36 SABLE RD - BUILDING INSPECTION the Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
+� Massachusetts State Building Code, 780 CMR SALEM
Revised,llnr 201/
Building Permit Application To Corl,%Kuct, Repair, Renovate Or Demolish a
One-or Ti )-Fn idv DivellhL
This Vection F r Official Ve Only
Building Permit fiber: - to plied:
Building Official(Print Name) Signature Date
SECTION I INFORMATION
r / 1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
L I a Is this an accepted street?yes no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
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 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone? Municipal ❑ On site disposal system El
if yes[]
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
rt1C(c� E2CJ-L<--rPeg ,
n I G 70
N:une(Print City.State,ZIP
�n Srb le Qii 1�,28"- 7%S' 7U�iU
No.and Street 'relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ 1 Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑r� Number of Units I Other ❑ Specify:
Brief Description of Proposed Work'-: Pm4e- c-r— S}`ti•r !'S
i
fz��vl�r) Px�c't `R C� SS�-.p yCann �jci S'� C -F C•C�i'-�F'U s t -I PS
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Labor and Materials) Official Use Only
I. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S 2. Other Fees: $ d
4. Mechanical (HVAC) S List: ZtJ
5. Mechanical (Fire S
Total All Fees: $
uression)
Check No._Check AntounC Cash AmounC _
6. Total Project Cost: S 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) g e4 2 1 (a
ki C k oLrr I of I.icense Number Espiratinn I ate
Nance of CSI.. I folder
List CSL'fype(see below)
'� R.;� I I � !,c t L-o
No. and Street Type Description
U Unrestricted(Buildings u' to 35,000 cu.11
R Restricted IX2 Funnily Dwelling
C'nylTown.State,ZIP M Masonr
RC Routine Covcrin
WS Window and Siding
SF Solid Fuel 13uming Appliances
cS-7ZCi-�70 3 �.tC -c( f g7 �o I c I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
encrr ( 9 (�c�nstyc an IL23-1u
II IC Registration Number hspiration Uutc
I IIC'ZJao;Q ny,Ngnl qr I11C Re istmnt Numc
((�Ic 19 r,I RI c�cQy-C( 2-1 S)%t- . c o
No. and Street
t-2- 1-- p7fA-- 770 Email address
City/Town, State, ZIP 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
P mt Owner's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
/�/C�ip�d _1 (/� tc ��Zgh
Print Owner's or Authorized Agent's Name f Electronic Signature) Date
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 b1.G.L. c. 142A.Other important information on the HIC Program can be found at
al .,�ggV'oca Information on the Construction Supervisor License can be found at www_nrtss.aov dL
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. it.) 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. •'Tohd Project Square Footage"may be substituted fix"fatal Project Cost'
tl
V assachuxtts - Department of Public,Safety
Board of Building RvImlatiuns and Standard~
Construction Supervisor License
License: CS 94216 - -
r
Rest?icterfto: 00 _
RICHARD J CACCIA
3 ARBELLA DR
BEVERLY, MA 01915
Expiration: 10/412011
(bnnniesiona•r Trp: 9040 -
Ofr, oiuclmerAt7lrl'98 tl091M 11On
HOME IpAPi20AENT C.ONTRACTOR
. - Rapistrat(ot r q 14
Wwk Enplr9tloFt� - -20 T DBti
a a'.
