12 QUADRANT RD - BUILDING INSPECTION (2) I � rI 1 � K � 31toZ � � 00
File Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
1
1 � Massachusetts State Building Code, 780 CNIR SALEM
Building Permit Application To Construct, Repair, Renovate Or Demolish a Revised blur?011
One-or Two-Family Divelling
• This Section For Official Use Only
Building Permit Number:
Date e pplied:
UuilJing Official(Pant Name). ,ure'>�
>. Signature Date
SECTION L SITE 1.1 Property Address: INFOR•IA..
1.2 Assessors blap&Parcel Numbers
r
I.I a Is this an accepted street?yes_ ❑o bfap Number >.
--. 1 arcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zuning District Proposed Us�__
Lot Area(sy It) Frontage(II)
1.5 Building Setbacks(ft)
Front Yard Side Yonis
lieyuired Provided Rear Yard
ReyuireD Provided Required y ProviJeD
1.6 Water Supply:(M.G.L e.40,§54) 1.7 Flood Zone Information:
I'ublic❑ Zone: I•g Sewage Disposal System:
Private fd� _ Outside Flood Zone?
Checkifyes❑ Municipal ❑ On site Disposal system ❑
2.1 Owncrt of Rewr SECTION2o PROPERTY OWNERSHIP(
d:
i FI'�me(Print) 7 e�/r7G
p Ctty,State,ZIP
12
IJtrY$�/i �Cc t _
Nu. anu Strut -"-
Telephone L•mail Address
SECTION J: DESCRIPTION OF PROPOSED WORK?(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ 1 Re airs s ❑ Alterations ❑
Demolition P O O Addition ❑
❑ Accessory Bldg.Cl Number of Units
Brief Description of Proposed �Vurk': Other ❑ Specify;
•r�(f9/ Air a;[� .z. ,'� Rr .,n
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and,Materials) Official Use Only
I. BuilJing g I. Building Permit Fee:.$ Indicate how fee is determined:
? Electrical S ❑Standard City/Town Application Fee
3. Plumbing S ❑Total Project Cost}(Item 6)x multiplier x
2. Other Fees: $
4. Mcchmiical (1-IVAC) $ List: -'
5. %lechanical (Fire
Su ression) $ total All Fces:S
6. Total Project Cost: ,,S 02D®r 00 Check No._Check Amount: Cash Amount:__
❑Paid in Full ❑Outstmtding Balance Due:
f
SECTION 5: CONSTRUCTION SERVICES
CS—o53693 9,—_S-�f—ate ;�
5.1 Construction Supervisor License(CSL) License Number Espimtion Date
L
v
Nantc of SL HOlder List CSL"type(see below)�—
q fype Description
No.aid Sued U Unrestricted Buildin s u to 35,000 cu. It.)
Resuicled I&2 Famil Dwellin
�Z�znQ M Mason
Cityll'own,State,"LIP RC Rootin Covering
WS Window and Sidin
SF Solid Fuel Burning Appliances
I Insulation
PZ2CL — D Ucmolitiun
'I'ele till."address
5.2 it, istered Nome Improvement Contractor(HIC) HlC Registration Number / Espimtion Date
, --t e)7 [4- 'o ,
[tic Co npall NameXrill' R gistrant Name # 7 /{Q C-n'I ,,e k t&k,
/�) C X t� u' -- Fm;ul address
No.atd Street n 10 7YS 305
�+1 ✓'^ — - 'Cole hone
City/Town,State,ZIP
ON INSURANCE AFFIDAVIT(M.G,L.C. 152.§ 25C(�),.
SECTION 6:WORKERS'CONIPENSAT[ .
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide
this affidavit will result in the denial of the IsWance of the building permit.
Signed Affidavit Attached? Yes ..........❑
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 10
t act oil my behalf,in all matters relative to work authorized by this building permit application.
9
Date
Print Owner's Nane(Electronic Signature)
SECTION 7b:OWNER!OR AUTHORIZED AGENT DECLARATION
Dy entering my name below,l 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.
