32 SETTLERS WAY - BUILDING INSPECTION (2) Tg
1 The Commonwealth of Massachusetts
� � Board of Building Regulations and Standards R CEI Et
OF
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Massachusetts State Building Code, 780 INSPECTI �
CMR NAlar�27Y
X� Building Pennit Application To Construct, Repair, Renovate Or Dem
'1 i gGsh J��
One-or vo-Family Dweller L01) 2 0
This Section For Official Use Only
( ^ Building Permit Number: Date Appl' d:
�{ ) Building Official(Print Name) Signature pate /
SECTION 1:SITE INFORMATION
CI.I Property t ddress: 1.2 Assessors Map& Parcel Numhers
� �w'd fi
` I.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(sy tl) Frontage(it)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
Lfi Water Supply:(NI.6.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood Zone?
Check if yes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner'of Recm•d:
f—�L u� --ft. 0/97D
Name(Print City,State,ZIP
3a 5�M-A
No,and Street 'fclephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New ConstructtEO
Existing Building❑ Owner-Occupied Repairs(s) rVIteration(s) ❑ Addition ❑
Demolition Accessory Bldg. Number of Units Other ❑ Specify:_ _
BrieflDescript'on of Proposed Vork":
/ t _e,Y1 iN aDY ly� r �
A—;VLSS11;Z. �8 ^ Q Y _ _
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and [Materials)
I. Building S i5op, I. Building Permit Fee: S Indicate how fee is determined:
3. Electrical $ ❑Standard City/Town Application Fee
❑"Total Project Cost(Item 6)x multiplier x _
3. Plumbing $ 2. Other Fees: $
4. Nlechanical (IIVAC) S List: c�
5. Nlechanical (Fire
Suppression) S Total All Fees:$_
Q
G. Total Project Cost: $
Check No.--Check Amount: Cash Arnount:
� —
t�, 0 D El Paid in Full ❑Outstanding Balance Due:
�� cck4luk l-
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 9 -9 v r
�.m -4 �d License Number E.epuation Da[c
Name of CSL Holder
la Y I UrN Sb- List CSL Type(see below)_
No.and Street 'type Description
or /� QI �D , U Unrestricted(Buildings up to 35,000 cu. It.
R Restricted M2 Farnily Dwelling
-
City Down,State,ZIP
M Masonry
RC Rooting Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
Regist/eerre�d,,F�me�I�mp/ro�veeJ��,�,e�nt/Contractor(HI
C) �O�D_(a_,�
'P� /�-'vt-"^mot ttr-Y�lJ1L-�-- �� FIl(; Registration Number . pi
IIC Com ty Nam F•or I IIC Reg7is-t-rant Name
Y 1 tJDzP
No. nd tree— Email address
City/Town,State,ZIP 1'cle hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(NLG.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 .......... 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—P-el-1
to act on my behalf, in all matters relative to work authorized by this building permit application.
t�-
SP �l P—WAV11A
Print Owner's Moe(Electronic Signature) Da e
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.
Pta�rr Mli d ��- .
ma's ur Authorized Agent s N:une(Elec(ronic Signature) 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(1-11Q Program), will not have access to the arbitration
program or guaranty fund tinder M.G.L.c. 142A.Other important information on the HIC Program can be found at
cvww.mass.vov/oca Information on the Construction Supervisor License can be found at www.rnass.t;ov/dps
2. When substantial work is planned, provide the information below:
Total flop=area(sq. ft.) (including garage, finished basement/antics,decks or porch)
Gross living area(sq. ft.) Habitable room comet
Number of fireplaces Number of bedrooms
Number ofbathrooms _ Numberofhalf/baths
Type of heating system_ _ Number of decks/porches _
Type of cooling system__ Enclosed— -----Open
3. -Fotal Project Square Footage" may be substituted for`Total Project Cost'
r
CITY of S�1LEl,f, ;tiL-1SS:ICHUSETTS
3 t ` BU=LNG DEP.1RT1ZNT
130 WASHNGTON STREET, 3%0 FLOOR
T�!L (978) 745-9595
KIJ(HERLEY DIUSCOLL FAX(978) 740-98-1S
PNLAYO1L T maws ST.Pip—us
DIRECTOR OF PUSUC PROPERTY/et:ILDLN(;CO%pttSStO EQ
Construction Debris Disposal affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section I l L5
Debris, cuid die provisions of rN101. c 40, S 54;
Building Permit 4 is issued with the condition
that
this work shall be disposed of in a properly licensed waste disposal facility as defined bylrblGng Lom
l! 1, S I SOA.
I'hc debris will be transpartcd by:
y
(name arhauler)
.1'he debris will be disposed ot'in
(narnc of Yacdity)
i
( ress0Ftiraility)
i
signature ofpermit applicant
I
CITY OF SAL.EM, NLNSSACHLSETTS
BUILDING DEPARTNir—NT
3 9 � 120 WASHINGTON STREET, 3"'FlOOR
�aQO TEL (978) 745-9595
FA_x(978) 740-9M
KI\[BERLEY DRISCOLL
MAYOR THo\IAs ST.PIERRs
DIRECTOR OF PUBLIC PROPERTY/BUII.DNG CO\LMISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Legibly
Name (Business Orga�nnit/atiorvi nd_i/vidual): �j Y / N
Address: fl 001/�//SLV
City/State/Zip: 5 `fit"_ i9i9?b Phone
Are you an employer?Check the appropriate box: 'rype of project(required):
I.❑ I 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.�am a sole proprietor or partner- listed on the attached.sheet.) ? ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp. insurance. y ❑ Building addition
[No workers'comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10,0 Electrical repairs or additions
J.❑ I am a homeowner doing all work right of exemption per MGL 11.❑ Plumbing repairs or additions
myself. [Ko workers' comp. C. 152, g 1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. [No workers' j;•❑ Other
comp.insurance required.)
•Any applicam float ducks but el mull also fill out the secaion below showing their workers'eompen etaun policy inlurmation.
'I Iomeuwm"who submit this sniciivit indicating they are doing all work and,hero hire outside contractors m,ul nthmil a now affidavit indicating such.
UngmUvn shut check this bus must auachsd an additiorml shut showing flu na,ne of the subtumncton and their workers'comp.policy information.
I ant an employer that is pravidhnK workers'compensation insurance for my employees. Ltelow Is the policy and job site
information.
Insurance Company
Policy A or Self-ins. Lic. tt: Expiration Dote:
Job Site Address: City/State/Zip:
Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of kfGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in(he form of STOP WORK ORDER and a line
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations ofthe DIA for insurance coverage verification.
h rho hereby of us er tb In in a Dies of pc that the imfornrathom provided above
is�s true and correct.
S', n t rot' Uurtt _j '/
Phone rJ -2
Ojjirial use only. Do nor write in this area,to be completed by city or town ojjheiuL
City ne Town: _._._. . .__ Permiul.icense N
Issuing Authority(circle one):
1. Board of Ilealth 2. Buildlm, Department 3.Ciiylrowu Clerk 4. Electrical inspector 5. Plumbing Inspector
6. Other
Contact Person: Phalle
[
1
Michael Lutrzykowski
From: Jeff Conley <s-jconley@comcast.net>
Sent: Wednesday, June 17, 2015 8:24 AM
To: Michael Lutrzykowski
Cc: Pele321@aol.com
Subject: building permit
Hello,
The Trustee of the Collins Cove Condo Assoc have approved the installation of sliders and windows for Joe
Gauvain who resides in unit#32—the installation is being done by Peter Michaud who always does good work here.
I thought I had sent this before but Peter called me this morning so just to be sure here it is again.
Jeff Conley
Treasurer
Collins Cove Condo Assoc
1