34 PURITAN RD - BUILDING INSPECTION 7 I lie Commonwealth of Massachusetts
Board of Building Regulations and Standards CI'fl' OF
I �1 Massachusetts State Building Code, 780 CMR SALE)
Building Permit Application To Construct, Repair. Renovate Or Demolish a
One-or Tuvr-Fumilr Divelliu.K
This Section For Official Use Only
Building Permit Number: / Date: '•d:
Building Official(Print N;unu•)
SECTION I: SITE INFO ATION
L I Pro
Address: 1.2 Assessors Nlap& Parcel Numbers
3.��u�.l� Rd -
I.la Is this an accepted street?yes no Map Numher Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District IRoposed Use Lot Area(sq II) Frontage(11)
1.5 Building Setbacks(R)
From Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c.40,§51) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private O Zone: _ Outside Flood Zone°Check if yes❑ Municipal ❑ On site disposal syslnn ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 wnert of Record:ATIUSCIA 111 S/+c,M MJq
Name(Prim) City,State,ZIP
31 �41 J-11-3dq-6I60
No.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORKr(check all that apply)
New Construction ❑ Existing Buildin Owner-Occupied Repairs(s) ❑ Alteration(s) CIAddition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ I Other Specify:
Brief Description of Proposed Work _
- n
SECTION 4: ESTLWATED CONSTRUCTION COSTS
Item Estimated Costs:
(Labor and Materials) Official Use Only
I. Building S I. Building Permit Fee: f Indicate hIdeternunedd:
'. Electrical S ❑Standard City/Town Application Fee
O Total Project Cost'(Item 6)x multiplier —1. Plumbing S ' OtherFees: S
J. Nicownical Ilt1'.\(') 5 List:
Nlcrh: tieal IFirc .Cu>>nasionl Total .\II Fces: S
ChakNo. Chcak :\mount: Cash \mount: _
n. Total Project Cost: S 7A10Q, 00 ❑ p:uid in Full ❑ Outstanding Bul:mcc Doc:
SECTION 5: C'ONS1'RUC'rION SERVICES
5.1 ('onstruction Supervisor License(CS 1.) t 6Lz5.1 6 y
g License Nunthcr I�gtirati,a Uum
Name al C'SI. I lnidcr ._.___—_ ' .
list CSl. I)pe hec.hclowl-_-_____.—__
3_Qvs7ffrs+ UL._____._ 1)pe Description
No, and Street
'A S ')O 1 I htrustricled(IIui)dings on to 35,000 cu. 11.)
R Restricted I.r2 Famil Dtwllin j
Cirri fart n.Gale.LIP \I Xlaonry
RC Rooling Coverin
._.—. R'S Window:md Siding
3Y7rts W IV f SF Solid Fuel Burning Appliances
,� Cph'vCb7• 1 Insulation
'I'cic hone F:nlaill ddress D Demolition
5.2 Registered Homes Improvement Contractor(HIC) /' 7
� L 1
M ASs W*AJ r• I& �"6*3 � I IIC Registration Number L. pir; ion Oulu
1
:Cd,
) :u a or I I�gistrant Name A44M W�(V^ �*C���U-
Nu.�yIn,y�S�ef�t Cj naii address
Sl NIA I'll ) 7fl Z �-� y�r
City/Town. State,ZIP relu hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 Alftdavit Attached? Yes .......... ❑ No........... O
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 W tc(�A')Z1� 14&N iM*S3 loy r
to act on my behalf, in all mattersrelative to work authorized by this building permi application.
1(ar 11,s�A 1 o 1 rA t !t/
P t Owner's Nane(ElccWnic Signature) I I 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 die best of my knowledge and understanding.
R u411r/``0 LIih" /z T /Z? l
Print omwr's or:\utharircJ.\gent':Hume(Flectrunic Signaure) I I Date
NOTES:
I. An Owner tvhu obtains a building permit to do his.her own work,ur an owner who hires an unregistered contractor
(nut registered in the Hume Improvement Contractor(HIC) Program), will It have access to the arbitration
program or guaranty fund under.M.G.L. c. 1 a2,4. Other important information on the HIC Program can be found at
tttt,t ma,. �; .t ,".1 Information on the Construction Supervisor License can be found at It\t,s ni.ts: „oN ,Ip,
2. \\'hen substantial work is planned, provide the infommntion below:
Total flour area(sy. @.) _ 1 including garage, lmished basemnCIlL attics,decks or porch)
Gross lining area I sq. it.) . _ Habitable room count
\umber of lirvi laces ._ Number of hedruunu
\'umher of hothroonu _ _ , - . Number ul'Inalf halhs
I
1)lie of heating sy stcnn Nunnhcr of decks, parches -
i
I'�Iwo eoohol; .�Stcnl _ 1`.11closed _ Open
L
.,Foial Project Square F oowgc-may he substituted li,r..fot;d I'rnjeel Cost" I
CITY OF SALEM
PUBLIC PROPRERTY
3° DEPARTMENT
Iu•.. ntl Y'InIN I.11
\1,1i rt
I!: \anlru.�iUu.\)i.r Y'Y)' � $,\11•u. M.1 U.\Lilt V 1 n J177,2
I'rd. �)Llii'K'r3 • f,.r '11M.!IG'LrM
Workers' Cumpeniatlon Inturunce %11141 vit: OullderyCuntracturs/ElectrlclanyPlumbers
I dlean hi unnullo
1 ' fnf Le 'AI
NJ Inc I Iluln h.a;t)rasnu.&Iww Ind,r Iluul): I A19 W
Wtlras.r: 3 (36A#W Aqfv
City,Stare,7fr' s MA Ple"
I \re t au un vuglloytrl Chuck f t:glproprldle ball:
1 I am a cmpluyur with 4 C1 I :1111 a jcnenl cnntraetol and 1 I)M orPrilJuet(requlrvd):
❑ unlPluycuY(cull antYur Part-time).• huvu hi(cJ the.ruh•cuntraviurs rt• ❑New cunsoruclium
I.un a Iola jimpriulnr or partner• hifed on the anaehed shoot l 7• ❑Remodeling
chip and havo no vinpluycvs Then iutrcontnetan have
Linyswq1t.
ie Inv In any capacity, workers'comp. Insurance, r' Demolition
rt'wimp. iusurrJuee 3. 0 We are a ent 9, ❑ OuilJine aJditiun
par*timt and its
otTkon haYw urvreirwl their 10.0 Electrical repairs or additions
oduiny ill work rightorarempt OR pvr&ML IL❑1•fumbin�rupuirs ur aJJitinne
i,,,xkca'cutup, c. 1i7, I(4),and wr hnvv nn
yairad.) r cmpleyvvs. ho,varkess' 12'0 RwI'npairs
cnmp, iltsurancu rcquirsd.J Inlertj__ (f_hoo
• ns.,;gdteaW IIIr1 cheb Ws'vim .dw'"1 uW Ike wruaa Wow'I Il,mv„r,wn he Ila,mar this a/1ldsvla indiu,in I i1'•w'na'YIY/wwlui runrfaM,Mlw pl,livr nilia,llMiW�
C„nlrwwMr IhM,hava this Dell nl,w alraen,ee•M adai �ryl.h,IIN aluw a Ibr nanM o/rM rlole ufKper rmom m"i.ul"il•n•w alnd@vil t 1
aerma as*Ifw*%Wtere'_ nd c,a,na uw'&
/tart un avepl*yri that Is pruvfd/nr rvurkert'rvrnpmmdon Lhrurrintt�w r*y vtnp/uyvr.R Bt/mv/s/A //y an rim a
br/urIIt;u R
In,uraucc C'umpany ,Vimt� ervI_)
.
Policy t ur 5dr•ins. gJr r4•-1 Y __•_
EApiraslon Dart:
Job Sity \Jdrerr: 7 ��OICL//� .. .
.\teach a a, C'ity'Jlale/zip:
py or Ill* werken'cumpunratlnn Palley duchwillua page Ohewing rM Polley numbs►and erplrartue duty,
Pallury to w9ure coveniyt as required wider Scdiun�Sr� ul•�IUL a. I31 eau lead to a im
Anc up rll.l'1 SIIO.tM an,Lur una•year impri.rmimunr, ar well ar civil(aenahly in Ihv 1'urm ur �TUP WORK ORDER send a RM
r up re i130 A0•,Jay '4ainbl ilt vlulutur. Ile advl.,cJ that a copy of iliih.lalvinum may be Iunv rdcJ to the Ullicu�I
Ial;�nyan,nu 41';6v MA ;or nl.nr.u•c,: o,vcrj;;tt \culi�apun.
/rerrby,,niA larder dw pain r,rr,J prnu/iie r u�yrr/nry ehvr rhr in urrnus/on Q�`� /• yrvriJeel abate is eat and corrcrR
Uate•
toIr wdy. /)a.tat writs in ddr Jrcu, to Ar rumpletrd by wy ur town o/1%i4i
(ltrurl'alrn: _
1„uiny .\uthltrity (circle ,Iuc1: Pcrmiftl.lnma e
I IL,IrJ dIIY.JIIt L Iluddnr; 1),p.Irtulcnt I. l:ih.'1'o,.nClcrk J, l••4•cftir.Il luyl.rtur 3. rluulbing Imycctor
b. 111heI
I
information and Instructions
Oil
+defined as
ovary pal+an n the service un,ler .Illy cuntrlct of hire.
�l,I,;,I:husetts l cn wal an a nylut ae I I i2 tc�wrcs all of another atgllo)crs 10 provide workers cuInpensautin far their cnlpluyees.
I`u r.u.all 10 tlua,ut ,
;.press ur anplied, oral or wnuan." orattun at tither legal cnnry,of any two or inure
urtrlarvhip,.11,0041100, corp lu yr of the
�n,•,nplupar I+JclincJ L"an mntvillerpal. p lu to vm layces. However the
toret}umg engaged in ()form entuemenhlp,I13110ctalloa of()that legal anaty'empuei deceased amp ,
the
e:mve,r of truslae of.et individual, p
r+one w do maintanrnce,con,truction of repair work tin such dwelling house ,
owner of a dwelling house having not more then three aparvnenu and who resides therein,or the oecupant tit
.Iwellu,g house of another who employ. Pe -
or on the.rounds or building appurtenant thereto shultilat because ofduch employment be deemed to be an aI^Ployer." '
mGL chapter 132. 423C(6) also states that"every state at local licensing.:+1(srs 10111had withhold fhI to fosse or
Uruct with he Insurance coverage required:
renewrl of r license tit pMrmin/Y operate
a business of to eoutruet bufldings In 1hi commeaweulta for say
r1C(71 able
eO Neinc�r the conunonwealth nut any of is political subdivisions shell
uypllsunt r,bo harnot pritduad'acceptabb evldeilh ufeuf^p
\JJiliunully, ,.IGL chapter I S i-
,:nter into any cantract to the pertomlun t cal PdbI,g Work a the contract n g aathmrlYv,dance cal cunlpliuttce with the insurance
requirements of this chupter have been p'
.%pplicanu 1 to our situation and. if
checking rite bocce that apply Y
as)and photo numbers)slang with lhait cartilicut KI)of
ptea.+e fill out the workers' compensation atlAdre completely,by t with no employees other than the
necessary,supply sub-conIn Cor(s)narna(sL aJJreW
workers' compen"Jon ilturarl if an LLC or LLP door have
it,swanae• Limited Liability Companies(LLC)or Limited Liability partnerships(LLP) P
metnben or Partners.are Mae required to carry the n partrilb T1f Industrial
should
empinyaee,r policy is required. 13e advised that this 1 be+sure to%Igo and data he Depurtmattt of InduIsvit
:;�ccidenu tar contlrtnad townatill*insurance c 1'cation for the gee
nnit at license is being requested, not the Dopertment of
be slurried to ihi airy or town that 1M uP0 uestiOne regarding the low car if you art required le obtain r workers'
tnJUatfial,\ccidanu. Should Ynu have any 4
compensation policy, please call the D@Pw=4'nt st the number listed below. Sdf-insured compaaita should enter the
sclf•insurance license numbs an the a ra riots lino.
(-try or-rows officials provid
Pleasc he+ura that the affidavit
ll is%;Okn avant the 0111u rintcd legibly. 'rho
has to contartment ct you regard!, thetapp cant•
of the affduvit f'ur y ,
licutione in an given onr, need only submit one a111dsvit indicating current
Phase be+ura to t111 in the purmit/licaise nwnber which w Pbe uiyd:is a iel'ere Y c number In addition,an applicant
drat must submit multiple pennit'licallnlaa f?•lob Sit*AJJresi'the applicant,+houlJ writs"all luwtiuns in (city car
ppliuy intocupy,ln(if'necessary)
J car marked by the city of town 'nay be provided to the
wwnL",\ copY atthe u1TlJrvit that has been officially sump
applicant as proof that a valid affidavit is on file riot tLlitte patmite at licenses. A new a111Juvtt or g m 1111ed nut each
venture
)our• a here a hums owner or citizen is obtaining a license ar pennit not related to any business car c()mtnareial vant'1n
4011
. is
lug licm+.+e of permit a burn leaves ate.)satJspll aJvay vOw your rea permd To inn 1 andete hl uu J atflyou have,Illy yulilwns.
I tic )ui:e of Inve,tigaliuns wuulJ lt;+♦ to diunk)
I,laa+a Jo not hes'tard 10 grve us a call
iiiiiiiii WINE,111111 Ill
fhc U.p.uunanl's aJ,La+s, talCphUnd inul fax nurn
The Commonwealth of Massachusetts 01
Deparanent of Industrial Accidenu
OBfee of IsvesdQadons
600 Washington Street
Boston, MA 02111
I't1, q 617.727-4900 ext 406 or 1.877•MASSAFE
Fax M 617-727-7749
www,mass.11ov/dia
CITY OF S,U-&Nf, ,ti us,kCfjUSETI"S
BLaDLYG DEP.IRT eNr
120 W.1iM04GTON STRUM, Y°Ftccit
IM (971) 745-9595
K1 MERI SY DRLSCOLL FAX(978) 740.99U
MUYolt TN0-%1M ST.PMMS
DIREcro&OPPLBt1CPROPEATY/BL DLNGCO\LV(SStONE,
Construction Debris Disposal Attldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CM
Debris, and the provisions of MGL a 40, S 54; R section 1 I Ls
Building Permit M is issued with the condition that the dcbria resulting from
this
S ISOA.work shall be disposed of in a properly
1 If, licensed waste disposal facility as defined by MGL c
The debris will be transported by:
&A13fI
(n+une of hauler)
The debris will be disposed of in
Du If SSt
. (name.o-ijy)._.
C'oha�ess S7- ��6�
(�Jdrar or F�c�luy)
lid" 'le ofpermrt Jpphunt
dLta