1 SHORE AVE - BUILDING INSPECTION (2) �
., �.,
/"� � The Commonwealth of Massachusctts
/� � Board of Building Regulations and Standards Town of
�lassachusrUs S�a�e 8uiiding Code, 780 CMR, 7'"edi�ion
/ �i� BuiWi�p
� Bwlding Permit Application To Cunstruct. Repair, Renovate Or Demolish a �
O�ir- or T��o-Fmriil� Dor!ling �
This Scc�ion For ORcial Ux Only
Bwlding Permi� Number: Date Applied: -
Signaiure: !/ `��'' �� �/� /„
Bwldin�{Comm�ssioner/Inspector o(Bwldinge Date
SECTtOIV 1:SITE IIVFORMATION
1.1 Propert Addre�r 1.2 Assesson Map& P�rcel Numben
/ �'�n f P ��
1.I a Is this an accepled streel'!yes no Map Number Parcel Number
1.� ZaninQ In(ormatlon:� 1.1 Property Dimenslona: �
c1, �,� �
2oning Disiric� Proposed'Use Lo�Area(sq fl) Frontage�R)
I.S BufldinQ Setb�ck�(R)
� Prom Yud Side Yards Reu Yard
Required ' Provided Requircd Provided Required Provided
1.6 Witer Supply:�M.G.L c.40,S54) 1,7 Flood Zone Inlorm�tlon: 1.8 SewaQe Dlspoe�l Sy�tem:
Zone: Ounide Flood 2one? Munici al O On si�e dis sal s stem ❑
Public O � Private O Check if es0 P P� Y
SECTION 2: PROPER7Y OWNERSHlP�
2. Owner�of Reeord• `
��/'� I /��o���i �S'A/7 / -r�a/�C �1/e .S'�/P�c S�'S'
Name I�im) Addtess for Service:
9��- �yy-�o�
Sigmrom Telephone �
SECTION J: DESCRlPTIOIY OF PROPOSED WORK�(check�11 that apply)
New Construction O Existing Building❑ Owner•Occupied O Repairs(s) ❑ Allera�ion(s) O Addition ❑
Demolition O Accessory Bldg. O Number of Units Other .Q'Specify:
Brief Description of Proposed Work=:
s r � a� �
-,--�— -
SECTION 1: ESTIMATED COIVSTRUCTION COSTS
���m Estima�ed Costr. 01MIcla1 Ufe Only
Labor and Materials
I. Building f (f d� �� Building Permi� Fee: f Indicate how fee is ddertnined:
❑Sundard CiryiTown Application Fee
2. Electrinl S ❑Total Project Cost�(Item 6)a multiplier a
7. Plumbing f 2. Other Feea: S , /
4. �lechanical IHVAC) S List: ���Z�
S Nrchanical 1 Fire 5 To�al All Fees: i
Su ression
Check Vo. Check AmounC Cash Amounl:
6. Total Project Cosf. T�(fiQo� Q� ❑ P�id in Full ❑Ouuianding Balance Due:
��''��-c� �U C'G��i� �
SECTIONS:
CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor (CSL)
`
/O /a,) D
TPed �� ^YO
bcr Eap6utionPato
L.,cume
n c N
r jr r' '1��
N;px of CSL ItylJer
Lut CSL Type het bcluw)
c L.�n r1
T Description
Addess
U Unrestricted (up to 35,000 Cu. Ft.)
R Restricted IB2 Family Dwelling
Signature
M .Mason Only
791-20 %iSl
RC Rcvdennal Roofin Covering
Telephone
wS RestJemial Window and Siding
5.2 Regbte^red- me m rovemeat Contractor (HIC) /L/� 7e? O
K-� �P �tsn a '�iaL . !)
Company Name orHI Registrant ame R�e7gistralt umber
:s 7t�1 -Y:071 (Je
Eapirat i n Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT (M.G.L. c. I52. 1 2SC(6))
Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide I
this affidavit will result in the denial of the Issuance of the building permit.
Signed ATdavit Attached? Yes .......... O No ........... O
1 SECTION 7a: OWNER AUTHORIZATION TO BE COMPLETED WHEN
I,
authorize
relative to work authorized by this building permit application.
as Owner of the subject property hereby
to act on my behalf, in all matters
SECTION 7b: OWNER' OR AUTHORIZED AGENT DECLARATION
as Owner or Authorized Agent hereby declare
that the statements and infoiination on the foregoing application are true and accurate, to the best of my knowledge and
Signature of Owner or Authorized Agent
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. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing (CSL) can be found in 780 CMR Regulations I IO.R6 and 110.RS, respectively.
