8 SETTLERS WAY - BUILDING INSPECTION (2) The Conin onwealth of Massachusetts
\1 Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
Revised Mar 2011
Building Permit Application To Construct,Repair, Renovate Or Demolish a
One-or Tiro-Farnily Dwelling
This Section For Official Use Only
Building Permit Number: Date Apli-ed:
Buildin_e Official(Print Name) Signature Vat,
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
1.1 a Is this an accepted street?yes_ n Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(ft)
1.5 Building Setbacks(ft)
® Front Yard Side Yards Rear Yard
•�5
Required Provided RequEd: Provided Required Provided
1.6 Water Supply: (M.G.L c,40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System-
Outside Outside Flood Zone? Mmticipal❑ On site disposal system ❑
Public❑ Private❑ Zone:
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Recor
\-�s NyamA
Name(Print) City,State,ZIP
.�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Nmnber of Units Other ❑ Specify:
Brief Description of Proposed Work':_- !t,(
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials)
1. Building $ I. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑ Standard City/Town Application Fee
O Total Project Cost'(Item 6)x multiplier x
3.Plumbing S 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amotmt:
6.Total Project Cost: S �bO OJ '4'�J 13 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
'a( License Number Expiration Date
Name of CSL Holder
'^w / � ,, ^ ^ , List CSL Type(see below) �
`d—`��\�`U�\, tl1 \J—�` Type Description
No.and Street
U Unrestricted(Buildings up to 35.000 cu.ft.
R Restricted 1&2 Family Dweller
City/To M Masonry
RC Roofuro Covniu
WS Window and Sider
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered]Tome Improvement Contractor(HIC)
HICRcgisinaTonNumber xpiraE tion Date
HIC Coni any me or Inc Registrant Name
g s'�� A1 �
No.and Street Email address
Cavaown.S te,Z 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 ..........1K No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR MI OR BUILDING PERT
1,as Owner of the subject property,hereby authorize r t%\NV
to ar '
act on�m,y//be`hhaallf..behalf.
all matters relative to work authorized by this btdlding permit application.
P vrt ONvrler's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest wider the pains and penalties of perjury that all of the information
contiw in tliis application is true and accurate to the best of my knowledge and understanding.
$r O er's or Au iorized Agent's Nanie(Electronic Siguatwe) 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(HIQ Program),will not have access to the arbitration
program or guaranty fund under M.G.L.c. 142A.Other important urfonriation on the HIC Program can be found at
www.mass.eov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dps
2. Mien 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
Nmnber of fireplaces Number of bedrooms
Nwnber 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"may be substituted for"Total Project Cost"
Y
f�
Air-Tight Weatherization LLC Estimate
9 Story Ave
Beverly, MA 01915 Date Estimate#
6/7/2013 79
Name/Address
Harry Demonaco
8 Settlers Way
Salem,Ma 01970
Project
Description Qty Rate Total
Demo and dispose of cabinets. 3,320.00 3,320.00
Install kitchen as per plan.
Open wall and install hutch. ,
Tile backsplash(Tile supplied by owner).Aprox 21sf
Sand and refinish kitchen floor aprox 260sf using oil base poly three
coats
Plumming to reconnect sink and icemake.This is a allowance 450.00 450.00
Install under Nicor cabinet lights.I feel this light is the best i used 1,500.00 1,500.00
them in my house.This is a allowance
Painting allowance if you want me to paint 800.00 800.00
If you have any questions please feel free to call me anytime. 0.00
Here is the number to my granit guy his name is Giammo his english -
is ok at best if you need me to make contact with him please let me
know.978-356-3052
Again I appoligize for taking so long this is not the norm for me.
Sign
Here
If you have any questions please feel free to call 978-998-4684
Total $6,070.00
Office of Consumer Affairs ane. Business Regulation
m 10 Park Plaza - Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 165640
Type: LLC
Expiration: 3/15/2014 Tr# 222331
AIR - TIGHT LLC. WEATHERAZATION
JAMES FORTIN ---
10 PINE KNOLL DR. —
BEVERLY, MA 01915 ---- ---- --- —__._
Update Address and return card.mark reason for change.
;)PS-GAI 0 50M-04,04-G10//1216 _ Address � Renewal _ Employment Lost Card
:7Rtl llajXielie&w,f
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
-HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 165640 Type: Office of Consumer Affairs and Business Regulation
'- -"- Expiration: 3/15/2014 LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
AIR-TIGHT LLC.WEATHERAZATION
JAMES FORTIN
10 PINE KNOLL DR. �4�� -
BEVERLY, MA 01915 Undersecrete Nott valid=hoot sig=----
1 �l.l��aC hll K•!!� Ilc •4 publ!i '.Ilrl,
5,,.:n! •! HuiLFu_ kr•tulelinl. .unf�l.ul,Llyd.,
.�.pf15tP:.Ct Cc
LlCen6e JS 52576
JAMES E FORTIN t
10 PINEKNOLL DR
BEVERLY, MA 01916 {
at
-,Pir-,00n 10/3/2013
_ The Commonwealth of Massachusetts
S_ Print Form `
Department of Industrial Accidents
Office of Investigations
I Congress Street, Suite 100
Boston, MA 02114-2017
eat www.mass.gov/dia
Workers' Compensation Insurance Affidavit: General Businesses
Applicant Information Please Print Legibly
Business/Organization Name:
Address: \PttUeJr�t� e
City/State/Zip: C'�\q\S Phone #: Q (.0
Are you an employer? Check the appropriate box: Business Type(required):
1.® 1 am a employer with k'S- employees(full and/ 5. ❑ Retail
or part-time).* 6. ❑ Restaurant/Bar/Eating Establishment
2.❑ 1 am a sole proprietor or partnership and have no 7. ❑ Office and/or Sales (incl. real estate, auto, etc.)
employees working for me in any capacity.
[No workers' comp. insurance required] 8. ❑ Non-profit
3.❑ We are a corporation and its officers have exercised 9. ❑ Entertainment
their right of exemption per c. 152, §1(4), and we have 10.❑ Manufacturing
no employees. [No workers' comp. insurance required]* I I.❑ Health Care
4.❑ We are a non-profit organization, staffed by volunteers,
with no employees. [No workers' comp. insurance req.] 12.®Other
Any applicant that checks box 41 must also fill out the section below showing their workers'compensation policy information.
**If the corporate officers have exempted themselves,but the corporation has other employees,a workers'compensation policy is required and such an
organization should check box N I.
I am an employer that is providing workers'compensation insurance for my employees. Below is the policy information.
Insurance Company Name: Gn, !s,1^%UV O_V�ea C--m
Insurer's Address:
City/State/Zip:
Policy#or Self-ins. Lic. # S—V`-' �...,.�t Le�. goo l.e Expiration Date: `l 1 1 ' [LA
Attach a copy of the workers' compensation policy declaration page(showing the policy 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 a
fine up to$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$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 DIA for insurance coverage verification.
I do hereby certify,under the pains and pens 'es of perjury that the information provided above is true and correct.
Signature /'O.d----�^ v— �y Date:
Phone#: � �� �' .C' 8W ..
Official use only. Do not write in this area, to be completed by city or town official
City or Town: Permit/License#
Issuing Authority (circle one):
1. Board of Health 2. Building Department 3. City/Town Clerk 4. Licensing Board 5. Selectmen's Office
6.Other
Contact Person: Phone#:
www.mass.gov/dia