53 RAYMOND RD - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
c " Board of Building Regulations and Standards
E ) Massachusetts State Building Code, 780 CMR SALEM
bOlb DEC
l 67—V Building Permit Application To Construct,Repair, Renovate Or emolish a
One-or Two-Family Dwelling
7:17 This Section For Official Use Only
Building Permit Number. Date Applied: ._.
(Z If0
.� Building Official(Print Name) Signature ate
SECTION 1:SITE INFORMATION
1.1 erty ddress: - 1.2 Assessors Map&Parcel Numbers
I.la Is this an ac epted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq it) Frontage(ft)
1.5 Building Setbacks Bit)
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❑ Private❑ Zone: Outside Flood Zone' Municipal❑ On site disposal system ❑
Checkifyes❑
SECTION 2: PROPERTY OWNERSHIP'
2 nert of Record, rvf f S3 ��y r�/
�I 1-W �,tl e Rti !uw!/ 6 le J1r 4l
Vme( City,State,ZIP r
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 ❑ Specify:
r/iefDescriptionofProposedWorl�: 06tYtt tAodVIA&eB"
. V X,�r� Ill a.vvy 'Cvt .fG4/Z
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee `
❑Total Project Cost (Item.6)x multiplier _ It
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $ Total All Fees: $
Su ression
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONST'RUCITION SERVICES
5.1 onstru 'onSupe 'isorLicense CSL) �/tyS� /OS6z / /_3o^Zc(�
0l �- WN/ t`JL enseNlumber ! Expiration Date
N71`CS Hold —
�4%� 5� t List CSL Type(see below) o
No. ^d Street y e Description
iJ Unrestricted(Buildings u to 35,000 cu.ft.
✓(C..,�1/� /-t'J/ V ` Restricted 1&2 Family Dwelling
City/Town,State, fP M Masonry
RC Roofing Covering
— WS Window and Sidin
�/ _O 7— 3 (/'(J I Solid Fuel Burning Appliances
IW/J XV _ t Insulation
Tee hone Email address D Demolition
5.R
ist ed Ho Improvement Contractor
Contractor(HIC) /�/Z-� / 9a1!
n�110 t�'�r`� C��'� HIIC Registration Number Expiration.D'ate ,ny N me or HIC egistr
i
NA5 Stree Email address
_—
Ci /Town,State,I tip 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 issu ce of the building permit.
Signed Affidavit Attached? Yes .......... No.—.......❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONT'RACTOR� BUIL NG PERMIT
1,as Owner of the subject property,hereby authorize
to act on my behalf,in all matters relative to work authorize this building permi applicafl n.
0 1 CSL All
�.
Print Owner's Name(Electronic Signature) to
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
contme m t plicatigtt is uv accurate
t curate to the best of my knowledge and understanding.
Prinrr's or Authorized A s Name(Electronic Signature) Date
NOTES: _
1. An Owner who o6tains a building permit to do his/her own work,or an owner who hires an unregistered contractor
(not registered in the Hone 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
wwti .mass.gov/oca 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 half/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"
CITY OF CJALEM, iNy'LkssACHUSETTS
BUlIDNG DEPs.RTx NT
120 W.+sHLNGTON STREET,r FLOOR
T .L. (978) 745-9595
FA.xc(978)740-9M
KINiBEpLEY DRISCOLL
NfAYOR T muAs ST.PtERRE
DIRECTOR OF PUBLIC PROPERTY/BI:UMNG COWNQ55IONER
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
f�/debris will
obe transported
(�by:
(name of hauler)
The debris will be disposed of in
(name of facility)
�e ct
(address of facility)
W �
signature of permit applicant
Ik ddIP
date
Jcbrivlrila:
i CITY OF S U.EIti1, NLA SSACHUSETTS
BUILDING DEPiRniENT
' 130 WASHINGTON STREET,31e FLOOR
" TEL (978)745-9595
FAX(978)740-9846
KIbIBERLEY DRISCOLL
INJAYOR THOilw ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BCiLDLtiG COJDMIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anpticant Information 1. /p Please Print Legibly
Name iBusincssOrsanizationiIndividual): Nf,`IriA` // rya L4n �n fitll9+-Cdy 7-
Address: � �W P, �q
City/State/Zip: % I�I4SS_� (q70 Phone #: l�S �-1 �C) /
Are pl,
an employer?ChVDatd;:C1l,*
roprietoe box: Type or project(required):
kl�1 am a employer with4. ❑ 1 am a general contractor and 1 6. ❑New construction
employccs(full and/o have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.I 7" ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. workers'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 I I.[]Plumbing repairs or additions
myself.[No workers'comp. C.. 152,91(4),and we have no 12.❑Roof repairs
insurance required.)t employees.[No workers' 13,❑Other
comp. insurance required.]
•Any applicant Ihut chwks box®I must also fill out the metiA below showing their worker'arompensuiwt policy information.
'I kmxowmn who suhmit this affidavit indicating they ate doing fill"rk and thm hire Mitide contractor must submit a new alridavil indicating such.
'Cor a cion that cheek this box most attached an additional shot showing the rune of the wD•corracEor and their workers'comp,policy intamnalm.
I am an employer that is providing workers'compeneadan insurance far ttgtsutpioyees. Below is the policy and fob silo
information.
-4AMs &qt
lnsuranceCompanyName: `^�., `� pw!'[N`1
Policy b or Sclf-ins..Lie.M � v v _/_D ���`O�h piration Date:/a)' 71- 247 [6'
n 70 23f6e-Vl(o fp `
Job Site Address:_ _ City/State/Zip: 10
Attach a copy of the workers'e . pens declaration page(showing the policy number and piradon date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition ofcriminal penalties of a
fine 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 to S250.00 a day against the violator. 13e advised that a copy of this statement may Ire forwarded to the Office of
investigations of the DIA for insurance coverage verification.
I do hereby cerdfy rat er pains d ens ofperjury that the informadaor provided abo a is re and correcit
SiLniture: h Date. ` C/ �"
P on N: — w�
Official use only. Do not write is this area,to be cornpleted by city or town a ffi ial
City or Town: Permidl.fcense 1l
Issuing Authority(circle one):
1.Board of Ilealth 2.Building Department 3.Cityfrown Clerk 4.Electrical inspector 5.Plumbing Inspector
6.Other
Phone M
.. ,! 7e Y` ,•••�V ABOJ1114de.CYMY1dE
Offlee of felasswer t{lYhin&prs(Oefskeeelt6ou
* t@p HOME fMPROVE4ENT COWTRRCTOR s"
. RpistraMon 1^,=18 `T�t. y
Espiration. '1'�'k I'101f6
ODWIN EMERC21 $
W.HOOFER GOOOWW
- . kAOSLYN ST", \�
�SAt:FJ�[,MA 01970 ` � • 4 _�do7eise'�
Massachusetts Department of Public Safety
f;�� -Boardof Building Regulations and Sfanda rds.
License:,CS-105621
i Constructicih Supervisor �.
�A
W.H.GOODWIN,III
9 ROSLYN STREET
SALEM MA 01970 ,
CA_ Expiration:
Commissioner 0113 012 0 7 6