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34 RAYMOND AVE - BUILDING INSPECTION (3) ti )hl . O'D C K #I)3 cE►vEo CTIO+ � The Commonwealth of Massachu INSP setts E CITY OF Board of Building Regulations and Standards ��I I Massachusetts State Building Code, 780 CMR Ia`5 p�J� ')Pevis7er�.V/ur 2011 Building Permit Application To Construct, Repair, Renovate Or Demolish a One-or Tivo-Farnily Dwelling This Section For Official Use Only Date. plied: Building Permit Number: s� 5 ��0b cst Duilding 011icial(Print Name). Signature Date SECTION 1:SITE INFORNIATION n LI Pro er ddress: I 1.2 Assessors Map&Parcel Numbers I.I a Is this an ac epted street?yes to hlap Number Parcel Number 1.3 zoning Information: Ld Property Dimensions: used Use Lot Area(sy tt) Frontage(It) `Luring District Pro P r 1.5 Building Setbacks(ft) Rear Yard Front Yard Side Yams Re uired Provided Required Provided Reyuired Provided y l.8 Sewage Disposal System: 1.6 Water Supply:(N1.G.L C.40,§Sy) 1.7 Flood Zone Information: Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑ Public❑ Private❑ Check if yes13 Y q SECTION2: PROPERTY OWNERSHIP! 2� 01 ner f/'f It c l4P/'N l �a P �' nirn F . +hme(Print' r/ Cily,State,ZIP Telephone Email Address No. and Street 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 ❑ Specify: p�'ff Description of Propose Work': / o,�� l c' 9% tv Qr i��` z=-�-�-_-:- w SECTION J: ESTIhIATED COt RUCTION COST9 Estimated Costs: Official Use Only Item Labor and Niaterials) S 3 QO/� QD 1. Duild+og Permit Fee:$ Indicate how tee is determined: I. Building ❑Standard City/ruwn Application Fee- . Electrical S ❑Total Project Costa(Item 6)x multiplier x 3. Plumbing S ?. Other Fees: S I. Mccttanical (11VAC) S List: i. \lechunicA (rirc S rota r\II Fees:S Suppression) Check No._Check Amount: Cash r\uu>unt 6. Total Project Cult S QDO. 00• ❑Paid in Full ❑Outstanding B3Il:mce Due: �a3 jai SEcru)tV 5: CONSTRUCTION SERVICES 5.1 C`'uustructiou Su/p�ctwisor Licc/use(CSL) ,95- 7 YSAlh //Sl-- 9-e ir eLicensese Number Expiration Date Name of CSL Holder ��77 ' - - List CSL'fype(see below) 1 oC rl I f �� Type Description o. ;III S'rrrvet - �� ,/ Ae) O �qr�/� U Unrestricted(Buildingsu to 35,000 cu. IL i-�YV l(V I V R Restricted 1&2 Family Dwelling Cityffown,State,ZIP ibl Nfasonry , RC Rooting Covering INS Window and Siding SF Solid Fuel Burning Appliances ��`36� I Insulation Tele hone Email address D Demolition icgr{er/ed� Ho nJ/IoLr.((Y 9� p)ent CgnfrnFtor(HIC) Iva PLO S. 7 6O �G, - II Tt CPc7 Ih➢ we u HIC Registration Number :.epirution Dole I((IC Cu.mno my N�al ic or I IIC gist ant Name Nu. tJ:greet Email address \ City/Town,State 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 Isfuance of the building permit. Signed Affidavit Attached? Yes ..........1 ` No...........❑ SECTION 7a:OWNER AUTHORIZATION.TO BE COMPLETED WHEN. OWNER'S AGENT OR CONTRACTOR APPLIES FORBUILDING PERAIIT I, as Owner of the subject property,hereby authorize p)'P f runt e //4a rA , W t9 act on my behalf,in all matters relative to work authorized by this building permit application. AIM a1110 w [ a P I Print Owner's Name(Electronic Signature) Dute 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 nod accurateto the best of my knowledge and understanding. f 1 P r M I CA&A Cl JV J3 �l S-• Nume•Hi terb or Authorized Agent's Name(Electronic Signature) Date NOTES: 1. An Owner who obtains a building permit to do his/her own work,or in 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 find under M.G.L.c. 142A.Other important information on the HIC Program can be found at wwvv.mass.uw:'oea Information on the Construction Supervisor License can be found at 'JLs 2. When substantial work is planned,provide the information below: Total floor area(sq. 11.) (including g rage, finished basement/attics,decks or porch) Gross living area(sq. 11.