39 SABLE RD - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
—' Board of Building Regulations and Standards
1 a� 'Massachusetts Stale Building Code, 780 CMR, 7"'edition Building Dept
1 Building Permit Application To Construct. Repair, Renovate Or Demolish a ANNE&
One- or Tu'o-F milr DmrlLng
This Seen For Official Use Only
Budding Permit Number: Date Applied: 7i
Signature:
Budding Commtsstoner/Ins ( Buildings Date
TION 1:SITE INFORMATION
I.I Prop )ert�xv dPPress: 1.2 Assessors Map& Parcel Numbers
3 9t�/ti��' Parcel Number
I.I a Is this an accepted street?yes no Map Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq n) Frontage(n)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
/V / 7:5 '
1.6 Water Supply:(M.G.L c.40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check it es❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Reeord: 9 sable k� Sk 1eV,,
fq �/IP ¢ `�f` Lelt,e.�•ai a— A 9 for Service:
Na (Print)
^�F=add- Sayer
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(.) I& Alteration(s) ❑ Addition Cl
Demolition ❑ 1 Accessory Bldg. ❑ I Number of Units_ Other ❑ S city:
Brief Des 'till n of Proposed Work:
�� I i
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs: OfIlcial Use Ooly
Item Labor and Materials
I. Building f I. Building Permit Fee: f Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical f ❑Total Project Cost'(Item 6)x multiplier x
3 Plumbing S 2. Other Fen: S
4. Mechanical (HVAC) S List:
i Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:_
6. Total Project Cost. S 1 ❑ Paid in Full ❑ Outstanding Balance Due:
� R
7
3
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supe visor(CSL) / / �
q� -J /11/�l�R� L-cc Num tbccrr Expiration Dam
N.4nic ol'CSL- Hylder f
Lut CSL
�. S'4,'p Type(sec below)
AJdrrss , / T'pe I Description
U i Unrestricted(up to 35.000 Cu. Ft.)
S.gnamrc R I Restricted 1&2 Family Dwellin
4 O M .Reason Only
10 ZP`IO RC I Residential Roofing Covering
Telephone wS Rcstdenual Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
S.2 I tered Home mpr vement ontractor(HIC)
?� .�y l�ia�v, �;d�n 197AZ9
HI Sympany N e or HIC Registrant N Rc siration Number
s w R •
Address G 9,;l'
Qlf 7 / Exififaliofi Date
Signature Telephone I J
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 2SC(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 ARdavit Attached? Yes .......... O No........... O
SECTION 7n: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.
Signature of Owner Date
SECTI N b:OWNEW ORAUTHORIZED AGENT DECLARATION
1• / u�A/01 9. , as Owner or Authorized Agent hereby declare
that the statements and in alion on the foregoing application are true and accurate,to the best of my knowledge and
beh
CIC
Print Name
Signature of OWMFor Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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.
2. When substantial work is planned,provide the information below:
Total floors 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
Typeof cooling system Enclosed Open
3. "Total Project Square Footage"may he substituted for 'Total Project Cost"
• CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
III v';1 '1: rl'ii • I \ 'i t V. ' •Ir.
Construction Debris Disposal Aftid.nit
(rcyuired lbr all dc11 full IIUlt and rcnu%aIon work)
In accurdance wtit the sixth edition of the State Building Code, 7S0 CAIR sccbon I I 1 5
Debris, and the provisions uf'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 properly licensed wa.ste disposal facility as defined by MGL c
I I I. S 150A.
The debris will be transported by:
I name of haJllor)
1 he debris will be disposed of'in :
D U
Inane ul Na 1 -• -
Lu1Jrc.. rrr Iauluyl
a anal e of pinnn apph�anl
z14KI417
.41r
CITY OF S.U.E.�t, . WSACHL-SETTS
BUI DIING DEPARTlE.NT
_. 10' ,WAsmxNGTON STREM 3w FLOOR
TEL (978) 745-959S
FAX(978) 740-98"
Kl.,,[BERj'EY DRISCOIL
MAYOR "IhObW ST.PIERRs _
DIRECTOR OF PLBLIC PROPERTY/BLaDLNG CO.%L%aSSIO,%ER
Workers' Compensation Insurance AMdavit: Builders/Contractors/Electric)mns/Plumbers
-%n Ilcant Information .Pl Printe
Nalne (BusirrnaOrganttarion,InJavtrlual): � 1111.dleU S� :77/1 e '
Address- �
�r1a d
city/slawzip: SJ&y -- ^4 d l97 d Phone,#: 77r-
%re on a employer'Cheek thh pproprisfe bolt: Type of project(required):
I. m a employer with 3 4. ❑ 1 Am a general contract"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 ahceL 1 7. ❑ Remodeling
P
.hip and have no employees These who-contractens have g. ❑ Demolition -
working for me in any capacity. workers'comp.insumnca 9. Building addition
(No workers'comp. insurance S. ❑ We are a corporation and its
rw:quireJ.)
odicers have exercised their I0.❑ Elacrrical repairs or additions
).❑ 1 am a homeowner sitting all work right of exemption per MGL I I-❑Plumbing repairs or additions
myself.(No workers'comp. C. 152,41(4),and we have no 12-❑ Roof repairs
insurance required.) t employees.(No workers'
comp. insurance required.) I5.0Other
'Any applicant 11 a chocks ban 01 must alesn fin a r t the ctioa brim thawing theirmp vorkcea'co nra6tn policy in/u a mudm
't hwwneuwrita who suhttie this aflidevir indicting they am doing all wort and then him amide emtractar mum sohmit a nea amdavir indicating gunk
=r.xw1a9on shot cheek this bra mud anaclted an aJdinionst had showing doe wtonrte dllle aThTOrU/slole and os*wWhem'a^r.Policy iofcamarien.
I arse an tmp/oyer thet b providing workers'compenradoa Ina rmoss jar my'amplaytes Qt/ow b rht pellry owd fai r/!e
injormanion. /J
Insurance Company Name: ,,tt WI�,,1 /qH
Policy 0 or Self-ins. Lie.H: e i/OO(o F 7t1Z Expiralion Date: 7
Job Site Address: �Y s��l� �tyf. f'� W` City/Statdzip: S_�. MA. 4! ?0
,%ctack a copy of the workers'compensation policy declaration pap(showing the polity number and esplrsdon dat4
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 S 1,500,00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fin
of up m S250.00 a day against the violator. Ile adviraxl that a copy of this statement maybe rurwarded to the Office of
Invcaugmiuna ol'the DIA for insurance coverage verification
/Jo hereby and penahlei ojper/ury that the informalloa provideed a Vf%7 t Fue r/ld a YNfGL
01ricial tut only. Da not write in thin area. to be.umplitted by dry or sown u/flcirL i
City or ruwn: _ _ ecrmita.lccnse M
Irsuing.whunty (circle one):
I. Ituard of lleAlh 2. RuilJing Deparlment ). Ciiy%forn Clerk 4. Flecirical Iinpector 5. Plumbing Inspector
6. Other
_„9--`•, L,,ntael Perron: __rhane.a: