their 10.❑ Electrical repass or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 11,❑ 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
cutup.insurance required.)
-Any applicant nut checks box HI must also fill out the section below showing their workers'compensation policy inli,rmation.
'I lomeownteers who suhmif this affidnvii indicating they arc doing all work and then hire outride conrmctom most submit a new alrtdavif indicating such.
:0,nlrwmm that check this box most attached an additional sheet showing the mmne of the sub.eonfractort and their workco'comp.policy infomution.
l ant un emtployer tliat is providing workers'comtpettsation insurance for my employees. Below Is the policy and job site
hifornmtiom
Insurance Company Name: _..---------
Policy 4 or Self-ins. Lie. tl: Expiration Date:
Job Site Address: 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 MOL c. 152 can lead to the imposition of criminal penalties of a
tine up to SI,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Ol'Iice of
Investigations of the DIA For insurance coverage verification.
I rlo hereby ter fy a to his turd penulties of perjury that the information provided above istrue and c'orrerL
S , n t ore Date: v C Z'r
Phone 2�2 — S U�
official use only. Do not write fit this area,to be completed by city or town official
City or Tuwn: . Permit/i.lcense N _
Issuing Authority(circle one):
1. Board of Ileallh 2, Building Department 3.Cityfrown Clerk J. Electrical Inspectur 5. Plumbing Inspector
6.Other
Contact Person: .. . . __ ...._ Phone 1:
CITY OF SAI.EI I, NWSACHUSETTS
BL'ILDNIG DEPARTMENT
120 W-ASHNGTON STREET,3'FLOOR
"�' z« .= TEL (978) 745-9595
KI\iBF;RT Y DRISCOLL Rux(978) 740-9846
�bLAYOR THOstAS ST.PtERRB
DIRECTOR OF PULIC PR0PERTY/8CIIDN(;CONWISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
fn accordance with the sixth edition of the State Building Code, 780 CMR section 1 t 1.5
Debris, and die provisions of NIGL c 40, S 54;
Building Permit f# 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 tMGL c
l 11, S 150A.
The debris wi 11 be transported by:
y
(name of hauler)
The debris will be disposed of in
J ✓ 117 17, OkK�i
(name of facility)
(address of facility)
signature of permit applicant
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