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches fype of cooling system Enclosed Open i "1\,ml Project Square Foout,e"may be substituted for"fatal Project Cost' �r --------------—-------— -- CITY OF SALENf, L%L1SSACHUsETTS A. r,:J/i� ©t.'tLOLNG DEP.IRT.%LE.VT 120 WASHLNGTON S-MEET, }'O FLOOR I�L (973) 745-9595 KIMBF.RLEY DRISCOLL FAX(973) 7-IQ984d Ar LAYO;a r 10au3 Sr.Ptt airs D17ECTOR OF Pt;'aUC PROPER Ty/aC1LDLNG CO-NOUSS(ONER Construction Debris Disposal Aftldavit (required for all demolition and renovation work) fn accordance with the sixth edition of the State Building Code, 730 QJR section 111,5 Debris, mid the provisions of rb(GL e 40, S 54; Building Permit k this work shall be is issued with the condition that the debris resulting from ! 11, S I SOA. disposed of in a properly licensed waste disposal facility as defined by r�1GL c The debris will be transported by: (name ut hauler) , The debris gqwiil�ll be disposed of in - (name of t'aedity) —_ . r JJress of tacduy) w (/ siyrraturc ufpermit applicant CITY OF SALEM, NLkSSACHL'SETTS - BUILDING DEPART>IE.NT 3 '„ttl 5 120 WASHCVGTON STREET, 3ro FLOOR �¢ TEL (978) 745-9595 F.s x(9 78) 740.9W K)\BERLEY DRISCOLL THOh1AS ST.PtFstfts IAYOR DIRECTOR OF PUBLIC PROPERTY/BUILDLNG CONMUSSIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Ptumbers Applicant information n Please Print Le ibi Name ranf 5Mi..p 4-1 Address: p'( /✓ 1 e, S7 City/State/Zip:! —a 7� MRI Phonelt: q,* S"/Y- aE2a Are you an employer?Check the appropriate box: Type of project(required): 1.❑ I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New conswc[ion employees(full and/or part-time).* have hired the sub-contractors 2 listed on the attached sheet.: 7• ❑ Remodeling 'un a sole proprietor or partner- and have no employees These sub-contractors have 8. ❑ Demolition _ working for me in any capacity. wodcers' comp. insurance• 9, ❑ Building addition [No workers*comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 10.0 Electrical repairs or additions 3.❑ I am a homeowner doing all work right of exemption per MGL 1 LCI Plumbing repairs or additions myself. [No workers'sump. c. 152, §1(4),and we have no 12.❑ Roof repairs insurance required.] t employees. [No workers' 13,❑ Other cutup. insurance required.] -Any applicant that checks bus 9I most also fill out the section below showing their workers'compensation policy int;umation. 'I6.memvners who submit this affidavit indicating they am doing all work and then hire outride contmetors must suhmit a new affidavit indicating ouch. <'.vxtun that check this box must attached an addiliuraal nhwt showing Ilia none of the subtanlndon and their workers'camp.policy infurmation. ee Ian:an empluyer that is providing)vorkers'conspensation insurance for my elnplayees. Helow Is floe policy cord Job site Jnforutulion. Insurance Company None: -------._ Policy B or Self-iris. Lie, d: __.._ Expiration Date: - Job Site Address: Cily/State/Zip: Atlach a copy of the workers'compensation policy declaration page(showing the policy number and expiration data). Failure to secure coverage as required under Section 25A of NIGL c. 152 can lead to the imposition of criminal penalties of a line up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline of up to S2SQ(10 a day against the violator. Be advised that a copy of this statement may be forwarded tothe Office of Investigations of the DIA fur insurance coverage verification. I do hereby, e ify«u t,lite a'rrvsrrA :altars of pe 'ury that the informadan provided above its true and correct. Sicnu4trr V — Phoned: 19M_y OJJiciol use only. Do not write its this area,to be cunspleted by city or town official City ar Tmvii: .__ Pcrmit/l.iccnse t! Issuing Aulhorily(circle uric): I. Board of health 2. Iluilding Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: J