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36 SCHOOL ST - BUILDING INSPECTION (2) r: ctL 2.SCI'p The Commonwealth of Massachusetts CITY OF Board of Building Regulations and Standards RE Massachusetts State Building Code, 780 CMR JNOM c C RE6 �p Building Permit Application To Construct,Repair, Renovate Or Demolish a ffIV C S One- or Two-Family Dwetling 1015 This Section For Official Use Only f� Building Perm it Number: D Applied: Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 1� G Sca�� ST. 1.1 a Is this an accepted street?yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: K2 Q,II AcR+= Zoning District Proposed Use Lot Area(sq It) Frontage(ft) 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,)d Private❑ Zone: _ Outside Flood Zone? Municipal lCK On site disposal system ❑ Check if yesl l SECTION 2: PROPERTY OWNERSHIP' 2.1 Ownert of Record: RLIAS LLc HAS) 1 6NE � M� a1�4� Name(Print) City,State,ZIP is MAKI< US TWHBNb Ca (OH No.and Street Telephone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify: Brief Description of Proposed Work': !NSTAl-( WVl KOOF LE SECTION 4: ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1. Building $ 4000 . 00 1. Building Permit Fee: $ Indicate how tee is determined: 2. Electrical $ ❑ Standard City/Town Application Fee ❑Total Project Cost (Item 6)x multiplier x 3. Plumbing $ 2. Other Fees: $ 17 4. Mechanical (HVAC) $ List: c2 S. Mechanical (Fire $Suppression) Total All Fees: $ Check No. Check Amount: Cash Amount-0 Paid in Full ❑ Outstanding Balance Due: t f, SECTIONS: CONSTRUCTION SERVICES 5.1 Construction Supervisor License (CSL) r—S— Og190, I OQ1(jS2 WiAIENo License Number - Ex na on Date Name of CSL Holder List CSL Type(see below) 4fi alL�itis . �� No.and Street 1\ VI pp q T e Description Unrestricted(Buildings up to 35,000 cu. ft. `1 Restricted 1&2 Family Dwelling City/Town,State,ZIP M Masonry RC Roofing Covering �1 �^ r1 WS Window and Siding 18r J Zl q?Z Nor IAW NOVA-tR . Co SF Solid Fuel Burning Appliances 1 1 I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) 14 c z�' T - 1 NVA Lo1ySjeUCTtoN & RFO-LwuG Ih/L xp i ion Date HIC Company Name or HIC Registrant Name M- 611TrmI �A ItWlAS QWOVA -CQ . Go01 N and St eet Email address Qt4ef 1Ek� gS� 1BIS2t 93Z'1 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 ..........A No........... ❑ SECTION 79: OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT I,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. Print Owner's Name(Electronic Signature) Date SECTION 7b: OWNEW 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. --F�M WA9 ti* Z - Is Print Owner's or Authorized Agent's Name(Electronic Signature) I Date NOTES: 1. 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 can be found at www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 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. ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" CITY OF SM EN1, X'LkSSACHUSETTS BL'B.DINtG DEPART\IEDIT t 120 W ASHINGTON STREET,P FLOOR TEL (978)745-959S FAX(978)740.9846 KI.,,{gFRT FY DRISCOLL MAYORTHOMAS ST.P>FxRs DIRECTOR OF PUBLIC PROPERTY/BL'IIDDIG COMMSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information p Please Print Legibly Name(Businesvorgani:ation/Individual): NOVA 'Copt ST�UGT Ie�J DC �&11�oIsE1-I IvC �NG Address: r�, MG0W5 rZ1> City/State/Z[p: hgRKLEAcI.`6, nA 9194C Phone#: -181 S21 g421 Are you an employer?Check the appropriate box: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(full and/or part-time).* have hired the sub-contractors 2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7• ❑Remodeling ship and have no employed These sub-contractors have 11. ❑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 repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.[No workers'comp. c. 152,§1(4),and we have no 12•❑Roof repairs insurance required.]t employees. [No workers' comp. insurance required.] 13.❑Other •Any applicant that chock$brat al must also fill out the soc11041 below stowing their wortten'compensation policy information *I lomeonmon,who submit this affidavit indicating they are doing all work and them hire outside conttacom must submit a new affidavit indicating such. •Camrac s,rs that chock this hat most attached an additional shaet showing the name of the sub-conomtors and their workers'comp,policy insuounr n. l am an employer that i1s prividing workers'compensation Insurance far my employees. Below Is the policy and fob site information. Insurance Company Name: Policy#or Self-ins.Lie.#: Expiration Date: Job Site Address: City/State/Zip: Attack a copy of the workers'compensation policy declaration page(showing the policy number and expiration hate). Failure to secure coverage as required under Station 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonment,as wall as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DtA for insurance coverage verification. l do hereby c tder the pains and penalties ofperjury that the information provided above/is true and correct Signature: Date, Phone#: 1g1 —52.1 _ �3Z'► Official use only. Do not write in this area,to be completed by city or town offklat City or•rown: Permit/License# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector S. Plumbing Inspector 6.Other Contact Person: Phone#: ' CITY OF SALSA MASSAG USE M BuALDngG DEPARnaNT 120 WASHNGTON SUM,YoROOR TEL(978)745-9595 RIMBERL.EYDRISQOLL PAX(978)740-9846 MAYOR THOMAS STYIERRE DIRECTOROFP[ ucFROPERTY/BIm.Dmomvj SIONER 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 c40, 5 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste deposit facility as defined by MGL c 111, 5150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: LLf ruN (name of facility) Sl �uZ��I twSQi.J C� (address of facility) Signature of applicant g Ati c:S7— Da e J Details Page 1 of 1 ?O Offida JPGsi;e Of `�CKOC V-0 O CC of f' b afety 2W Sc u i/ Nlias=_Eea Home Stsie Agencies, FName� Details e: =OVASZ A WABNO me:2: Marblehead MA 01945 U 'ted tates icense No: CS-089905 License Type. Construction Supervisor Profession: Building Licenses Date of Last Renewal: 5/20/2014 Issue Date: Expiration Date: 6/4/2016 License Status: Active Today's Date: 8/25/2015 Secondary License: Doing Business As: atus Change: -LiceDse Renewal- - o Prerequisite Information No Discipline Information ocumen um _----- Close Window ©2011 Commonwealth of Massachusetts Site Policies Contact Us http://elicense.chs.state.ma.us/Verification/Details.aspx?agency_id=l&license_id=278846& 8/25/2015