12 SETTLERS WAY - BUILDING INSPECTION v
The Commonwealth of Massachusetts
1 "iµ Board of Building Regulations and Standards CITY OF
4'" Massachusetts State Building Code, 780 CMR SALEN1
Reviser/.Iku ?Ill/
Building Permit Application To Construct, Repair, Renovate Or Demolis
One-or Two-Fun ilv Du ellin,g
This Section For fficial Use Only
Building Permit Number: JDate Applied:
Building Official(Print Name) Signat a Date
SECTION I: SITE INFORNIATION 41
1.1 Property Address: 1.2 Assessors Map& P cel Numbers
1.la 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 It) Frontage(It)
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 02/ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal bite disposal system ❑
SECTION2: PROPERTY OWNERSHIP'2.�1+Owner'of Record:
l'TC.B r- 17 av,a.1 L 'S C.,l Q m VY1 C. 0 1 C/ a 3
Name(Print) � City,Slate,ZIP
l-) ge+Mtr3 \,LJ ot. 17�17 4y50�L
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building Owner-Occupied Repairs(s) ❑ I Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ I Number of Units_ Other ❑ Specify:
Brief Description of Proposed ork-:
1.�
SECTION 4: ESTINIATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Building S 3 W 1. Building Permit Fee:$ Indicate how fee is determined:
'. Electrical ❑Standard City/Town Application Fee
C� ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing S U L' 2. Other Fees: S
q. Mechanical (IIV.\C) S List:
S. Alechanieal (Fire S
Summression) Total All Fees: S
Check No. _Check Amount: __Cush AmounC
G. Total Project Cost: S 3 6a,o(J ❑ Paid in Full ❑Outstanding Balance Due:
l9r* 1 °26 9/�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) (-I 5
�-- License Number ILcpirallon 13ote
Niulc of C'SL I IulJer
r I.is[CSL Type(see below)
l ` 3 L&r - --- - Type Description
No, and Street
, � �n , ^ \^,, ' U I Inrestricted(Buildings ti to 35.000 cu. 11.)
I�1): o%&�"_� R Restricted l&217amil Dwellill
L'itclfo%%n,State.ZIP M Mason
ry
7�t� �30^ G y b RC Roofing C'uecrin
1 WS Window and Siding
�i G°07Y1eW1(,n SF Solid Fuel Burning Appliances
C,IChU V-) 4oc-an YIc-II I Insulation
'telephone ('.mail address D Demolition
5.2 Registered Home
Improvement Contractor(HIC)
S `-`�'G'n C�'�' LLB IIIC Registration Number Expiration Date
I IIC Compmly Name or I TIC'Registrant Name
I S c,U�Y. 2 0 r c (1C C
No.and Street Email address
�tllens�. rn� 0It � g�6-1,16 s� �
City/Town.State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.4 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 Issuan a of the building permit.
Signed Affidavit Attached? Yes ..........d No........... ❑
SECTION 7a: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:OWNERI 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.
I PhM n n-)I me )1
Print Owwer's or \uthorireJ Agent's Name(likcuunic Signature) I 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 M.G.L.c. 1 12A.Other important information on the HIC Program can be found at
�.ca Information on the Construction Supervisor License can be found at p diji
2. When substantial work is planned, provide the information below:
Total flour area(sq. ft.) (including garage, finished basementiattics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces__ — Number of bedrooms
Number of bathrooms Number ol'halfr'baths
1)pe of heating system Number ofJecks, porches_
T)Peofcoolnlgsystelll Enclose)
1. total Project Square Footage-may be substituted filr"Total Project Cost"
CITY of S.wEat, AASSACH US ETTS
OLMDLNG DEP.1RTtEVT
120 W.kiH RE
LNGTON STET, YQ FLOOR
Tt+L (978) 745.9595
KENMERLEY ORLSCOLL FAX(978) 740.9846
MAYOR TNO.�Us ST.PM1j4
DIRECTOR OP PCBLIC PROPHRTY/8CILDLNG CONNISSIONER
Construction Debris Disposal Atildavit
(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 MOL c 40, S 54;
Building permit g 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 NIGL c
I 11, S 150A.
