18 RAYMOND AVE - BUILDING INSPECTION (2) i The Commonwealth of Massachusetts RECEIVED
ra;4 ry,t Board of Building Regulations and Standarrds �TIONA� SER ICESrrrY of
Massachusetts State Building Code, 780fiw SALEM
Otted�Llar 201/
Building Permit Application To Construct, Repair, Renov �QG[krtoshA
One-or Two-Family Dwelling OO��YY ff77„Nt�
This Section For Official Use Only
Building Permit Number: Da Apppplied:
Building Official(Print Name) Signature Date
SECTION I: SITE INFORMATION
L1 Pro erty �JJress: 1.2 Assessors Map& Parcel Numbers
I.i a 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 It) Frontage(Il)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Rcquimd Provided Required Provided
1.6 Wate Supply: (M.G.I.c.40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Lone: Outside Flood Zone?Puhlic Private❑ — Check if yes❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
Name(Print) Cily,State,ZIP
3 (0I Bg on3s
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Spccify: _
Brief Description of Proposed Work':_ST21P pr- 4&01 Mgtlot) ria Or prr/S �G E of
IZE_ el �Qr�/>J�sp?�tl/_� N_�1.5_�w�.��luasN�ni6e,cS • !�•LC-rr_af�z_r+_�r,��.o 0�� GG
_ • r2r0(o ^•r=a-CkJ�� urC or0 r%st[�Q/f/O� `<i_—
lP1 «J AT h*1
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ ova, ao 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S
4. Mechanical (FIVAC) $ List:
5. Mechanical (Fire $
Su ression) Total All Fees:$
Check No._ Check Amount:Cash Amount: _
6. Total Project Cost: $ /3 000, p0 ❑ paid in Full ❑ Outstanding Balance Due:
1 i
9 `
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor,License(CSL) CJ/
�` License;Number Gs 'mno Dale
Namc of CS
List CSL"Type(sec below)
No.7tr�Streel
r ( 'Type Description
U'p,_�r U Unrestricted(Buildings u to 35,000 cu.ft.
/� NW6AA /!!� R Restricted I&2 Family Dwelling
City/Town,State,ZIP M Masonry
Roofing Covering
Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Tele hone Email address Demolition
5.2 Registered Home/Improvement Contractor(HIC)
�( L/ 21(G� 5 liistratir E. irat on Date
IIIC Company Na e or C R IIegistrant Name
�-- I. 2 5 -
N
street
2^„, , M o
City/Town,
gllaay'rrf6G, Email address
te,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
to 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: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
4's
Print a wner or Authorized Agent's Name(Electronic Signature) to
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 M.G.L.c. 142A.Other important information on the HIC Program can be found at
www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
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 _ Numberofhalf/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"
t° CITY OF &U-EM, ANSSACHUSETTS
k t BUILDING DEPARTNT—NT
120 WASHIINGTON STREET, 3'a FLOOR
TEL (978) 745-9595
F.ur(978) 730-9M
KINiB Ri EY DRISCOL-L
MAYOR T Holi tAs ST.PIEM
DIRECTOR OF PUBLIC PROPERTY/BUILDNG CO\L\IISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information_ Please Print l e ihly
Name(nosiness Orgvsiratiom'Individual): /A-Nfl!!rL �"t'{t/ lOr�hCAL�t/CS
Address: b55-0At nAA si A"7 ,Q
City/State/Zip: amk, � O!hfQ Phone #:(?',�J'�
Are you on employer!Check the appropriate box: '1'ype of project(rcqul red): -
1.ElI am a employer with 4. ❑ I am a general contractor and I
drttpinyees(full and/or part-time).
• have hired the sub-contractors 6. El New conswetion
2.❑ lama sale proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have S. ❑ Demolition
working for me in any capacity. workers'camp.insurance. 9, ❑ Building addition
[No workers'comp. insurance 5. ElWe are a corporation and its
required.) officers have exercised their lU.❑ Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions
myself. (No workers' cutup. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' 13.❑ Other
cutup. insurance required.)
-Any upplitant that dlecks but At most also rill out the section below showing their wodun'cumpensatiun policy inn,"ation.
'I(.,meow fun Who suhntit this orB,i-Ivit indicating they tee doing all work and then hire outride contractors most submit a new afrdavil indicating such. _
<-nnrxton Out check this box must anachut on addidurwl,;hr t showing the nano of the sub-eemnctun and their workers'comp.policy inWnnation,
i out can employer that/s providing workers'compensatlon insurance for my eaployees. Beluty is the policy and fob site
informarian.
Insurance Company Name:—, /L f —AUfuml=
Pulicy p or Sclf-ins. Lie. 0: Expiration Date: JV10 /
lob Site Adtkess: /&14MNo AVE City/State/Zip: SlYM,M4 a1q`76
\ttach a copy of the svorhers'compensation pulley declaration page(showing the pulley number and explratlon date).
Failure to secure coverage as required under Section 25A ot'MGL c. 152 can lead to the imposition ofcriminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a tine
orup to S250.00 a day against the violator. 13e advised that a copy of this.statement may he forwarded to the 011iec of
I I1wY511gUIIlI11x cal the D1A far ItlSafallCt ulvemgC VCCIfICahnn.
1 rlo hereby e•erd y trader the sins and penalties of perjury that the infuriation provided abov true and correct.
S t'li t re' Data:
Phone 1 rl
OJ/ic•iul use unly. Du not Ivrite is this area,to be completed by city or totvn ogirciu[
City or Town: .__ Pcrmitlf.)ccmc l!
Issuing Awhority (circle one): -_- --- --
1. Board of ileanh 2. Building I)eparlment 3.Cilyffuwn Clerk a. Electrical lospectur 5. Plumbing Inspector
6. Other
Contact Verson:_.____
mow`-
CITY OF &U-E1I, A-USACHUSETTS
BCUMLNG DEP:IR-I ONT
130 WASHLNGTON STREET, YO FLOOR
TEL (978) 7d5-9595
F
KIJ[HEJ2L�Y DIL(SCOLL .mx(978) 7-W-9844
,bL4Y0;'L 1�-torus ST.PtLvts
DIRHCTOROFPt: ucPROPERTy/HCaMLNGCONLIUSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CNIR section 1 l 1.5
Debris, mid the provisions of NIGL c 40, S 54;
Building Permit !t is issued with the condition that the debris resulting from
this work shall be d
1 t, S I SOA. isposed of in a properly licensed waste disposal racility as defined by �vIGL c
1
The debris will be transported by:
r `
(name orltauler) -
The debris will be disposed of in
(name oe racdity)
(�dJras of taeliny)
Sly aNre Ur}lerRl .1 tll'alll --