�.r _ Date
print owner's or Authorized Agent's Nome(Electronic Signature)
NOTES:
l (not registered it obtains Home improvement rmitto do
Contractor(FIIC)/her own sProgmm)n iiillrn iter`have access t ires an othe arbitration contractor
Construction rt IfounJ at
tl 142AOl important nF og'am
nrgramorguarltylor ease can be ttdatww . l
e Supervsv ofnform on on th
v When substantial work is planned,provide the infornmtion below:(including garage, finished basement/attics,decks or porch)
Total floor area(sq. ft.) Habitable room count
Gross living area(sq. ttJ Number of bedrooms
Number of fireplaces Number of half/baths
Number of bathrooms Number of decks/porches
l 'fype of healing system Enclosed —Open
"fype of cooling system
3. "Total Project Square Footage"may be substituted for"Cot i Project Cost"
CITY OF SM.EM, N1,NSSACHL'SETTS
/ Bull-DING DEP.k RTNW-NT
120 WASHNGTON STREET, 3"FLOOR
TEL (978) 745-9595
F.LX(978) 740-9846
1CI\BERRY DRISCOLL
v1AYOR THON415 ST.PIEaRE
DIRECTOR OF PUBLIC PROPERTY/BCILDNG COMMIS51ONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information // Please Print Le ibl
Nan1 L' (BusincssOrgan i:atiorulndividual); rZ 4tt;7 C '?„'?j Q 1P
Address:�C7CC/F,9i
City/State/Zip: . �f ✓'r �'/ f Phone tE: 271— ASS - s'& -6'
A,rree,y/oy,an employer'Check the appropriate box: 'type of project(required):
I.L�l tam a employer with� 1 4• ❑ I am a general contractor and I 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ tam a sole proprietor or partner- listed on the attached sheet.) 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
INo workers' comp. insurance 5. ❑ We are a corporation mid its
required.)
officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repairs or additions
myself. [No workers'sump. C. 152, g 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' I3 ❑ Other
conip.insurance required:)
-Any applicant dtad checks box AI most also fill out the section below showing their workers'compensation policy m4nmalion.
t I4.vuwnen who submit this alydavit indicating they arc doing all work and then hire outside contractors mint.mhmit a new airdavil indicating such.
$:nmrite,that cheek this box mwl attached an additional sheet showing the nano of the sub-con racton and their workers'comp,policy information.
fain an employer that is providinK workers'c-umpeusadois insurance for my emplayees. Below is the policy and job site
iufonaWion.
Insurance Company Name: ��' .`t'tf}� lt•� _-Z,�SvP�4�f/C-eT-
Policyd or Self im. Lie. 0: C.S -O-S36 r? _
Q p n— Expiration Date: te^
Job SlteAddress: /� ttUrl ota&' !x(,! City/State/Zip%lis '"
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under'Suction 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
tine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a line
of up.m 5250.00 a day against the violator. ne advised that a copy of this statement Inay be forwarded to the Office of '
Investigutions of the-DIA for insurance coverage verification.
l do hereby Zx4i&
under the palas mrd penoldes ajperjury that Me information provided above is true cord correct.
c— yA
1'n;Lurt; fit Date: /� - C7 i OL2
Official use only, no not write in dJs area,to be caurpleted by city or town official
Ciry or l'uwn: Pcrmit/Llccnse tl _
issuing rlulicorily(circle one):
I. Board of Ilcallh 2. Building Department 3.Cityfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
G.Other
Contact Person: _ Phone tl:
)
t Massachusetts-Department of Public Safety
Board of Building Regulations and Standards
.Construction Supervisor -
License: CS-053693 5� r T
ROGER A TREMpLAY,;
29 HATHAW AY A VEJ-
Beverly MA 0191S `
p
Expiration
Commissioner 05/09/2015
_ $ Officepf Consumer Affairs&B slness Regulel,i{�n n�
HOME-IMPROVEMENTCONTRACTOR Y
Registration ,ys145375
expiration 1/13l2013 Pnvate Cbiporatio..
s
ROGER A.TREMBLEYCONTRACTORS, INC-45
4 ,,ROGER TREMBLE'
10 COLONIAL RD SUITEE43- ( '1
SALEM,MA 01970
r j 'Undersecretary'
" n
her CITY OF SM-F—M, )v :1SSACHUSETI'S
t. BUILDNIG DEPARTNIEIiT
130� WASHNGTON STREET Yo FLOOR
TEL (978) 745-9595
FAX(978) 740-9846
lu\iHERLEY DRISCOLL
NLAYO$ Tfio.ws ST.PIE.atts
DIRECTOR OF PUBLIC PROPERTY/B[:ILDNIG COMMISSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 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 rV[GL c
11 t, S 150A.
'l'hc debris will be transported by:
y
r (\
9 �* AuLN /�e�tsl/iY Cc��ll- c�It�
(name of hauler)
The debris will be disposed of in
(narne of facility)
( Jdress of thcility)
7�
signature of permit applican
,2012
date