12 ROCKDALE AVE - BUILDING INSPECTION The Commonwealth of Massachusetts
I�ISPECTIOPiRL S RVIri€
Board of Building Regulations and Standar s SALEMALEM
Massachusetts State Building Code,780 CMR��II ff � Mar 2011
Building Permit Application To Construct,Repair,Renovate(5r 17emolish aA �
f� One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: D e pplied:
LO
I Building Official(Print Name) Signature Date
U ) SECTION 1: SITE INFORMATION
j 1.1 Propert Addr ss• 1.2 Assessors Map&Parcel Numbers
Lla Is this an accepted street?yes no Map Number Parcel Number
1.3 t�ng Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
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 SewageDisposal System:
Public I) Private❑ Zone: _ Outside Flood Zone? Municipal Cl/On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
e_r.. C)C �avt , tN//h O )ci 70
Nam6(Print) City,State,ZIP -
[ �1_ 97$-5711iLY
No.and Street Telephone Email Addres
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ffi Alteration(s) Er I Addition ❑ -
Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': .ws r ,n te,J -k Le�.5
ne-vJ viu n -T/lc _
flcz n(,,)-hh\ 1-., fS RSS S A L-10, 1,1ei-/ '%/ P_
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ S SOO. 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ VO- 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ �U .00 ❑Paid in Full ❑Outstanding Balance Due:
(Yl
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) (,� ry c,J �
i / /
License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
/j //,v G S
No.and Street Type Description
P /a7/1/1 /� U Unrestricted(Buildings u to 35,000 cu.ft.
�/c
? R Restricted 1&2 Family Dwelling
City/Town�,Stp&e,ZI �/ M Mason
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor((HIC)
f/')'J HIC Registration Number Expiration Date
H1C_Qompany Name or HIC F�egistrant ame
.S 5 �C�.�?Y.4/ S� 5 -s
�/r q ? cshroCUY1ir( hw.c4
No.a� eet/ / �/A � Email address
City/Town, Sta 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 lg:� f"PI17 J
to act on my behalf,in all matters relative to work authorized by this building permit application.
Q , k,UEI/1 Ca� s
t Pri wner's Name(Electr is�ature) Date
SECTION 7b:OWNER' 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 i is a ation is true an ur to to the best of my knowledge and understanding.
i
Pr' er's or Authorized Age s e(Electronic Signature) Date
NOTES:
1. 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.pov/dgs
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 halfibaths
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"
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston,AM 02111
www.massgov/dia
Workers' Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name(Business ftaaizetion/ladividual): _e/',nC4/1
Address: S—/� e7;,- 1A1
City/State/Zip: opec%, till `A Phone-M q
Are you an employer?Check the appropriate box: Type of project(required):
1.El am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
,{� employees(full and/or part-time).• have hired the sub-contractors
i9
2. I am a We proprietor or partner- listed on the-attached sheet 7. ®Remodeling
Ship and have no employees These subcontractors have 8. ❑Demolition
working for me in any capacity. employees and have workers' 9. ❑Building addition
[No workers'comp.insurance coMP'insurance.t
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised their 1 L❑Plumbing repairs or additions
myself[No workers'comp_ right of exemption per MGL 12.❑Roof repairs
insurance .]t c.152,§1(4),and we have no
employees.[No workers' 13.❑Other
comp:insurance required.]
*Any applicant flatchecks box#1 mustalso,fill out the section below showing their worsers'eomp®sation policy infommtion,
t Homeowners wbo submit this affidavit indicating they are doing all workand thin hire outside contractors mrstsubmit anew a&davitindicating such.
lContrsctorsthardisekiliaboxnnstanichedanadditimal sheashoweigthemancofdesubcoabactorsandstacwhetherormtthosecoutwhave .
employees. If the subcontractors have employees,they r®stpmvide their workers'comp.policy number
I am an employer that isprovidixg workers'compensation insurance for my employees Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: 12 � � HL� City/State/Zip:
Attach a copy of the workers'compensation policy declaration page(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 a
fine up to$1,500.00 and/or one-year imprisonme4 as well as civil penalties in the form of a STOP WORK ORDER and a tine
of up to$250.00 a day against the violator.{i Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby eertify the and penalties that the information provided above is true and correct
Si Date: 7 �✓� _
Phone#
Offretal use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/Liceme#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Citytrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#: