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2 1-2 ROPES ST - BUILDING INSPECTION (4) M ,,� L k The Commonwealth of Massachusetts %Vu Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 730 CMR SALEM Building Permit A plication Construct, Repair, Renovate Or Demolish a Rev6sed,tlar 201/ One-nr wo-Fomily Dwelling is Section For Ot2icial Use Building Permit Number: Onl Date:Applied: [3uilding Official(Pant Name) Signa, a: : � (p SECTION 1:SITIE INFORSIATION ate 1.1 Property ddress: 2-112 4 10 r--C f S Y 1.2 Assessors Map& Parcel Numbers L I a Is this an accepted street?yes no Map Number 1.3 Zoning Information: I Parcel Number C`_� Ld Property Dimensions: Zoning District Use Lot Area(sy R) Frontage(It) 1.5 Building Setbacks(ft) Front Yard Side Yams Provided Re Require) Provided Rear Yard Required aired y Provided 1.6 Water Supply:(M.G.L c.40,§54) 1.7 Flood Zone Information: Public❑ Private❑ Zone: 1.8 Sewage Disposal System: _ Outside Flood Zone? Check ifyes❑ Municipal❑ On site disposal system ❑ SECTION 2- PROPERTY OWNERSHiP1 2.1 Owner'of Rc//co^rd: rvy�me I run) v ate, r V i2 2 . ^�77 /�S,,,, any,al ate,ZlP \� l J/J o ; 7 No attd Start � Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED 1VORW(check all that apply) New Construction ❑ Existing Building Owner-Occu ied Re airs s w�,1,r p P OJT` Alteration(s) ❑ Addition ElDemolition ❑ Accessory Bldg. ❑ 1 Number of Units Brief Description of Proposed Work': ! Other ❑ s ecity: 1 Tc1,.� ✓A- T c r• MID n SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Labor and,Materials) Official Use Only I. Budding ,S I. Building Permit Fee:$ Indicate how fee is determined: 2. Electrical S ❑Standard City/Town Application Fee 3. Plumbing S ❑Total Project Cost'(Item 6)x multiplier x 2. Other Fees: S 4. Mechanical (fIVAC) S List: 5. i\Iechanical (Fire Su ression) $ fotal All Fees:S 6. Total Project Cost: .$ Check No._Check Amount: Cash Amount: ®�©° ❑Pail in Full 0 Outstanding Balance Due: sEc•rwN s: coNs•raoc•r10N sEa—v►cEs 5.1 Construction Supervisor License(CSL) License Numb Expiration Date ,ane of CSL Holder List CSL'rype(see below) Type ' Description �v No,and Street U Unrestricted lluildin s u to 35,0110 Z 0 R Restricted l&2 Fund Dwellin IVI Mason City/I'own,State, RC Raclin Covering 1 WS Window and Sidin SF Solid Fuel Burning Appliances I Insulation D Demolition Tele honeEmail address / l�o /V- 2 3- 5.2 Registered home Improvement Contractor(RIC) HlC Registration Number Expiration Date HIC Cum :my NTN/r HI Regis trant Name Email address 0 o.a d Street may,0 10)� Z 9 _ �— 5 xf /'�' Tele hone _ - Cit /Town,State,ZIP SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(p'Gcation`SFai§re[(provide Workers Compensation Insurance affidavit must be completed and submitted with this application. this affidavit will result in the denial of the Issuance of the building permit. Signed Affidavit Attached? Yes ..........❑ No....... ...❑ OWNER U A .TH Z ORIATION:TO BE COMPLETED WHEN SECTION 7a: : OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize t9 act on my behalf,in all matters relative to work authorized by this building permit application. Date Print Owner's Nanre(Electronic Signature) 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 in this application is true and accurate to the best of my knowledge and understanding. nD��gx �y Ma S Date Print owner's or Authorized Ag.nt s Nome(EI cLronn,Signature) NOTES: (An not registwho ered i obtains Home Imp opermit Cto ontractor(IIIC)his/her own vProgram),orK,or nv lltn iter vhave access t ires an nthe arbitration program or guaranty fund under M.G.L.c. Id2A.Other important information on the HIC Program can be found at ww.v.ma_ ss °=t Information on the Construction Supervisor License can be found at w'ww,mass''ov/`I is 2. When substantial work is planned,provide the informationi uing garage, finished basemenUattics,decks or porch) Total floor area(sq. ft.) Habitable room count Gross living area(sq. ft.)______.---- Number of bedrooms Number of fireplaces lumber of half/baths Number of bathrooms ,lumber of decks/porches s stem Open re of heatinS Y Enclosed rYl ---- Type of cooling s'yst ru 3. "Total Project Square Footage"may be substituted for`Total Project Cost' it I • 6 1� Massachusetts -Department of Public Safety i Board of Building Regulations and Standards Construction Supervisor License: CS-062234 GEORGEJGLYNbS 60 EASTERN AVE N ESSEX MA 01929 Expiration Commissioner09/20/2015 I I _ Y _Office of Consumer Affairs&Business Regulation ME IMPROVEMENT CONTRACTOR egistration: 177026 Type:. i Expiration 110I23201 Corporation j f GEROGE GLYNOS CONSTRUCTION INC. e� GEORGE GLYNOS 60-EASTERN UNIT 2 ESSEX,MA 01929 Undersecretary I a CITY OF SAS -M, NL-kSS:ICHUSETTS BUILDING DEPARTMENT 120 WASHNGTON STREET, Son FLOOR TEL (978) 745-9595 FA_x(978) 740-9846 KID fBFRt F_Y DRISC011 MAYORTHoatAs ST.P1&eR& DIRECTOR OF PUBLIC PROPERTY/BU IIDNG CONNISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Aprificant Information //�� // // Please Print Legibly Name (Busire/•sOrgmsizatiom'Individual): t_nCy�4�Q, ! �v/yn / l 19Y7fTn✓Cr1e+� lr'1 Address: B U �, STe rry City/State/Zip: L;3e_Xt /VP (QIq 24 Phone R15 • Are you an employer?Check the appropriate box: 'type of project(required): ).❑ lam a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2�1 con a sole proprietor or partner- listed on the attached sheet.t 7• ❑ Remodeling ship and have no employees These sub-contractors have 8. ❑ 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.❑ Electrical repaus or additions 3.0 1 am a homeowner doing all work right of exemption per MGL I I.[] Plumbing repairs or additions myself.(No workers'comp. C. 152,g 1(4),and we have no 12.❑ Roof repairs - insurance required.)t employees. LNo workers' i;.❑ Other comp. insurance required.j . •Any applicant drat checks box 01 mast also rill out the we liun baow showing their worked compemmion policy inn,nnatiun. 'I lomauwncnx who when this anlrhvi,indicting thry arc doing all work and then hire uutsido contnetan mtut aihmil a new a?davit indicting such, :C,,nt mclun,hul check this box must anached on additiuwl.hat showing Iha mmne of the si bKonlnctora and iheirworken'comp.policy information. l am un employer that is providing workers'compensation Lrsurancejor my employees. Below is the policy rand jub site information. InSaranL'e Company Name: -------- Policy N or Self-its. Lie.H: Expiration Date: Job Site Address: City/Stute/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 ot'MGL c. 152 can lead to the imposition ofcriminal penalties of a line up to S1,500.00 and/or one-year imprisonmcn4 as well as civil penalties in the form of a STOP WORK ORDER and a fine. orup to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of investigutions of the DIA for insurance coverage verification. /du ltereby cerrijy corder to pains d penalties ajperjury that the ierfornm0att provided above is true and correct. i t Datd: P n OJ)iciai use only, no not write in this area,to be completed by city up town njjicfaf City or Town: PermitfLlccme N Issuing Aulhurily(circle one): 1. Board of llealth 2, Buildln"Deparintant 3.Cityfrown Clerk 4. Electrical luspector 5. Plumbing lal.speetor 6.Other I Contact Person: __ Phone CITY OF SiULEM) ;AXSSACHUSETI-S ©UILDLNG DEPARTNL&NT t y` 120 WASHLNGTON STREET, Yo FLOOR -� TEL (978) 745-9595 F-kX(978) 740-98 46 Kf\tBF_RLEY DRISCOI.L NLAYOR THo.%LAs ST.PIERR$ DIRECTOR OF PUBLIC PROPERTY/WaMLNG COJOIISSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Coda, 780 CMR section 1 t 1.5 Debris, mid the provisions of NfOL c 40, S 54; Building Permit ik 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,tv1GL c 111, S 150A. The debris will be transported by: y y �Dr� ft1 CFiI ��nr (name of hauler) The debris will be disposed of in (name of facility) le p-, (address of racility) I / ❑ture of permit applicant date id,rr..i r,'.Lz