14 SABLE ROAD WEST - BUILDING INSPECTION The Conunonwealth of Massachusetts J
Huard tit Building Regulations and Standards Pt)fi
i1 Massachusetts State Building Code, 730 C NIR. 7 edition. ( 'tiP
Building Permit Application To Construct, Repair. Reno%ate Or Demolish a Rrrnr,!hum,u
One-or Tn u-Funrihy Dn ellirt,if
This Section For Official Use Only
0 Building Permit Num r: Date Applied: [1` I ` O -
�/�./ Signature: G' 69.0 L> ---
- i3uil mg Co missioned Imlxoor of Build..gs Date
SECTION 1: SITE INFORMATION
1.1 Properly :address: 1.2 Assessors Map & Parcel Numbers
1.la Is this an accepted street? yes_ no Map Number Parcel Number n -
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning Di>tt ict. Protwsrd Use Lot Area tsq It) Frontage i it)
1.5 Building Setbacks (ft)
+a.
Front Yiu - Side Yards _ _ Rear Yard
Required Provided Required Provided Required pi (Jed
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 ❑ Pri rate❑ Check if yes❑ Municipal ❑ On site disposal system ❑
t
SECTION 2: PROPERTY OWNERSHIP(
-4 2.1
/® f /nett of Re�9rd �: � 5 �
Nam• Pr ) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK=(check all that apply)
,New Construction ❑ Existing Building ❑ Owner-Occupied ❑ 1 Repairs(,) ❑ Alteration(s) ❑ Addition
Demolition ❑ Accessory Bldg. ❑ Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work': fie' X /O' A-pol"bn/ 5 U/V e'Gbn•J
12c-o +x t:�� -�IZ W rlSt+. rvlPkc H rcS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
I. Building $ Op o 1. Building Permit Fee: $ Indicate how fee is determined:
n. Electrical $ �� ❑Standard City/Town Application Fee
❑Total Project Cost (Item 6) x multiplier ,x
3. Plumbing $
�, QDO _. Other Fees: $
a. Mechanical (HVAC) $ List
S. Mechanical (Fire
Suppression) Total All Fees: $
�7Jj� Check No. Check Amount Cash .l mount`___
6. Total Project Cost: $ 91J - ❑ Paid in Full ❑ Outstanding Balance Due:_______J
AND i� 1 L( 5 001Lts }-
SECTION 5: CONSTRUCTION SERVICES
5.1 /1L4—icensed Construction Supervisor(CSI,)
/ *tA D M. CJ License Number Espn,mon Date
N ann•of C5l flulilcr (f
_ D Ctir�$E Loa CSI_Type Ise, below') _
1dJr e "I' e Descri noon
L Unresiricied rt) to li.(N 001 1'1.r
R Restricted 1&'_ Faintly Dw ¢ellin
5)gnat e M Masonry Only
r1'lg'14`I^Z('1 0 RC Residential Rootin g Coseriue
T,Icphonc .„. • %%S Residi ital Wtnthm and Std111e _ f
SF Residential Solid Fuel Ifunun❑ 1 t than,: Ins).�Ilau� n
D Residential Demolition
5.2 /77tl�I d 1 ome Imp, v� ement*Contractor (HIC) '—_
j! M Un/Ji� / 7� /
HIC Cumpmty anu or HIC Regis tt Name Regauauun Nunther
AJdr•s /IgTf�d9
puation Date
l Si e 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 pnn'ide „'
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
t, �Aae/D jo/NT o as Owner of the subject property hereby
authorize -1,4 fl-,Q ,Q M. to act on my behalf. in all matters
relative to
work
�au)thor d by is building permit application.
SSS�ture of Owner Date
/f SECTION
7b: OWNEW OR AUTHORIZED AGENT DECLARATION
JA[, /A•eio X4 (. v✓E1A , 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
beha
W
Print N me
R
Signaun- o Authonzc Agent Date
(Signed under tine pains and penalties of er'u )
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 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 110.R6 and I IQ.R5. respectively.
'_ When substantial work is planned, provide the information below:
Total flours area(Sq. Ft.) IZA (including garage, finished basement/anics. decks or porch)
Gross living area ISq. Ft.) Habitable room count
Number of tireplaces Number of bedrooms _
Number tit bathrooms Numberof halt/ba)h_, _
Type of heating system ¢��-n Ho�M 2 Number of decks/ porches
Type of cooling .system
3. "Total Project Square Footage—may be substituted for "Total Project Cost"
CITY OF SALEM
PUBLIC PROPRERTY
1r% DEPARTMENT
. ... \Ls�, at IJ. U_s-I�:�.,,:, �i:hlll • it;: V. \I s..s, I ., �, , . :ll
rs
N%orkers' Compensation Insurance :%ftida%it: Builders/ContractoniElect Pici`e Print l eb'hl
1 tlicant Information (/1
\,II IIc ,nu.mr.. l hyan v,tuon Indic'dual I: 1A11 IC `
\'unless: 1 O '! *rye S1—
City titatuZip:
r rrI(A IJI`r3a Phone 4: R"1F7�FY ly
tire you in employer:' Check t e appropriate box:
rype of project(required):
employer w ith q. ❑ 1 and a general contractor and 1 6 ❑ New construction
employees(full and'or part-time).' have hired the sub-ccuitractor5 7. ❑ Remodeling
'.❑ I am a sole proprietor Vr,p�rtner-,.
listed on the attached sheet. t
�r. these sub-contractors have 8. ❑ Demolition
ship and have no ems).oyees workers' comp. insurance. y. ❑ 13uilding addition
working for me in any capacity. 5. ❑ We are a corporation and its -
[No workers' comp insurance officers have exercised their l0.❑ Electrical repairs or additions
required.] bin additions
},❑ 1 am a homeowner doing all work right of exemption per Iv1GL I I.❑ Plumbing re ons
Pairs or a -
C. 152, $1(4),and we have no 12.0 Roof repairs
myself. worker;cutup. employees. [No workers'
insurancee r reequired.[ 13.❑ Other
comp. insurance required.[
•AIIy,,pp h,ano that checks box 91 mint also till out the section below showing their workers compensation policy Information.
t I lomeUWOers Who submit th19 alnttaVjt Indicating they are doing all work and then tore outside contractors must)abmll a new aftlltaV111nttlCdling such.
$\muactors that check this hox must attached an udduRmol sheet showing the name of the sub-contractors and their workers'comp,policy information.
l urn ate employer that is providing workers'compensation insurance for troy employees. Below is the policy and job site
information. C� T ,/ /r��,�&
Insurance Company Name:_42—� rJT�/' ���
Expiration Date:
Policy As or Self-ins. Lic. q:
7��j�3 �>0
Job Site Address:
Jel SO4e—te �n r�E-ST City,state/7.ip:
.\teach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date).
E;lilure to secure co% f'erage as required under Section 25A o MGL C. 152 can lead to the imposition of criminal penalties of a
tine up to S1.ioo on and'or one-year imprisonment. as well as civil penalties in the ti rm of a STOP WORK ORDER and a tine
„1 (11) to S'511.00.1 day against the %iolator. lie advised that a copy of ill's stalcment may be lbnvarded to the Office of
tin cannauon; of the MA for insurance ancrage �entica0on.
1 Ju hereby r roil. r er lire pun a d Ilerialtiev of perjury that lire irrprurution provided above A true and correct
Date: 6 26 lib'
i nyn,Lit ur0
one -lV ^ZS'to
olllcial use mdr. no turf it rite in this area, to be completed by city or to n•tt official.
I'ermibl.icense Ali
('its or rower. _ _. . _-._... . . _. .. --
Issuing %uthority (circle (one):
I. Board of llcalth 2. Building Deparhuent 3. (�itN, fown Clerk J. Electrical Inspector S. Plumbing Inspector
0, 0(her ----- --_._----
Contact Person: - -- _-- Phone ----
Information and Instructions
\I.i—i.!uoetu General I at., chillier I icquurs .ill clnplo%crs fo pro%ide oorkcrs' amgwn,auon fix their eniplmees.