R.� A'CONSTRUCTION"--
rTf^HARD CiA',
BEVERLY; MA01915 Uedersecretzel
" k CITY OF SALEM
tw PUBLIC PROPRERTY
*ter DEPARTMENT
-moo
N\\tst
I�:\VA\IIL\la\1\jI YCL•T a jdl t•.N. III -a 1 IN IAW�
I'M-011-713-9395 It F.\x. 9)N.71VI.yyb
Workers' Cumpensadon Insurance A(Bdavit: Builders/Contractors/Electricians/Plumbers
�unllcant Information �/1 i Plcr+e Print LeetAly
�2iIRlt3llL,uneyi QraanvalioNlnJ'vuluall: L-�( (� tnQnS—t^(�� � r
Address: (JrIl o
City,Slam Zip- ( VQ`V-1 /I'/F} 010,E Mone /l:_Eli — 777
.Are)too an employer?Check the appropriate box:
1'ypa of project(nqulred):
I I.❑ I:un a ampluycr with 4. 0 I umr general contractor and 1
cnapluyvcs(full andtur part-time).• have hired the sub-cunlraclurs G. 0 New construction
21 1 im a tole proprietor or partner• listed on the anachcd sheet. : ?• ❑ Remodeling
ship and have no umpluyces These subcontractors have tl. O Oemolirion
working for me in any capacity, workers'comp, insurance.
I No workers'cutup. insurance 5. 0 We are a corporation and its 0 Duilding addition
requircd.j o1Tlcen have exercised their 10.0 Electrical repairs or additions
).0 1 am a homeowner filling all work right of exemption per b( 11.0 Plumbing repairs or additions
myself. (No workers'cutup. C. 152,§1(4),and we hove no 12.❑ Rtau1'repair insurance required.) t cmploycea.(No worker'
comp. il>.untncu required.J 15.0 Other.
'\ns.ygfLa'yM 1110 chucks boa e1 mull also lilt tors the%%hill Iwtuty dww"I 'twit wutbwl cum mwiun'Ilvmw,wtwn wbes aubmtl Ibis amdavit indlu'in r a a W pdiey nttu'a nias
•('. is
vltm ft"AN dKVII this bar miles anscin t.tn addM''trrutl.�whwl.Attwuta Ihe'tame*(the rutren ranun and their\�iuAan�a1Rda Ihcn mrbrmatiun,
comp.M Y
l our all eulpleyer that It pruvidlne iverkers'clanpen.tarion hl turancirfor toy ernptuyeer. Beluly Is the pulity anJ/ob.sift
h1`ornlu/inn.
Insurance C'umpany, Vmne:
Policy 4 ur Sclf--ins. Lic.Al:
— . .. - Expiration Date:
tub Site :Address: C'uy,Jtute/Ltp;
.Attach it copy of the worker'cumpenxatiun pulley det:14rutlun page(showing the policy number and expiration date).
Failure to wcure cuveruge as required under Sccliun 25A ul'JIGL c. 152 can lead to rite imposition of criminal penalties of a
tine up its.S1.5110.00 and/ur one-year imprisonment, as well as civil Itcnalucs in the I'unn of a STOP WORK ORDER and a fine
Of up to i250.na it Jay against file violator. Ile adirmed that a copy of this smlcmcnt may be forwarded to the Office ul'
111% ul'[7te ILIA for iorur ice covcragu\arilicanun.
/,/a hereby 1 erlify un,Ier lb,s pul�1011 tier u/perjury thus the lu/brmatlon provided ubuve is true alnd correct
Daa �Z 3�l/
tit, : •:,. —
Oflicial tote mdy. /2u nlat writs,in r/dr area,tube cun=V0
is o//ieioA
Ciry or'I'mrn: 0_Asuinp.Aulhurily(circle onc):
Ilnurd of Ilvalth 2. 0uildin. Dcpartmenl 1.t:igJctrical tospccror i, Plumbing laapeerorib. Other �7:
Information and Instructions
Massachtiseus l cneral Laws chayrer I s2 requires all veryo icon in the ss to ervice of another tindert0nnY cuniract f for their lhire.
I'ursuant to tills statute, an emplurrn is Joined as"-.every p
%press or unplicd, oral or written."
