3 RAYMOND AVE - BUILDING INSPECTION (2) r The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or Demolish a
^ , One-or Two-Family Dwelling
`V This Section For Official Use Only
Building Permit Number: Date Applied:
0 2r.
.Building Official(Print Name) Signature I U0D to
SECTION 1:SITE INFORMATION
1.1 Property A�rdress: 1.2 Assessors Map&Parcel Numbers
Z—�.T YMOM/I R��t i
L 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 ft) Frontage(Il)
1.5 Building Setbacks(R)
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 At Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system ❑
r" Check if es❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Q�wner'of 7g�eAc�or—d:
V("I/Y'// !n
Name(Print) City,State,ZIP
3 AMelDNioAVE, 979- 868-N?2 RPAT0449cL3�' Gn�ll�
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) ❑ 1 Alteration(s)X I Addition ❑
Demolition A Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': (taRA44 KI 6d4-j 0-1r�, 9AA66-k
Klnr(,2d.y 0('6-&Ok &LLe.. 9itMCd.
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ Qp p 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ 00 ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ "77 O 2. Other.Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$ -
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �� ❑Paid in Full ❑Outstanding Balance Due:
/2) 'Jog
9�1 A�L,u'5�-n t
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) C S _Q,�D ZB Z t'f'� � �<j
PKit rlo�(Z�Lt — License Norther Expiration Date
Name of CSL Holder List CSL Type(see below)
SO 4vA'af ��
No.and Street Ty Description
119.IA n�L��t��,� t�A[l. OJ01�i� U Unrestricted(Buildings up to 35,000 cu.ft.
! Y7�J 1 Restricted 1&2 Famil Dwelling
CitylTown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
/n�� y/t(/t,//,' �,'I` n ('„ (L SF Solid Fuel Burning Appliances
(JL T M (— C I 1 Insulation
Telephone Email address D Demolition
5.2 Registered Home Improveme�Cptractor(HIC) ����� � 11114116
� �/ �/
RR, V'L�L4 o� HIC Registration Number xpibrat1 Date
HIC me or,HIC Registrant Name
R�
No.and Strr ,aL,`4_ ,t��'I 6(g�s� �/���j !// Email address
City/Town,State,ZIP']�'tJ f1 Telephone
�"
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.152.§ 25C(6))
Workers Compensation Insurance affidavit must he 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_ j fflV IP 66KLO K f-1 ,
to act on my behalf,in all matters relative to work authoriz this building permit application.
RYAN PJrTF� 9'� 98 A0
Print Owner's Name(Electronic Signature) p .., r i I Date
SECTION 7b:OWNER[OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereb ttest under the pains and penalties of perjury that all of the information
contained in this application is true accurate to the best of my knowledge and understanding.
'P4fUlP 10 �V 1,0
Print Owner's or Authorized Agent' a(Ylectnmic Signature) Date
NOTES:
l. 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. 142A.Other important information on the HIC Program can be found at
www.mass.eov/oea Information on the Construction Supervisor License can be found at www.mass.eov/dos
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 haWbaths
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"
CITY OF S.UEM, 'LNSSACHUSE1TS
' BUHMmIG DEPARTMENT
\ 120 WASHNGTON STREET,r FLOOR
T L (978)745-9595
FAx(978) 740-9846
KI-,iBERLEY DRISCOLL
MAYOR Tkomm ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BUIIDL\G COMMSSIONER
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:
Mcdagup tiwa
(name of hauler)
The debris will be disposed of in :
(name of facility)
nL� t1A
(address of facility)
sin ermit applicant
0 z31�
date
Jcbriw(rdw
i CITY OF S.UE:Nt 1N'L-1sskcHLSETTS
BUILDING DEPARTMENT
' 130 WASHLNIGTON STREET,3-FLOOR
T L (978)745-9595
FAX(978) 740-9846
KI.\iBERLEY DRISCOLL
MAYOR THOMAS ST.PtERRa
DIRECTOR OF PUBLIC PROPERTY/Bl:nMDZG CO\54SSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information /y p Please Print Legibly
Name(Business;Organizatlontlndividuall: �/I IGi! (5—dN2NLt�
Address: b�4N1 ePl�,
City/State/zip: tIONL Y49TMq- 0/1'1 Phnnen:-l7— C) —gfTJ
Are you an employer?Cheek the appropriate box: Type of project(required):
1.❑ I am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(f dl and/or part-time).* have hired the sub-contractors
2. 1 am a sole proprietor or partner. listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity, workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance 5. ElWe are a corporation and its 10.❑ Electrical repairs or additions
required.] officers have exercised their
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.❑Odur
comp.insurance required.]
Any appliuwa tha checks box Of most atw+fill out the section below showing their worken'compensation policy infum+aaon.
f I Inmeownen who subn+it this affidavit indicating they am doing all work and then hire outside contractors must suhmit a now affidavit irdiming suds
:Contractors that cheek this box must anxhed an additional.heel showing the tunic of the sub< ntrwtm and theit wodosn,comp,policy infomatim
l am an employer that is providing workers'compensation Insurance for my employees. Below is the policy and fob site
information.
Insurance Company dame:
Policy#or Self-ins.Lis#: Expiration Date: r
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=ore coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to 51,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to 5250.00 a Jaya ainst the violator. Be advised that a copy of this statement may be forwarded to the Office of
aliutu ul'tit Investige D for insurance coverage verification.
l do hereby cerd r e the pains and penalties of perjury that the information pra Wiled above is true and correct
. m t are• Oate'
P o C 41-71
Official use only. Do not write in this urea,to be coarpleted by city or town ofciat
City or Town: Permit/l.icense# _
Issuing Authority(circle one): _
1.Board of Health 2.Building Department 3.Cilyffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: _ __ Phone#:
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ce of Consumer Affairs&Business Regulation
ME IMPROVEMENT CONTRACTOR
{ !Stratton j
f 1�W,4672 Type:
iration: 11l16/2016 DBA ,
I PHIL GOUZOULE C6<+1ST
PHILLIP GOUZOULE .y ��
.. 50 EVANS RD
MARBLEHEAD, MA 01945 g
Undersecretary
. . it
s Massachusetts Department of Public Safety
Board of Building Regulations and Standards
License: CS-040282
Construction Supervisor
PHILIP GOUZOULE�
50 EVANS RD Y
MARBLEHEAD MA 01.946 ` =
Expiration:
Commissioner 04/17/2018