53 RAYMOND RD - BUILDING INSPECTION I) The Commonwealth of Massachusetts
Board of Building Regulations and Standards Town of
� Massachusetts State Building Code, 780 CMR, 7'"edition use Budding Dept
Building Permit Application To cL Repair, Renovate Or Demolish a *Woso*Aa
qmt<or Two-Faint t Dwelling
This Section Fo Official Use Only
J1dm ,,,Numb Permit NPrDate Applied:
: BwldingInspecto i � s DateS ON 1: SITE INFORMATION
erty Addr1.2 Assessors Map& Parcel Numbers
Ois an acce no Map Number Parcel Number
ng Inform1.4 Property Dimensions:
strict Lot Area(sq B) Frontage(it)
. ing 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:
Zone: _ Outside Flood Zone?
Public❑ Private❑ Check if es❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP[
.115 rt of Record: / �3 �d � if S� y
rtatnt) ,tJ Address for ServicJe:S/T
§-4nlnuref Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition Or Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
G C �
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OlVlclal Use Only
Labor and Materials
I. Building Permit Fee: f Indicate how fee is determined:
I. Building E 3 S(�,ap
❑Standard City/Town Application Fee
2. Electrical S 617S rjp ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ ,d 2. Other Fees: S
4. Mechanical (HVAC) SD List:
o
S. .Mechanical (Fire S
Total All fees: f
Suppression)
Check No. _Check Amount: Cash Amount:
6. Total Project Cost: 1 GbO pp 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) gao -
'' Licensc Number Expiration Date
N:)roc ofC L- Hpldrr List CSL Type(see below)
ID
Description
Address
[Residential
nrestnctrd u to J5,000 Cu. FIJ
-�� estricted I&2 Family Dwelling
Signature ason Only
esidential Roofin Covering
Telephone esidential Window and Siding
sidential Solid Fuel Burnin Appliance Installation
Demolition
5.2 Registered Home ImprovementT(`ontractor(HIC)
?/�6r/L �r C�000f4,01,ktY/'s 42lr ,G i, 46f /D Xa22
HIC Company Name or HIC Registrant Name Registration Number
Add e
�/'zM/�1 1,7,b,, 11 jW 0/1� Vq eog Expiration Date
Signature Telephone
SECT ON 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 151.1 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........... O
SECTION 7n:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, g% orl-�jyh "'o + �j .eA � as Owner of the subject property hereby
authorize S`/ ✓e— A/r AC N-t<Li-. to act on my behalf,in all matters
relaeto 'r,k, authorized by tthhii7�s building permit application.V "/ � / ! �,car Fbehalf
Nwner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
/�„/ as Owner or Authorized Agent hereby declare
the state cots and information on the foregoing application are true and accurate,to the best of my knowledge and
/,�7 /
Print Name (1
Signature of Ow er or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 W 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 780 CMR Regulations I IO.R6 and I IO.RS, respectively.
When substantial work is planned,provide the information below:
tal floors area(Sq. Ft.) (including garage, finished basement/anics, decks or porch)
oss living area(Sq. Ft.) Habitable room count
Number of fireplaces Number of bedrooms
Number of bathrooms 7— Number of half/baths
Type of heating system' Number of decks/ porches
Type of cooling system Enclosed Open
1. "Total Project Square Footage"may be substituted for 'Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
:',I . I IJ� \� r,ll;`.. .. •..1:SIIf � 1\II \I, \I\.,U . . .I1
Construction Debris Disposal Affidavit
(reiluired fior ❑II demolition wid renovation work)
In accurdance %%itll the sixth edition of the State Building Code, 780 CAIR section 11 L5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the debris resulting from
this work shall he disposed of in a pruperly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
I name uC hauler)
the debris will be disposed ot'in
/AZPsLa
(name o ae itv)/hAss
nlJllre.. Id l]nlitvl
N L'lldl l' UI Ili 11111( .I�I�II�
zZ
I,I lr
`a
7,(�e >oaminonu�ealol o�,llaaaac/ruoekz
Board of Building Regulations and Standards 3
/ - Construction Supervisor License
Lksnse: CS 49880 i
. ExWratbn:` J*/2010 T00
A 18B8B
�J 1/ Ili
STEPHEN W Wit CHE€L r
5 APACHE WAY
WILMINGTON.MA 01887 � ComWulouer
�,/ir. V�omvmanuiealUe a�.�l�.raoar/euor�
Board of Building Regulations and Standards
�[( - HOME IMPROVEMENT CONTRACTOR
Registration: 108222
Expiration: 8/14/2010 Tr# 272784
Type: DRA
TIMBERLINE WOODWORKERS -
Stephen Winchell
5 Apache Way �.y..�O..a..`
Wilmington,MA 01887 Administrator
CITY OF S.U.E.N1, .LkSSACHL:SETTS
BUILDING DEPARTNMNT
120 WASHI NGTON STREET, Ye FLOOR
TE1 (978) 745-9595
FAX(971) 740-9"6
D
KIJ[BF�tI EY RISCOLL
HEY DRAYOR T?IOhus ST.PmitaB
DIRECTOR OF PLBLIC PROPERTY/lIV I DLVG CO\LMBSSIONER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electricians/Plumbers
karilicant Information Please Print Legibly
�—. / � /
VatnelUasinvv.Organi:adon,InJtvtdwll: /�;7r�//L/ c G✓/1////Arri�rf ��1�1' l�/%/�Gli>6
Address: 4A-eIIr L-ttfJOY
City/State/Zip: �✓///Yl�r7L/i /tsr� Ol`�'J Phone
,%re you an employer?Cheek the Appropriate box: Type of project(required):
I.❑ U I am a employer with 4. 1 am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time)." have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached shceL : ?• ❑ Remodeling
,hip and have no employees These subcontractor have S. ❑ Demolition
working for me in any capacity. worker'comp. insurance. 9. ❑ Building addition
(No workers' comp. insurance S. ❑ We are a corporation and its 10.0 Electrical repair or additions
required.] officers have exercised their
3.❑ 1 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 repair
insurance required.l t cmployces. [No worker' I3.❑other
insurance rme irtd.J
•Any applicant nut chocks boa Of must alwr fill out the session bet"showing their workers'compensation policy infurmatlon.
t I I..teuwnsn who subnit this affidavit indicating ihcy aril doing all work and the"hire trtmide eontrnetota must suhntit a new,afltdovit indicating sash
{..tractors that cha k this box most anwhed an additiwml thew showing the tome of t11a aubavnttncton and their wwkesa'comp,policy intormotim.
l una an employer that it providing'workers'compensadon/nsaronee for my employers Below/s the policy and/ob site
information.
Insurance Company Name:
Policy #or Self-ins. Lie.#: Expiration Date:
Job Site Address: City/Staw/Zip:
Attach a copy of the workers'compensation poUcy declaration pegs(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of■
fine up to S I.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 S250.00 a day against the violator. Ile advi.wd chats copy of this statement maybe forwarded to the Office of
Invesitgatiom of she DIA for insurance coverage verification.
l do hereby certify under the pains and penalt/es of perjury that rho btformudotr provided above is true and correct.
';n_narUre:.,
iOffi al use only. Do not write in this area,to be cuntpleted by city or town a f cial
City or Tuwn: __ Fermit/1.lcerse#__
Issuing Aulhority (circle one): —
I. hoard of Millis 2, Building Department J. C'ilyfrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Contact Person; _ .. _ ._. ___ Phone#•