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 halfbaths
Type of heating system Number of decks/ porches
Ty pe of cooling system Enclosed Open
3. "Total Project Square Footage' may he +uhslitutcd for 'Total Project Cost"
CITY OF S.U2,N[, ,'L%L-kSSACHUSETTS
BUMI)IING DEP.kRTatENT
• y 120 WASHINGTON STREET; iso FLOOR
a>`
TEL (978) 745-9595
FAx (978) 740-9846
KI.N(BEA(EY DRiSCOL[
HAYOR I1tOhfAg ST.POERRs
DIRECTOR OF PLOLIC PROPERTY/!L'QDLNG COSLNfI5S10-i
IRF1
Workers' Compensation Insurance Afildavit: Builders/Contractors/ElectriclanslPlumbers
Anollcant Information % Please Print WilliY
Nalne (Busirn+rOrranuahonlnJtviduA0'- 4,4!:;1 zaa ba ,-1 u e:A.- mrd
Address: ,V _ 1/, 9e Q 51
City/StatdZip* Linn _MaSS Phone Al- zV �yy ySs�
,\re ou an employer' Check the appropriate box:
Tyof i"" Ct (required):
I . I am a employs wilk �
•. 0 1 am a general contractor and 1
6.;Now cons[[ucrion
employees (full and/or part-time). .
have hired the w6-caNraemnt
7. Remodeling
2.0 I atm a sole proprietor or partner-
listed on the attached sheet:
;hip and have no employees
These sub-contrsetats have
V. 0 Demolition
workingfor me in as capacity.
Y P ty•
insurance
workers' comp. insututee
S. ❑ We aro a corporation and i1a
9. C] Building addition
I No workers* comp.
required.)
otTlcros have exercised their
10.0 Electrical repairs or additions
3. 1 am a homeowner doing all work
right of exemption per MGL
11.0 Plumbing repairs or additions
myself. [No workers' comp.
insurance required.) t
c. 132, f 1(4), and we have no
employees. [No workers'
12.0 Roof repairs
13.lq_A �? �10�
pI Dllt4
coma mia"nce reauired.l
• Any aPplicsm iha chocb boa el musialso filloul the r lim below abowiog rhtle wwkm' ew w u lkm puliry infumullow.
t I I.mwuwnes Who submit this mfldsve ind{eting iAsy am doing all work and their him oueide connoetwo mum nhtnil s nine amdlvil indicating suck
l.mim"m the cheek this bar mud anachod an 3"lia al duet showing the ower of eta aAwmtnmnto an/ their wwksto' comp, policy intonation.
I are an employer that Is providing• workers' compentioden Insatroaee for my emplayaas Se/ow /s floe pol1a7 and Job silo
irtformadan. A � _
In.urunce Company Name:1-7 1 r ' r
Policy M or Self -ins. Lie. V: 7616 n BUD 9 Expiration Date.
Job Site Addreas: / S/JJ f(° hue City/StatdZip: ° -V'L Sj
,mach a copy of Ibe workers' compensation policy declaration pap (showing the policy number an explradon date).
Failure to secure coverage as required under Section 25A of MGL e. 132 can lead to the imposition of criminal penalties of a
fine up to S 1.500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER.and a ring
of up to 5250.00 a day against the violator. Ik advi..-kd that a copy of this statement may be furwarded to the Office of
I nvcot gat ions the DIA for insurance coverage vcntication. - -
1,16 hereby cn y under the pats and penaldes 0/perjury that the infarmadow provided ve it true wed carred
amu' / I r Dal
Ptttrc a, 00 ..S
Ofcia/ use only. Do not write in this area, ro be . utnpleted by city or town o/f heit
City or ruwn: Yrrmit/Llccnse M
hsuing Authurtty (circle tine):
I- Iluard of Ileallh 2. Ruilding Department I cilylrown Clerk 4. Elecrriul Inspector 5. Plumbing Inspector
6. 01 her
.. C„ntacl Person: - _ -- -. Phone g: ...�..a,:- _...
CITY OF SALLM
PUBLIC: PROPRERTY
DEPARTMENT
Ili 'r'V. •I:. r:.r: I ,C '.'.t V:'Nln
Construction Debris Disposal Aflidmi it
(I'C(ILIiied l'or all dcmoliIion and IrnocaIIon \vurk)
In accurdaucc \lith the sixth edition oft lie State Building Code, 780 CNIR section 111.5
Dcbris, and the pro\'isiuns of %IGL c 40. S 54;
Building Permil H is issued with the condition that the debris resulting front
this work shall he disposed of in a properly licensed waste disposal hcility as defined by MGL e
I 11. S 150A.
The debris will be transported by:
,n4 �2
t uamc of hauler)
I he debris will be disposed ol'in :
ZVn r _1 _ ns-�
name ul 13uh .v)
.1 nnIA 14 \ L �l hit
t.uldre ..,r Nuhry
aenalulc .1t p: nu11 a1,11h\ant
913161
,lal: