22 RAYMOND RD - BUILDING INSPECTION (4) bThe Commonwealth of Massachusetts
\? Board of Building RCgtllallOnS and Standards Pc)Iz
4 Massachusetts State Building Code. 780 CN1R, 7 edition
Building Permit Application To Construct. Repair. Renovate Or Demolish a Krrur,/
O) - or ro-Family Do e ling 1. 'oo,4
hi Se-tion For Official Use Only
Building Permit Not ber. Date Applied: O
` O O
t
7 0
i a n:u tire: ------
Buildin,yommissloncd nsm Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map & Parcel Numbers —
R 0..01 Rd
--
i.l.t L;this an accepted street? )es.__- no _ hlup Number P:urrl \umhcr
---- I l.J Property --- -------�
1 13 Zoning Information: , P y Dimensions:
Zoning D,Sl r ict Proposed Use Lot Area(sq fU Frontage (it)
1.5 Building Setbacks (ft)
j Front Yard Side Yards Rear Yard -
�� Required_ Provided Required Provided Required Pm. t,lcd _. 1
1.6 Water Supply: (M G.L c. 10, §51) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone?
j Public ❑ Private ❑ Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
?.1 ONner'of Reco d:
J nneee(Pri tit) Address for Service:
jam- -----
j 4,euature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
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7
New Construction ❑ [Accessory
Existing Building ❑ Owner-Occupied ❑ Repairs(s) ❑ Alterttion(s) ❑ Addition
Demolition " Bldg. ❑ I Number of Units Other ❑ Specify: _ _ —..
--
I Boa Des rip[ion of Proposed Work':_______ —
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ 1. Building Permit Fee: $ Indicate how fee is delctiruncal
❑ Standard City/Town Application Fee
2. Electrical $ ❑Total Project Cost' (Item 6) x multiplier x
I
3. Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) .$ List
5. Mechanical (Fire
TotalSuppression) All Fees: S � • !J/Jy
Check No. Check Amount: Ca.h .-%mount: _
b. Total Project Cost: $ ��,d ❑ Paid m Full ❑ Outstanding Balance Due:_-----
i
SECTION 5: CONSTRUCTION SERVICES
S.1 Licensed Construction Supervisor(CSL) Qg!rZ 6
Qo1d Je It n C/N License Number L\pllation Uaie
Name of CSI. [older
f
-261
' ���D ) _ 5+ # `� List CSI_ T�pc tuc heloss)�_
\ddre+> n o\ T• c Ucscn iuon
L Unrestricted lop to 35.010 Cu. Ft !
R Restricted l&2 Famih, D\selling
Signatru M ..\lasmvv Only
71r1 7$a-7-{7C! RC Residential Roof,nu—Co\enne
Telephone \l'S Rrs_:denuul k\ ndim .ind Siduu _
SF Residemi:d Solid Fuel li o n i u ie .\ >>I i ante III I ank I
D Re idenlial Denudmon
5.2 Registered Home Improvement Contractor (HIC)
HIC Company Name or HIC Registrant Name Registration Nuinhcr --
Address
E cpi rationDate
Signature '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 piocide
this affidavit will result in the denial of the Issuance of the building permit.
Sismed Affidavit Attached? Yes .......... ❑ No ...... ❑
r S CTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN — — —
J'WNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
as Owner of the subject property hereby
authorize to act on my behalf, in all matters
relative t rk authorized by this building permit application.
Si ore Oro',
Owner _ ---_ — Date i
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate. to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under die pains and penalties of er'u )
NOTES:
I. An Owner who obtains a building permit to do his/her own \vork,or an owner who hires an Unregistered contractor
(nut 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 and
Construction Supervisor Licensing (CSL)can be found in 730 CMR Regulations I IO.R6 and I IO.RS, respectively.
'. When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) (including garage, finished basement/anics, decks or porch)
Gross living area (Sq. Ft.) Habitable room count _
Number of fireplaces _. Number of bedrooms
Number of bathrooms Number othalt/baths
fv pe f healing system Number of decks/ porches
4 o _ .