The debris will be transported by:
L� SmS ,
(Mama of haular)
The debris will be disposed of in :
� ernrf �C ,
(Mama or facility;
l ��� rMCQr Velma �n
(iddrea or facdiry)
siynanrre of Permit applicant
- ` r
CITY OF SALEM
PUBLIC PROPRERTY
(a DEPARTMENT
Luc.Mf l Y InIK ur,
\Itlty
L:UrAttl,At:l�,.�i18!!1' to idll'VI, M.1 a1.11Jn it I no177,^,
Wurkers' Cumpenaatlon Insurance 110duvit: Hill lders/Con trap:tun/Elee trlclans/Ylumbers
l I sllc•ant Infirnnallo
PI rInt Le 'hl
Naine Illuultc,tit)rganlrninrvleJnulaalE�rtGh-S/fYf1S ��� A
Ca •e Ants !_I_r•
llldruzs: r 2�
�1f n\�1f Phoned: .-7n tuaj.(I 5;
I.I .1 ry t o au vlltployor'! Check the apprnprlute boy:
1 ant a vmpluyur Willi 4. ❑ I am I')pe ofproJeel lred):� ;!general couuaetor and I (irequ
3.
enlpluyuu>r((lull ind/urpatt-tints).• huva hired thu.�uh•cunoacwn
f• �'' ewtxlruCuun❑ 1 and a 101e prnpricttrr or partner- listed on the anached shout t �• Rernalelind
.vhip;l ld have no mnpluyevs These sub-contractors haw working lire into in any capacity, workers'comp• Insurance. e' Cj Demolition
I No Workers'Crop. insurance J. ❑ We are a erhporetion and its 9 ❑ Uuildind addition
squired.) )treat*11aw e1urcircd their 10•0 Electrical repairs or additions
1.❑ 1 um a homuuwnvr Doing all work I right of efc,nption pur NICE I L❑Plumbing spuirs or atlditinty
myself. Ko,vnrlturs'euotp. C. 152.11(4),
and wr huvo no
nrurunco rcyuirtd.J r .mpluyevs.INo workers' I ❑Ruul'lepuin
eolnp; insurance required.J Other
\Iq.,,phcaa IhW cAccb Neel MUM.Ilw On uW Inv w0wt kht,r aww"J I
I,umwlwnfn who„Jmtir rlif•nlJavlr iMrlearin I e brit tYwYWf'cwnyr•1WIwt Ilulivy Infiarr4,tiw�T•luinw." r s who Y IAu Ea>t mtW anaAf4 i Jodie^' +u J4ine dl wurk nd Ihet hire uwfidf cultrnc
urW.how.Auxin the ru ,tlrf I4wr.uh44 a nfW,IRJfril inJiaylna 4KA,
e nyf/IIMIaetiNrgrAtreaMlIAfe4wepf'
/ .prdKyInlbrnraitl�
Ilia that If prvrJr//nr IvrrArri'rurnprurnllan Lrrarnnrr jar/ny nnp/uyrra Brlury/s rM pu/ley unJ/ob.,il�
InsurunceCentpany Vmne:� ��(YluRl fG�S
Iulicy41!(Self•inr. tic,M;cos(„/1rr Q _pO .
—�.—�•3�i1 LzSLa_r I
Erpiratlon Date:
Job Silo dddresv: e � '�—r�-
\ttach creasy of Root,forkare'vumpunlatloa pu e) declaration pule(shawl lure M rhetpolley number and p►atlua duH),
I1at I),ceure cove rage as squired u u uJer Secliun:1A 4NIGL c. I)1 eau lead t the impo
'^e till?I)1'LS110.1k7 anJlur ur•year 6npri.vmm�cnt, a1 w o(liell s civil(enalhcs in Ilia ora STOP WORK ORDER and J fine
of op fit i?J0 00 a Jay Ruins!the vi,,l.uar. Ile advl.ta•d that a al n:.,hgawlm ul':he I11,\ ;or ul,nr.u'ce cuvcra�u t\I uiaahu a lly urlhi% ijiemunt may be I6rwardvd to thor Ullicv vf
/Ju llerrAy t rrrijy 1,ndrr 1/1r paint ImJ prnn/five u/per.... Avr,Ar in urmarlon
yroviJrtl abort it nor and vorrvct
,I_J Ili 1
I'IY . .� idle
I
rlj/lciul ate only. /)d nnr Irrirr in lhir"ev, lu Ar ruurylvlyd by airy ur roan a//Irir(
i
fire ve I'nrvn: _
1,winl I(IIr.\u,hurit ---- parminLlhntr e '
I y (cirvlonnel:
I IluurJ IUt !. IIuJIhIr�6. Offivr
Ilap.trtmvul L liq.'1'vlanClerk J, l'luctrir.11 Intpa'rur i, plumbing Intyccror
i
I 11II L,ct I',nap: _
information and Instructions
n their
PIoYeCs
v r+on in the service of another under•Illy:unmet of hire,
\Llai•IC hUaen$6,;neral LAWS chJplef I J2 Iegturei Jll eltiployei IO n the Ja vIcc%vor 0 f �o'nP
1`unuJnt to till$ ,tJtute, An retpl4a'ee is Jelined Ja". eery pc
lion
jr 'Invited. oral or wrJtten." orau In or other legal endry,or Ally Iwo or more
he
to.•Jnployer it defined as ,an individual,purmenhip, Lfilli he le Cory
tom em ioycee. Hawevcr the
.�r the luregomg engaged m a iuml enrerpnse, and htcluJing tits legal rcpreseuutives ut a deceased empluyor,or i
eumver f the
or uustee of,ut individual,p$tmenhtp,assoetauoa or other legal endry,emp Y g ' P
�m ba JeemeJ to be An ampluyer."
another who employ$ actions w Jo maintenunco,cun$vucriotror repair work on such Awaiting house
owner of k dwelling house having not more than three aparonent$and who 'ell trepan or the occupant o
,Iwclling house of urtenant thereto$hull not because of such employm'
or,tit the grounds or building JPD
�IiJL chapter 132, §23CI6)also $laces that"wary irate or local tract buildings ag 1$hhre withhold the Its olrad e
rene$v h of a Ilccstss ur permit to Operate a business or 9e coca uYa with the lnsurine�overagelragch or spy
oypllcunt oho has not produced acceptable evidence of comp of its olilirai subdivisions'halt
1JJilionully,SIGL chapter 132, li5C(7)'•tales"Neither the conunonwcuhh not any D
table 9
enter into Joy cIGL Ot in the verfomwn evema JbiII�t contracting until till g aulhorityv•Janee ui cumpli utuwith tits insurance
requirerttcnts of this chapter have been p'
ApyUcsnn y ` apply to our situation and.if
ttiation affidavit corn letal huyc checking
the
eI�r wihb then y itlificatels)of
p
Please rill out the worker' cumpe namals),addresslns)aatd P LLP with no employelle other than the
necc$$ury,supply sub- ability tors) have
aired to carry worker' contpensa"O submitted to the Depurotmetn o industrial
iniw�ance, Limited Liability Compsaics(LLC)or Limited Liability partnerships
manber or partner, ape not required
employee,u polity is required Be advised that this affidavit be naydri aliment of
Also be lure to sip and Jute the uesstted.not the pcpwit should
%ccidenu for confirmation of insurmeo c Ikuion for the permit or licarw i$being requested.to obtain u workers'
he rcuinted to the city or town that the upD ueniosta regarding rh law or if you Are required
Industrial Accidonu. Should you have any 4
cotnpett.+atiunvolicy, plea call the Depurtrrtent at the number listed below. Selfin$ured companies should enter the
ir
self-insurance license number on the appeal lfi&kto line.
