10 SMITH ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
( �I. Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 730 CN Revised
IR SdM
d Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section For'Official Use Only
Building Permit 'umber. Date Applied:?:
Building Official(Pant Name) . Signature Date
SECTION 1:SITE:INFORMATION
1.1 Pro ty ress: (I�r I f 1.2 Assessors Map& Parcel Numbers
1.1a Is this an accepted street? yes no Nfap 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
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.3 Sewage Disposal System:
Public❑ Private ❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
` SECTION 2:, PROPERTY OWNERSHIP''
2.1 Owner'of Record:
�BSSt c< M ✓�olac k
Name(Print) City,State,ZIP
1 o sue, t!-� S�
No. and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK4'(check all that apply)
New Construction ❑ Existing Building ❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg, Cl Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work:
t lace wt . JP. r fi dd^
SECTION4: ESTIMATED-CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only .,
Labor and Materials
1. Building I Building Permit:Fee: $ Indicate how fee is determined:,
2. Electrical S ❑ Standa d CityYTown Application Fee
❑ Total Ptolect Cost"(Item.6)x multiplier x
3. Plumbing S 2 Other Fees: /!\/
4. Mechanical (IIVAC) S Ltsta �� bbbY
5. Mechanical (Fire $
Su t r ession) "foul \ll Fees: $
Check No. Check Amount: Cash \mount'.
6. I'utal Project Cost: 3 00
r 0 I 0 Paid in Full 0 Outstanding Balance Dn�:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
License Nunber Expiration Date
Name of CST, Holder
List CSL Type(see below)
No. and Street Type _ Description
U Unrestricted (Buildings UP to 35,000 cu. ft.)
_ R Restricted 1&2 Family Dwelling
City/Town, State, ZIP M Nlasonr
RC Rooting Covcrin
W'S Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(IIIC)
IIIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No. and Street Email address
City/Town, State, ZIP Tele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L,e. 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
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 7h: 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 applicatio is true and a-curate to the est of my knowledge and understanding.
Print Owner's or Authorized Agent's Name(Electronic 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(HIC) Program), will not have access to the arbitration
program or guaranty fund under M.G.L. c. I42A. Other important information on the HIC Program can be found at
www.mass. ov:%oca Information on the Construction Supervisor License can be found at www.n ass.�m��/d/dws
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 urea(sq 11.) _ Habitable room count
Number of fireplaces----- Numberofbedrooms
Number of bathrooms _ Number of half/baths _
Type of heating system _ _ Number of,lecks/porches ------— --
I'ypeorcooling.sy,lcnt_ --- Enclosed-- _Open- _
S. `'futal III )ject Syuoro I'i?o tag o may be subshunod for''To tal Project('o;t'
CITY OF SAL.EM, ND SSACHUSE-M
ButwziG DEPARTMEINT
1 r 120 W.ASHNGTON STREET, 3" FLOOR
T EL (978) 745-9595
Fix(978) 740-9846
KI\tBERL.EY DRISCOLL
*Vfl TT-osw ST.PtERRs
DIRECTOR OF PUBLIC PROPERTY/BUILI)MG COSNISSIONER
Construction Debris Disposal Affldavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section It 1.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit i# 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 MGL c
111, S 150A.
The debris will be transported by: 1
���✓ � ��v✓ �p� T I �� a
(name of hauler)
The debris will be disposed of in
(name of facility)
-- —(address of facility)
signature of permit applicant
dam
NOTICE NOTICE
TO
" µ TO
EMPLOYEES EMPLOYEES
The Commonwealth of
ACCIlDENTSs
DEPARTMENT OF IN
600 Washington Street, Boston, Massachusetts 02111
617-727-4900
As required by Massachusetts General Law, Chapter 152, Sections 21, 22 & 30, this will give you
notice that I(we) have provided for payment to our injured employees under the above mentioned
chapter by insuring with:
ASSOCIATED EMPLOYERS INSURANCE COMPANY
NAME OF INSURANCE COMPANY
54 THIRD AVENUE P.O. BOX 4070 BURLINGTON MA 01803-0970
ADDRESS OF INSURANCE COMPANY
WCG 5006255012012 04/20/2012 - 04/20/2013
POLICY NUMBER EFFECTIVE DATES
24 Federal Street 4th Floor
Boston Insurance Brokerage Inc Boston I MA 02110 (617) 556-7000
NAME OF INSURANCE AGENT ADDRESS PHONE
Ebersole Construction LLC 87 Flint Street Salem, MA 01970
EMPLOYER ADDRESS
02/22/2012
EMPLOYER'S WORKERS COMPENSATION OFFICER(IF ANY) DATE
MEDICAL TREATMENT
The above named insurer is required in cases of personal injuries arising out of and in the course of employment to furnish
adequate and reasonable hospital and medical services in accordance with the provisions of the Workers Compensation Act.
A copy of the First Report of Injury must be given to the injured employee. The employee may select his or her own physician.
The reasonable cost of the services provided by the treating physician will be paid by the insurer,if the treatment is necessary
and reasonably connected to the work related injury. In cases requiring hospital attention,employees are hereby notified that
the insurer has arranged for such attention at the
NEAREST AND BEST MEDICAL FACILITY
NAME OF HOSPITAL ADDRESS
ruld—u „n „"CrrV" RV VATPIr ."VFR
HeWlE 11PRC EMEiNT CONTRACTOR fa
•� Registration:„ 14E495" Type:
Expiration. 4/a n13
T / _ i Ltd Liability Co,,:
EBE OLE CONSTRUCTION LLC77 e
ANDRE .EBERSOLE
87 FLINT ST ' -
SALEM, MA 01970
IinJc1•sccrc Lary.
y-X7-0)
+�- Ma%sachusetts - Department of Public Safetc
1 Board of Building Rct:ulutinns and Standards
Construction Supervisor License
License: CS 86492
az'
ANDRE L EBERSOLE
87 FLINT ST
SALEM, MA 01970
Expiration: 4/22/2013
('nmmi.vioner' T,#: 13316