An employer is defined as"an individual,partnership,assOcatnon.corporation li other legal entry,or any two or more
•a the Gnegoing engaged in a joint enterprise. and including the legal representatives of a Jea'slo ees ed INowevcroyer,or hhe
eserver or trustee ul'.ur individual,partnership,association or other legal entity.employing ' p y'
owner of a dwelling house having not more than three apartments and who resides herein,or the occupandwelling t of the
,Iwclling flutist of another who employs
Persons to do inotntenallct-becarase of suehuemplaymcnt be Deemed tocunstrct,01"Of repair work on �be an empl yerre'
or on the grounds or building appurtenant
ad
�IGL chapter 152. Qt_5C(ts) also o operate e"every bu netss or to constate or local truct buildings Incensing 21gency lthe Otmrnoawteallb for any he issuance r
ermit to V e coverage required:'
renewal t a license or p linnet with the insurance a
applicant "too has not produced acceptable evidence a of sump
AJJilionally, SIGL chapter 152, a25C(7)states"Neither the commonwealth not any of its political subdivisions shall
enter into any contract for he perfomaance of public work until acceptable evidence of coniyli uiu with the insurance
requirements of his chapter have been presented to the contracting authority."
Applicants
please fill out the workers' compensation affidavit completelYhone number(s)sing tile bong wick theiroxes that `Y to certificate(s)of situation Your and,if
necessary, supply sub-contrrctor(s)name(s), address(es)and p Partnerships with
insurance. Limited Liability Companies(LLCworkers'Limitconsped ebivanoninsuronc (If an)LLC oruLLP done have
er than the
members or partners,are not required to carry
employees,a policy is required. Be advised that this alIldavit tray be submitted to he Deportment of Industrial
Also be
to
he redeemed to the oily or town insthaurance
cO cation for the peon sure
licenw�s being requd date the e ted. not hedaviL eDepartment should
industrial Aecidenu. Should you have any questions regarding the low or if you are required to obtain u workers'
compensation policy, please call the Department'it the number listed below. Self-insured companies should enter their
self-insurance license number on the appro riots line.
City or Town Offlelals
please he sure that the affidavit is complete:end printed legibly. The Department has provided u space at the bottom
of die affidavit for you to till out in the event the Office of Investigations has to contact you regarding the app
I'I:ase be sure to fill in the permidlicenso number which will be ustd as s reference number. In addition,an applicant
that must submit multiple pennitllicense applications in any given year,need only submit Ono affidavit indicating current
-Job Site policy informal''the ufflduvitthat has been officially tamped or markedrby�Ins city oretown nay d underprovided to the in y tit
Y P
town)."A copy
applicant as Proof'that a valid affidavit is on file For future permits Or licenses. Anew affidavit must be filled out each
year. Where is a home owner i r citizen is obtaining a license or pennit not related to any business or commercial venture
t i.c. a dug license or permit to burn leaves etoJ said person is NOT required to complete this affidavit.
1 he r),lice of Investigations would like to thank you in advance fur your cooperation and shuuld you have;try questions,
please Jo not hesimto to give us a call.
fhc Ucparunent's address, telephone anti fax number.
The Commonwealth of Massachusetts
Department of Industrial Accidents
oMce of Invesdgadons
600 Washington Street
Boston, MA 02111
"fe1. N 617-727.4900 ext 406 or 1-877-MASSAFE
Fax N 617-727-7749
t,••„cJ <.+o hs www.ma.w.gov/dia
CITY OF S.ULE.NI, 'L-1SS.ICHCSETTS
OLLIDDLVG DEP.IRTNI&rT
120 WASHMIGTON STREET, 3 °FLOOR
TEL (978) 74S-9595
FAX(978) 740.9846
KIJBERIEY DRISCOLL
MAYOR THOmU ST.PIERRB
DIRECTOR OF PLBLIC PROPERTY/BCILDLNG COMMISSIONER
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 Al 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 debris will be transported by: 1
C�CC t 9 C CD(-�!Lr�U C-�( Ci✓)
(name of hauler)
The debris will be disposed of in
1 � S1C n c4gn9
(name of facility)
SL(.�fy�C' O'F-( C'GSCI
(address of facility)
signatu fpermitapplicant
5
date
Ichn vl(da