I'ul,u.uu of (Ills ,(aft a•. .ut einphrr'ee I, dc1mcd is dery per,on In the ,cntee of .nuaher under.uiv eontract of hire.
yncs or Implied, oral or %tnrten."
eorld ter its defined .Is .,if unh,,dual. I imicr,hip. .t,;oct.lnon. corp,ir:won or other local crini%. .or .up hso or more
,.I the iote_Untg engaged in a joint enlcipn,e. and niclwhng the Icpal rcpresrn[an�c, o(a drera,cJ cmplr, era or the
:.•ccn�cr or rru,tce of an uidn IJual. paimer,hlp. .t,,.Icn.tnon or other Icgal entry, cniplo,mg cmplu�aes. Ilu«ever die
WA tier Of a dtsellmg house his Ing nor move than three ;Iparoncnts and �%ho reside, thciem. or the occupant of the
J��ci:mg liou,e III another w ho enq,lo,s person, to Jo maintenance. con,trucuon or repair work on ouch dss elhing house
,r ,on the -rounds Or building .Ippunen.uu Ihercw ,hall no[ because of.urh cmplo%men( be Jecmed to be an cmplu}er.-
\IGI. chapter I�', �'SC(h) also ,rates that 'c%cry state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable es idence of compliance with the insurance coverage required."
.\oldItionally. \IGL chapter 152, ¢li('l-) ,rates "\'eidier the coninwnwcalth nor tiny of as political ,ubdiviNions ,hall
corer into any contract for rile perlLrmance Of public Murk until acceptable c%idence of compliance with (he insurance
rcquoements of this chapter hacc been presented to (lie contracting authority.-
Applicants
Please fill Out the workers' compensation affidavit completely, by checking the boxesthat apply to your situation and, if
necessary. Supply sub-conrractor(5) naine(s). address(es) and phone number(s) along with [heir'certi ficate(s)of
insurance. Limited Liability Companies (LLC)or Limited Liability Partnerships(LLP) with no employees other than the
members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP dues have
employees, a policy is required. Be advised that this affidavit may he submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested, not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy, please call the Department at the number listed below. Self-insured companies should enter their
,elf-insurance license number on the appropriate line.
City or Town Officials
Please he sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
,It [he affidavit for you to till Out in the event file Office Of Investigations has to contact you regarding the applicant.
Please be sure to till in the permit,license number which will be used as a reference number. In addition, an applicant
that must submit multiple permiulicense applications in any given year, need only submit one affidavit indicating current
policy information (if necessary) and under"Job Site Address"the applicant should write "all locations in (city or
own)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof(hat a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
y car. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
1 i.e. a Jog license or permit to burn leaves ctc.),aid person is NOT required to complete this affidavit.
I lie Uffice of Imestig;uions would like m thank }ou in advance fix vour cooperation and should you ha%e any questions,
plca,e do not he,tate to give us a call
I he Depot nncin , address, telephone and fax ❑iniber:
The Commonwealth of Massachusetts
Department of Industrial Accidents
Office of Investigations
600 Washington Street
Boston, MA 021 1 1
Tel. # 617-727-4900 ext 406 or 1-877-MASSAFE
ere I,cd ;_,(r-t5 Fax # 617-727-7749
www.mass.gov/dia
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
O'S 181:1 T ♦ SA I'M. %I.\i.i.V Ili .I I ".
Construction Debris Disposal Affidavit
(re(Iuired liar all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Dcbris, and the provisions of MGL c 40, S 54;
Building Permit it is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111. 5 150A.
The debriswill be transported by:
,
(name of hauler)
'I he debris will be disposed of in
male of tacitity)
taJdress of facility)
applicant
- Ine
AbL ML 7U51153W04 Uie/'I`J 'U2 '17:45 NO.U15 U6/1U
ABL, Inc. MORTGAGE INSPECTION PLAN
REGISTERED LAND SURVEYORS BUYER MARIO PINTO & CATHY CASTONGUAY
P.O. Sax 70702
Qim LENDOR. UNION TRUST MORTGAGE `unsiga ond Villog� .Station '
I WORCESTER, MA 01607 T
508-852-5205 (PHONE) LocAnoN 14 SABLE ROAD WEST
508-853-8364 (FAX) SALEM
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