22 SOUTHWICK ST - BUILDING INSPECTION t
The Commonwealth of Massachusetts CITY OF
a q(—�� : Board of Building Regulations and Standards SALEM
(� �� Massachusetts State Building Code, 780 CMR Revised Mar 2011
` �` Building Permit Application To Construct, Repair,Renovate Or Demolish a
n( 1v\ One-or Two-Family Dwelling
(1`�^ This Section For Official Use Only
. I Building Permit Number: Date Applied:
rySfCe' �/Z
Building Official(Print Name) Signa Date
SECTION 1:SITE INFORMATION
1.1 Property Address: pp 1.2 Assessors Map&'Parcel Numbers
n A))C�(U�
l.]a Is this an accepted street?yes Map Number Parcel Number
_ no_
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq ft) Frontage(it)
1.5 Building Setbacks(it)
Front Yard Side Yards FYardRequred Prc�Yided Requiredtsystm
1.7 Flood Zone Information: 1.8 Sewage DisZone: _ Outside Flood Zone? Municipal❑ On ❑
Public❑ Private❑ Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record: Noll Q ( 7a
Name(Print) City,State,ZIP
q� �d1f1)ie� �f >�7�fs �63a�
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOR]e(check all that apply)
New Construction❑ Ff
xisting Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ 1Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Wprkfk: �SU
W1N OWS Q
I i 5
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs Official Use Only
Item Labor and Materials
1.Building $ fX1 1. Building Pertnit Fee:$ Indicate how fee is determined:
❑Standard City/Fown.Application Fee
2.Electrical $ ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees:
4.Mechanical (HVAC) $ List: /` U
5.Mechanical (Fire $ Total All Fees:$
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) �seum � _
Q 3- ( 0� License Exp on ate Name of L Holder
f &b List CSL Type(see below)
No.and Street U, 1 _ Type Description
1 Z/ , l(��U.� In 114.,O ' g'� U - Unrestricted(Buildings u el ing cu.ft.
1 TJw UJ V�/1 R Restricted 1&2 FamilyDwelling
City/Town,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
j Insulation
Telephone Email address D Demolition
5.2 Registered`(Home Improvement Contractor(HIC)
- WA 't'o AUJ 'V ,6AA Corp HICRegis E�ati nDate
HIC o pany N e HIC R t N
4n ft o M Iaeolpop Cou'�rR� 1/D��rm /V�_
No.and tree[ E ailt �—
�q�b e17S�la��aa�i
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 ... ...... ❑ 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 �eFll PVl)D-G—,wAAA,A)
to act on my behalf,in all matters relative to work authorized by this buil ing pe it application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNER'OR AUTHORIZED AGENT DECLARATION
By entering my name below,I hereby attest under the pains and penalties of pedury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding. -
Print Owner's or Authorized Agent's Name(Electronic Signature) Date
NOTES:
1. 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 can be found at
wLv .mass.eov/oca Information on the Construction Supervisor License can be found at www.mass gov/dos/dos
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 half1baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
3. "Total Project Square Footage"may be substituted for"Total Project Cost"
. P
;. CITY OF Sm Em. xiAsS.,ICHUSETTS
BuMDING DEPARINIENT
120 WASHINGTON STREET,3w FLOOR
TEL (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
LfAYOR THom S ST.PIEm
DIRECTOR OF PUBLIC PROPERTY/Bt:BDING CoJLNUMONER
. ......... ....
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name(Businc-wOrganizatioNindividual): IDEAL PROPERTY
MAINTENANCE CORP
Address: 96 LAKE STREET
City/State/zip: TEWKSBI(RIA A 61276
Are on an employer?Check the appropriate box: Type of project(required):
1. 1 am a employer with ,�_ 4. ❑ 1 on a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).' have hired the sub-contractors
2.0 1 am a sole proprietor or partner- listed on the attached sheet t 7• ❑Remodeling
ship and have no employees These sub-contractors have g. ❑Demolition
working for me in any capacity. workers'comp.insupce. 9. ❑ Building addition
(No workers'comp. insurance 5. Cl We area corporation and its
required.) officers have exercised thew 10.[1 Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I L❑Plumbing repairs or additions
myself.[No workers'comp. c. 152,§1(4),and we have no 12.❑Roof repairs
insurance required.]t employees.[No workers' 13.❑Other
comp.insurance required.]
•Any apphram that chocks box#1 must also fill out the section below skawiug their worker'compensation policy information.
'homeowner whosubmit this affidavit indicating they am doing all work and then hits outside ecntmpors most submit a new,affidavit indicating such
!Commons that check this boc mudattachcd an additional ahmt showing the name of the sub.pmtrctom and their workma'comp.policy information.
1 um an employer that ie providing workers'compensaton Insurance jar my employees. Below is the pulley and Job site
injormmioa.
Insurance Company Name: //�� �iS /'
Policy#or Self-ins.Lie.#: W c- V0Q 1 � s D
o— \S Fxpimtion Date: 6
Job Site Address: ��, � )U4L�dr JC St Ciry/State/Zip. SA&_Z
Attach a copy of the Workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MGL c. 152 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 fine
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
Invosligatiuns of the DIA for insurance coverage verification.