Ocy or Town 0111141e15
the applicant
Please he+Ora that t uu to 1�11 nutsin�ho event the O Tleelof�lnlwnTgat Department
has to contacta YOU rcgartiing d It space at that bottom
Of the atffidavit cur y
n addition,
Applications w in any given year, need only submit une aRldavit indicating curreur
I'I.asO be suro to till in the pOrmit/license nwnbOr which will be used't'tcantrefehnuWrence iwrite'nll(lut:utiuni n st aDD tINY
Ilt
gist,oust submit m(if nee pennitJ'INid unLsoder Site Address'the upv '" roviJud to the
Policy infa motion(if necessary)' ed or marked by he city or town truly bo p
nswnl• . %copy of the affidavit that has boast officially sump'
Permits Or licensee. A new arllJuvtt must be tilled out each
ennit not related to any business or eorttnterciai venture
Applicant u proof thtt a valid Affidavit is on rite for Allure p
y mtr. Where a hum$owner or citizen is obtaining a license or p
(i,e, a dug liecom are permit to burn hi cte.)laid person is 140T required to complete Iris affidavit. uouons.
I hc ')dice at loverrigatiuny wuld lug w thank you in JJv;utce for your cooperation Jnd should you hu%d.uty 4
pleu,e du not llesltata to give us A cJ11.
nc� Ucvarunent'+Jddreri, rolcvhuno Jnd rateThs CrNn OMMOrtwealth of Massaehux"
Department of industrial Accidents
O(Aee of lsvesdiladons
600 Washington Street
80310n, MA 02111
ref, M 617.721F�00 ext 0211d9
67a "•MASSAFE
n.0 S wwW.dull.jov/dia
mnil Affairs
SS Regu�u?eCla
Office of Consumer.U'fai�s&B�ness Regulation
" HOME IMPROVEMENT CONTRACTOR
G Registration: 154017
Expiration: V31/2013 Type:
Ltd Liability Corpo
DO BSONS GENERAL CONTRACTORS LLC.
1 L
RICHARD 000NNELL.-,._
153 ALLEN RD - `r
BILLERICA MA01821
Undersecretary
' Massachusetts- Depnrtmcnt of Public Safch
Bojirtl of Buildin„ Rcpulalions and Standards
�MJ Construction Supervisor License
License: CS 45867
RICHARD J OCONNELL
153 ALLEN RD
BILLERICA, MA 01821
o--
��'- '�� Expiration: 12/25/2012
('nnmdsti"O1'r Tr#: 8435
NOTICE w NOTICE
TO 0 TO
EMPLOYEES
r• EMPLOYEES
yp V
tlll III
The Co I' nwea.1th of Massachusetts
DEPARTM NT OF INDUSTRIAL ACCIDENTS
600 Washin n Street, Boston, Massachusetts 02111
617�-7 .i1_ 4900 -- http://w^w'w.mass.gov/dia
As required by Massachusetts Gen 1 Law, Chapter 152,Sections 21, 22&.30, this will give you notice that
I (we) have provided for paytn 1.to our injured employees under the above mentioned chapter by
insuring with:
HART D UNDERWRITERS INSURANCE COMPANY
+� AM]E OF INSURANCE COMPANY
P.D. BOX 14
MIDDLEBORO 02344-1450 �—
DRESS OF INSURANCE COMPANY
(6560UB-9934L24-2-11 ) 01 -15-11 TO 01-15-12
POLICY NUMBER EFFECTIVE DATES
WOLPERT INS AGCY INC p 18 JOHN STREET PLACE
WORCESTER _ _ MA 01609
NAME OF INSURANCE AGEN ADDRESS PHONE#
DOC AND SONS GENERAL ' 153 ALLEN ROAD
CONTRACTORS LLC d .
BILLERICA
MA 01821
a EMPLOYER — -�g — ADDRESS
ME � !
EMPLOYER'S WORKERS OM I, NSATION OFFICER (IF ANY) DATE
DICAL TREATMENT
The above named insurer is requ d in cases of personal injuries arising out of and in the course of
employment to furnish adequate ", d reasonable hospital and medical services in accordance with the
provisions of the Workers' Compe ation Act. A copy of the First Report of Injury must be given to the
injured employee. The employee n"y select his or her own physician. The reasonable cast of the services
< provided by the treating physician ll be paid by the insurer, if the treatment is necessary and reasonably
connected to the work related injwv, . in cases requiring hospital attention, employees are hereby notified
that the insurer has arranged for suOP attention at the
i '
NAME OF HOSPITAL. ADDRESS
TO B POSTED BY EMPLOYER
004022 YV20P1G02