5 SCHOOL ST - UNIT 8 BPA 10-33 BATHROOM The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR, 7'"edition
Building Dept
Building Permit Application To Construct. Repair, Renovate Or Demolish a
Otte. or Tiro-FamdY Dn'elling
� This Section For Official Use Only
( 3 Building Permit Number Date Applied: r ' '
ISignature: ' G
Bui mg_ ommissioner/Inspector of Buildings Date
SECTION 1:SITE INFORMATION
.� I.I.Pro ert /A ress• 1.2 Assessors Map& Parcel Numbers
1.1 a Is this an accepted street?yes_. no Map Number Parcel Number
I.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq R) Frontage(it)
1.5 Building Setbacks(11)
Front Yard Side Yards Rem Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c.40,S54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
/ Zone: _ Outside Flood Zone?
Public f3 Private❑ Check it es❑ Municipal 9bn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'ci jj�1ecor
i7H hfo 9 s �t� LiUI.IC P�— SCt_X/� S /
Name(Print) Address for Service: _
4'�2Y- `70I S
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction O Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) O Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work': Oe✓"✓I
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: OMClal Use Only
Labor and Materials
I. Building 1. Building Permit Fee: S Indicate how fee is determined:
O Standard City/Town Application Fee
2. Electrical ( 0Ov, S ❑Total Project Cost'(Item 6)x multiplier x
J Plumbing S 2. Other Fees: S
4, Mechanical (HVAC) S List:
5 Mechanical (Fire S
Su ression Total All Fees: S
Check No. _Check Amount: Cash Amount:_
6. Total Project Cost: 1 0 paid in Full O Outstanding Balance Due:
SECTION S: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
t�M HV—, 2. — /�/�L �Tl License Numtxr Expiration Date
N;gpC)Cul C CSL- Helder U- 'YJ/C-
List CSL Type bee below)�_
Tc�)V C a
0 0/ct3 T Description
fe U Unrestricted u to 35.000 Cu. Ft.)
R Restricted 1&1 FamilyDwelhn
i - are _� M •Mason Only
RC Residential Roofing Covering
Telephone WS Residential Window and Siding
Sle Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
S. egl>ttered F{pme I� e,(neot Cotpctor(HIC) I7�b l
HIC ComttpaoyJ,NameCor HIC Regi�y✓ant�N tamUe Registration Number
Address -O.(�� I ration Date
Signatun Telephone
TION 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 AlTidavit Attached? Yes.......... No........... O
SECTION 7s: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.
Si nature of Owner Date -
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
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
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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.R5, respectively.
2. When substantial work is planned,provide the information below:
Total floors area(Sq. FL) (including garage, finished basementlattics, decks or porch)
Gross living area(Sq. Ft.) Habitable room count
Number of fireplaces .Number of bedrooms
Number of bathrooms Number of halfbaths
Type of heating system Number of decks/ porches
Ty pe of cooling system Enclosed Open
1. 'Total Project Square Footage"may he substituted for 'Total Project Cost"
CITY OF S U EM, �LNSS.ICHL'SETTS
BL'ILDLNG DEPARTMEI iT
120 WASHINGTON STREET, )sa FLOOR
TEL (978) 745-9595
FA .X(978) 740-984
KI.,IBERLEY DRISCOLL THo&AS ST.PmRRa
.%SAYOA
DIRECTOR OF Pl:BLIC PROPERTY/gl'QDLVG COSLLrtiSStONiER
Workers' Compensation Insurance Affidavit: builders/Contractors/Electricians/Plumbers
applicant Information Please Print Legibly
Nalne (dusimw or&4nizaiion•Inrhvidul): �= �' 1 C U IrY✓t ✓C r C57'
Address: 22, LA�JGt
cily/srate/zip: ��lu.T�3� t�,OlSih�4�e a: �'i2 n 82� �r 6U�
Are you an employer?Check the appropriate bolt Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1
nployees(full and/or pan-time).• have hired the sub-contracmn 6. ❑N conatructioa
2. 1 ac a sole proprietor ar partner- listed on the attached sheet : 7. Remodeling
;hip and have no employees These sub-contractors have g. ❑ Demolition
working for me io any capacity. works"'comp.insurance. 9. ❑ Building addition
[No workers' comp. insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their 10.0 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL 1 I.❑Plumbing repairs a additions
myself.(No worker*comp. c. 152.§1(4),and we have no 12.❑ Roof repairs
insurance required.] t employees. (No workers' I].❑Other
comp. insurance required.]
'Any applicant this chocks two el must aim fill out the section below shawiag their workers•compareatwn policy infunwlon.
'I huneuet me who submit the aflldsvit indicuing they ane doing all work and these him outside earan'"a must submit a new amdsvis indicators suck
-f.m•m ore that chuck this ban muss attwhad an additiaal chat.hawing the•amet of tier nt4eontraebn and their wrarkem'comp.policy infanrotim.
I am an employer that it providlntf warders'compensation Insaroare for my employeex Below!i the polay amd/oA rlh
informmlon.
Insurance Company Name:
Policy M or Self-ins. Lic.N: Expiration Date.-
Job Site Address: City/State/zip:
Attack a copy or the workers'compensation policy declaration page(showing the polity 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
Fine up to S 1.500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Ile advised that a copy of this statement maybe forwarded to the OIYce of
Invesligaiiona of the DIA for insurance coverage verification.
I do herreby certify r rh pains asset Pena des Of perdsrry that the information provided above is true and correct
Win• r I it
Phon a: 7Y �� / 7 �c�n`-h
iO� sera•cial Only. Do not write in this area, to be a arrepleted by wiry or to wn O/f,-iaL
City or fuwn: _ eermit(l.icense N__
Issuing Aulhordy (circle )ne): j
I. Ituard of Ilralih 2. Building Department 3. City/town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6. Other
Lmitact Person: _ __. _. Phone p•
s.` CITY OF SALEM
��.
PUBLIC PRc)PRERTY
DEPARTMENT
JyMV
Construction Debris Disposal Aflida%it
(tcyuircd l6r ❑II demolition :old rcnuvation wurk)
In accurdance \\ith the sixth edition of the Slate Building Code, 780 CMR section I 1 1 5
Dcbtis, and the provisions of.b1GL c 40, S 54;
Building Permit H is issued with the condition that the debris resulting from
this work shall he disposed of in it properly licensed waste disposal facility as defined by MGL c
I11. S 150A.
The debris will be itansportcd by:
InamcuChuJtrl
I he debris will be disposed ofin
L,(O
(�� (nalnr ul luclluy)
1•1ildress Ail laclluyl
cu Nlwe nt prunit .yglhrunl
J
dice
Massachusetts- Department of Public Safcty
Board of Building Regulations and Standards
�J Construction Supervisor License
License: CS W678
Restricted to: 00
JOHN R TESTAVERDE
27 UNCAS RD
GLOUCESTER, MA 01930
Expiration: X16i2011
( nuni..iom,r Tr#: 11064
License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration_ 122002 Board of Building Regulations and Standards
Expiration:' 7/9/2010 Tr# 0 One Ashburton Place Rm 1301
Type:. Individual Boston,Ma.02108
JOHN R.TESTAVERDE.:"
N TESTAVERDE
27 U
27 NCAS RD.
GLOUCESTER, MA 01930- Administrator talid without signature j