I do hereby certify under the pains and pens/ties ojperJury that the injormadon provided abovJe is truee d correct
Signature: Date'
P 06
—
Onlcial use only. Do not write in this area,io be completed by city or town oJJlciat
City or Town: Permitii.feense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk 4.Electrical Inspector S.Plumbing Inspector
6.Other
Contact Person: Phone#:
1
CITY OF S.UEM$ NLNSS-kcHUSETTS
BuILDNG DEPART:�LENT
130 WASHNGTON STREET,3"F t oOR
TEI.. (978) 745-9595
FAY.(978) 740-9846
KIifBERLEY DRISCOLL
MAYOR T Ho&w ST.FhERRE
DIRECTOR OF PUBLIC PROPERTY/BCII ING CONL\IISSIONER
Construction Debris Disposal Affidavit
(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 MGL c 40, S 54;
Building Permit # 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:
S 6? )a2222`
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
signature of permit icant OO�
to
dubriSufT;IJC
9fie -6gw~1we 4� tta
Office of Consumer Affairs and Business Regulation
10 Park Plaza-.Suite 5170
Boston, Massac setts 02116
Home Improvement tQr Registration .
Registration: 108329
Type: Private Corporation
_ s Expiration: 8/17/2012. Tr# 203404
w
IDEAL PROPERTY MAINT. CORP . Y
Brian Moore >
ti
96 Lake Street w
Tewksbury, MA 01876
` i
1I
�: . :• 12 Tho�N�a
sus» .t
training
Par
SAM
N , X
C• 34 SbirICY Lane
i•: ,';a 2/1211amdalc
7 Course Date 0 Ex2/12/19
gg Expiration Date:
S.
J - 'certificate Number:R-R-18867
�tr3` Date: Ill �id
State of New Hampshire
- Poiwnlng noon Program
HeaahY Homes Mart bye ad C O N E S T.
1 . -,_*
I LEAD ABATEMENT CONTRACTOR
I BRIAN MoORE i
DC-219
( License M 2119i2013
4 a
Expiration Date:
� � er�ritero,Director 1191WI
_ Division of Public Health ° �`K•9,. , •t
NOT A LEGAL FORM OF ICJ =
i chuseM
CommonWWth of as da►ds
Department of La¢ *1,
Heather E Rowe.Dimetor
Deleader Supervisor
BRIAN J.MOORIE
Elf.Date 0211
. Exp.Date 08/22112
. DS000268 q
Ng�yerof q.O.N.E.S.T. - i
WN 11m,1',I�II' p,111'II ��1n,11�
. II�II WII��IIIIII�P'W�I�II�II Jw4v�R
+mussothuse
tt's U riK ncnt of•Public
Boar(I Saf'ct�
of 13uilttimt Rt-j atiuns and Ststntlxrtls "
Construction Supervisor License
License: CS 54380 .
i' BRIAN J MOORE
34 SHIRLEY LANE
SHREWSBURY,'MA 01545
_Expiration: 7/24/2012
('ununlsluner. _ Tr#: 30572
Monday, June 20,2011 12:13 PM WILMINGTON INSURANCE AGEN 0706575724 P.06
CERTIFICATE OF LIABILITY INSURANCE 'RTEPIRfi
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THIS CERTIFICATE 18 ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIONTS UPON THE CERTIFICATE HOLDER THIS
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BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED
REPRESENTATNE OR PRODUCER AND THE CERTIFICATE HOLDER.
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PRODUCER 878B38O
Rmmaton msurence AggenoYY 878867•t17 N ,
Pive MWde wx Avenue Unk 14 P.0.Box 1010 _
Ilningten MA 01907.0390 � a�.IIDEAL-i
John F.D AIWY --
INSURe S AFFORDING rVARAGE Wcs
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Towksbury,MA01876 rINSURBRO,
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THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAME ABOVE FOR THE POLICY FER100
!NmewrrO. NOTINRHSTANDINrn ANY REQUIREMENT, TERM OR COND!TION OF ANY CCNTRACT OR,OTHER DOCUMENT WITH RESPECT TO WMOH THIS
CERTIFICATE MAY BE ISSUED OR MAY PERTAIN. THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS,
FXCLIISIONS AND CONDITIONS OF SUCH POLICIEA.LIMITS SHOWN MAY HAVE EEFN REDUCED BY PAID CLAIMS.
rl TYPE DF INSURANCEMg& IMF LRaTS
GENERALLLMLm EACHocc!IRRENCE 100000
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CIOFSAL SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE
THE EXPIRATION OATS TNEREOP, NOTICE WLL EE DELIVERED IN
ACCORDANCE MTN THE POLICY PROVISION8•
City of Salem
Houalnb Rehablllbotlon Program AUTHORIM REPRSSENTEIVO
120 Washington St 31'd Floor 101,41
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