6 QUADRANT RD - BUILDING INSPECTION r_
The Commonwealth of Massachusctts
+� Board of Building Regulations and Standards Town
Massachuseus State Building Code, 780 CMR, T"edition Building Dept
Building Permit Application To Construct. Repair. Renovate Or Demolish a
One. or Two-Fond i Duelling
This Section ForlOfficial Use Only
Building Permit m c I late Applied:
i
Signature: O
Building Commissioner/Inspec or ( l Date
CT ION 1: SITE INFORMATION
1.1 Prope ddress• / 1.2 Assessors Map& Parcel Numbers
r� �a�r rr i ad
1.1 a Is this an accepted street'?yes no Map Number Parcel Number.
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use La Area(sq R) Frontage 1 N
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.ao,ssa) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if vesO
SECTION 2: PROPERTY OWNERSHIP'
2.1 qJrner of Recorq: /
Name(Print) Address for Service:
Signature Telephone
SECTION l: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) aVf Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ IOther Cl Specify:
Brief Description of Proposed Work':
r ,Pis- .i
Cyr- r-?1 -- f
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: 011lclal Use Only
Ile t Labor and Materials
I. Building S /a U(t> 1. Building Permit Fee: f Indicate how fee is determined:
O Standard City/Town Application Fee
2 Electrical f r,1 Dui ❑Total Project Cost'(Item 6)x multiplier x
J. Plumbing S l/j 2. Other Fees: f
J. Mechanical (HVAC) S List:
5 Mechanical (Fire S Total All Fees: S
Su ress on
-'( Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S I�aJQ,GV 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supers isor(CSL) JSF
� 'r 13
��IA,I �t'2 "�`4K umber Expuauon Date
N.yx't'CSL HyIJe( r / r Type(sce below)
PrP 9LY Description
A
/fin ^ Unrestricted u to 33,000 Cu. Ft.
�'•�"�� Restricted Ik2 FamilyD%elhn
Sianature ! J?21 Mason Only
(.t�7 Y Residential Rooftn Covering
Telephone Residential Window and Side
Residential Solid Fuel Burrimll Appliance Installation
D Residential Demolition
5.2 R,Sylster�ome Improvement Contractor(HIC) 12�j 6j �jZ
/lip r�Ja`�� Rle isnral on Number
HIC Company Name or HIC Registrant Name g p/
f fL�,v_ QiDir�> 2;�gis e (� 3LtA t �Z�O 1 (O
' Expiration Date
Signature Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.e. 152.125C(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this andavit will result in the denial of the Issuance f the building permit.
Signed Affidavit Attached? Yes .......... No...........O
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 to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the regoing application are true and accurate,to the best of my knowledge and
behalf.f �-
A
signature of Owner or Authonz gent
Si tied under the pains and penalties of perjury
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),wi11W have access to the arbitration
program or guaranty fund under M.G.L. c. 1 a2A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and 1 10.RS,respectively.
2. When substantial work is planned,provide the information below
Total floors area(Sq. Ft.) (including garage, finished basenrent/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 he substituted for"Total Project Cost'
CITY OF S.1LE.-tt, AASSACHL;SETTS
BUILDING DEPARTULNT
120 WASHINGTON STREET, Yo FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
K1%fBERIEY DRISCOLL
MAYOR T HomAs ST.PIEm
DIRECTOR OF PUBLIC PROPERTY/fICI DLNG CO\QBSSIO%ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information Please Print Legibly
Vatne (Business.Organi:ation,imbvtdud):
Address: r ,2� � �1croS �elCl tMl 01�5°i3
City/Statdzip: L Phone N: C
Are u as employer'Cluck the appropriate boa: Type of project(required):
I. am a employer wits 4. ❑ 1 am a general contractor and 1
employees(full and/or pan-time).• have hired the subcontractors 6. VC] tlw constrsactiotr
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet : 7. odeling
;hip and have no employees These subcontractors have B. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9, ❑Building addition
[No worker'comp. insurance S. ❑ We are a corporation and its I0.0 Electrical repairs or additions
required.( officers have exercised thew
3.❑ I am a homeowner doing all work right of exemption per MOL 11.❑Plumbing repairs or additions
myself.(Na workers'comp. c. 152,§1(41 and we have no 12.0 Roof repairs
insurance required.( t employees.LINO workers' 13.❑Other
comp. insurance require.)
;Any'appatant Iho dwOm Boa el mull aim fin out 11w seclioa l cltsw dtowieg Their workon'comprm athtn policy infum ation
1 I.mwttwnws who sulainit this aflldi vie idioung they an;doing all work and thou him oubide eonnomom mot auhmit a new amdsvit indiraing suck
['.mtr:non that Awk this hex mud aaached an addimmal A e1 showing dw t tithe sutteomr wsm and they worlwrs'comp.policy infomtatim.
l am am employer that 6 providing worker'compensadon/nenraoee jar my employees Below is the palley and fob site
information.
Insurance Company Vame: !/V'd�(-SGi�.ili l l/% �� A
Policy M or Self•ins. Lie. H: /I2i *02/ Expiration Date: 1 —
Job Sire Address: (aa) ,17' / t_)/e City/StatrlZip:��/ L
,%ttach a copy of fife workers'eompensatlos policy declaratba page(showing the policy suo bor and eapirsdoe date}
Failure to secure coverage as required under Section 23A of,%IGL e. 152 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$250.00 a day against the violator. Ile advisLd that a copy of this statement maybe forwarded to the Office of
Inveotgatium of the DIA for insurance coverage verification.
l do hereby cerrij rho pains(andd Pen/aldrs ojperJury that the hlformadaa provided above is truer an t d correc
Date: ?.&;, f
PFone A: `
iOfficial use only. Da not write in this area, to be,urrepleted by city or town oJfl4-ia2
City or rusvn: __ _ ecrmit/I.lccnse#
1%suing Aulhorily (circle une): _ —
L Iluard of Ile-Ah 2. Building Department 3.City/rown Clerk a. Electrical Inspector 5. Plumbing Impeetor
6. 01her
U,nuct Person: __. _-. Phone p'
CITY OF SALEM
-ts,
PUBLIC PROPRERTY
DEPARTMENT
M l20WAill1N(;:0NS1fnEFT 0SAHM, MASiM lit 'i I iN319"
978-145--M5 0 FAX:978-740-9846
Construction Debris Disposal Affidavit
(required lur 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
I 11. S 150A.
The debris will be transported by:
flame of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
r signature of permit applicant
(Idte