13 SETTLERS WAY - BUILDING INSPECTION The Commonwealth of Massachusetts
;� 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 Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date plied:
/lr>W
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
P��i�PG- r (.�tJc7
I.la Is this an accepted street?yes no Map Number Pavicel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Usc Lot Area(sq fl) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.1,c. 40,§54) 1.7 Flood "Lone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check ifyes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSIIIPt
2.1 Ownerl of Record: �
�F F C o� I�J City, �ii/a s s ofan �o .
No.and Street "telephone Email Add
ross
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ 1 Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specify:
Bri SJ,f Description of Propose Work'`:
rt°
S CTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials)
I. Building $ 6—.7�)J)67. cr/r I. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑ Standard Cityrrown Application Fee
❑Total Project Cost'(Item 6)x multiplier x_
3. Plumbing $ �. Other Fees: $
4. Mechanical (IIVAC) $ List:
5. Mechanical (Fire $ -
Su ression) Total All Fees: $_
Check No. Check Amount:_ Cash Amount:
6. Total Project Cost: $ 00- _ ❑ paid in Full ❑ Outstanding Balance Due: --
2[ 1^l
SECTION 5: CONSTRUCTION SERVICES
5.1 C nstructio��ngqSupe isor Licen a(CSL)
/��� lC A License Number E.epiritnon Date
Name of CSL,Holder
nn / List CSL.Typc(see below)
Q
`JYI q
No.and Street Type Description
e U Unrestricted(Buildings u to 35,000 cu. ft.)
- R Restricted M2 Famil Dwelling
City/Town,State,ZIP
M Masonry
RC I Roofing Covering
rx JO OC WS Window rmd Siclin
ID
Solid Fuel Burning Appliances
Insulation
Telc hone Email address Demolition
5 Registered dome Improvement Contractor(IIIC)�ic� �030�� t� �� iGC Registration Numbcr E, puation Date
I IIC Compyyiy Namq or IiIC Regia{r�mu Name
No. and tree[ Email address
S� �� of 9, g7x�yv-
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 .......... �Y No........... ❑
SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, as Owner of the subject property, hereby authorize �P/I`e if
to act on my behalf, n all matters relative to work authorized by this building permit application.
F ina
7 F L,tM /"o (/ la Aye/ G�
Print Owner's Name(Electronic Signat rc) I ,Date
SECTION 7b: OWNER[ OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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 unclerstanding.
PrieF 's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
I. An Owner who obtains a building permit to do his/lier 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. a 142A. Other important information on the HIC Program can be found at
www.nmss.eov/oca Information on the Construction Supervisor License can be found at www.mass.rov/dps
2. When substantial work is planned, provide the information below:
Total Boor area(sq. tl.) (including garage, finished basement/attics,decks or porch)
Gross living area(sq. R.) Habitable room count_
Number of fireplaces_____ Number of bedrooms
Number of bathrooms Numberofhalf/baths _
Type of heating system Number of decks/porches
Type of cooling systcrn Enclosed
3. "Total Project Square Footage" may be substituted for"Total Project Cost'
otitns %,ove Willuow approval rage t or 1
From: Jeff Conley<s!oonley@comcast.net>
To: mlutrzykowski<mluhzykowski@salem.com>
Cc: Pele321 <Pele321@aol.com>
Subject: Collins Cove window approval
Date: Thu, Dec 4, 2014 9:11 am
Good Morning,
Peter Michaud will be installing two Andersen sliders in unit#26 with the approval of the Trustees and
another in unit#13 also with the approval of the Trustees. Peter has always done an excellent job with his
installations and he is the guy we recommend to our owners to install windows and sliders.
Jeff Conley, Treasurer
Collins Cove Condominium Trust
https://mail.aol.com/38865-111/aol-6/en-us/mail/PrintMessage.aspx 12/4/2014
,n}vr-
CfTY OF S.Uz,%[, �tiL"1SS.ICHUSETTS
/ LMDLNG DEP.IRT\t&NT
120
_0 T-ISIANGTOV STmEET, }w FLOOR
` -f.!L (973) 745-9595
KIMBERLEY DRISCOLL FAA(978) 74 -9&fS
NLAYO;"t
r-to►us Sr.P[��tg
Dt..xECTOA OFPCBL[C PROPE.gTY/8L•,LDO✓G COSL}OSS[OVE3
Construction Debris JDisPosal F1ttIdavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CUR section I ( 1
Debris, -and the provisions of tXMIL c 40, S 54; .5
Building Permit # is issued with the condition that the debris resulting from
l 11, S I SOA.
this work shall be disposed of in a properly licensed waste disposal facility as defined by NIGL c
The debris will be transported by:
(name ut hauler)
'I'lte dchris will be disposed of in
(name ut'f]cdity)
--� sue- �✓. .��-p-�-I
h� s.toYracility)
I
siynarure uFPcrntife ("•, —"
PP t�nu
---- Luc ---
CITY OF S:u.ENI, %L Llss:1CHUSETTS
! T
BUILDING DEPARTJtEINT
120 WASHLNGTON STREET, 3aa FLOOR
l` TEL (978) 745-9595
F.A-x(978) 730-9844
K1JtBERLF_Y DRISCOLL
,tLAYOR THOMAs ST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BUILDI-NG CONMISSIONER
Workers' Curnpensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A t alicant Informatints rt t c Please Print Le ibl
Natnc tllusinexsOrgtninnalinn Individual): / /I �1 , `� �S y(�p
Address: _1 YJ Y I
City/Blatt/Zip: AD el97tl? Phone lk _7-1/4/ —r2.3 8'0
Are you an employer!Check the appropriate box: [EI
project(required):
I.❑ I am a employer with 4. 0 I am a general contractor and 1ew ctntstruction
employees(full and/or part-time).* have hired the sub-contractors
2.�irta a sdayrepsretvr or partner- - listed on the attached sheet. t emodeling,hip and have no employees These sub-contractors have emolitionworking far me in any capacity. workers'camp. insurance. ilding addition
INo workers•' camp. insurance 5. 0 We are a corporation and its
required.) officers have exercised their ectrical repairs or additions
3.0 1 am a homeowner doing all work right of exemption per MOL mbing repairs or additions
myself. (No workers' comp. c. 152, 41(4),and we have no of repairsinsurance requited.) t employees. (No workers'ctnnp. insurance required,) er
•Any appli,tt don checks bus#t most also rill out the section below showina their walked compensation policy iolLrmalton.
'I tameuwtwrs,who suhoit this amdavit indicating they ate doing all work and then hire ou side contmctan most sid mit a new anrdavit indicating such.
$lmtr:wtur%that check this box most anachd an addidultal,hest showinu the none orthe sobaamraelors and their woken'cutup.policy hoonnatian.
I am an employer drut Is providing workers'compensation insuruueejor my eutp/ayees. Helow Is the poi/cy and fob site
irtjormation.
Insurance Company Name•. _. ____
Policy 4 or Scif-ins. Lie,th Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the Ivoriten' compensatlou policy declaration pale(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of XIGL e. 152 can lead to the imposition ofcriminal penalties of a
tine up to S I,500.00 and/or one-year imprisonment,as well as civil penalties in the farm of a STOP WORK ORDER and a fine
of up to S25000 i day against the violsmr. Be advised that a copy of this statement may lw furwardcd to tic Off ice of
Iuvrsligwiuns of lbc DIA for insurance coverage verification.
/du hereby a Ider the paill g/des ojper/ury that the i 1forvoation provided above is true and correct.
Phone i' � 7U —25
O%/idol use only. Oa our write in this area, to be completed by city ur town o/Jlcioi
City nr'fuwn: Pcrmidl.lcensc#________. . ..---
Issuing Authority (circle une):
I. Board of Ileallh 2. Iluildlmi Ueparintent 1.Ciiyinnsn Clerk d. Electrical rnspector 5. Plumbing luspecror
0. Other
(.odi:lct Pers... i
. ___—._. _..___ Pholle B: I