"type of cooling system Enclosed _ Open
3. "Total Project Square Footage" may be substituted for "Total Project Cost"
DURABLE GENERAL POWER OF ATTORNEY
_Iyi - JAMES .G. McNIFF, of Salem, Massachusetts, as
principal, hereby appoint Claire Pelletier, of 33 Tuttle Drive,
Acton, Massachusetts 01720, my attorney-in-fact for me, and in
my name and on my behalf, to do and execute all or any of the
following acts and things, as fully as I might or could do if
personally present :
1 . To endorse any check payable to me, to draw checks
against, make withdrawals from, make deposits to, or renew any
bank, credit union, or money market fund account, certificate of
deposit, repurchase agreement, or similar form of savings or in-
vestment, over which I may have a power of withdrawal .
2 . To buy and sell securities of all types, including
stocks and bonds .
3 . To enter any safe deposit box which I may enter,
and to remove any contents from such box or make additions to
such contents .
4 . To sign and file any state or Federal income tax
or other tax return or forms which may relate to me, for any
year or years, with full authority to deal with state and
Federal authorities about such tax.
5 . To make application on my behalf for any real es-
RIFF S MORSE.P.C. tate or other tax abatement, any benefits from the Social
LAW OFRCES
E CORPORATE MACE Security Administration or other retirement or disability pro-
*FERNCROFT ROAD
ANVERS.MA 01923
EL(SOBI 779.7123 )
u
O%ISOBI 7)0.)184
J
gram, any medical, life or other insurance benefits, and any
public assistance benefits to which I may be entitled.
6 . To manage, maintain, develop, and insure any real
estate which I may own, and to sell , mortgage or lease such real
estate .
7 . To apply for my benefit such amounts of my assets
as said Claire Pelletier, with absolute discretion, thinks ad-
visable for my care, comfort and support.
B . Subject to approval of and appointment by probate
court, to act as my guardian or conservator in the event of my
disability or incapacity.
9 . To transfer any of my assets, with absolute dis-
cretion, to the trustee or trustees of any trust I may have cre-
ated during my lifetime.
10 . To execute and deliver all instruments including,
but not limited to, instruments of conveyance, transfer or con-
tract, and to do all acts in my name that in the sole discretion
of said Claire Pelletier are necessary or advisable for the con-
duct of my personal or business affairs .
11 . In the event said Claire Pelletier shall fail or
cease to serve as my attorney-in-fact under this Power of
Attorney, I hereby designate George E. Morse, of Danvers ,
Massachusetts, to serve as my attorney-in-fact under and in
accordance with this Power of Attorney.
DlF @ MORSE.P.C-
LAW OFFICES 12 . This Power of Attorney is to be construed and in-
E CORPORATE PLACE
5 MRNCROFT ROAD terpreted as a general power of attorney. The enumeration of
%N V ERS.MA 01923
EL.(SOB)774-7123
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specific items, acts, rights, or powers herein does not limit or
restrict, and is not to be construed or interpreted as limiting
or restricting the general powers herein granted to my attorney-
in-fact .
THIS POWER OF ATTORNEY SHALL NOT BE AFFECTED BY MY
SUBSEQUENT DISABILITY OR INCAPACITY. Reference in this document
to the disability or incapacity of the principal shall mean the
mental illness or other disability of the principal recognized
under the General Laws of the Commonwealth of Massachusetts.
IN WITNESS WHEREOF, I have hereunto set my hand and
seal this day of Cc�` Sr' 1997 .
�-3&mes G. McNiff
COMMONWEALTH OF MASSACHUSETTS
Essex, ss . ��' S� 1997
Then personally appeared the above-named James G.
McNiff, and acknowledged the foregoing instrument to be his free
act and deed, before me,
Notary Public
My commission expires : ]/ � �3
a OIFF 5 MORSE.P.C.
LAW OfFICES
NE CORPORATE PLACE
SS PERNCROFT ROAD
DANVERS.MA 01923
TEL.(SOB]TT<-T 123
FAX(SO6)7747 169
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