4B SPRUANCE WAY - BUILDING INSPECTION (3) The Commonwealth of Massachusetts
CITY OF
V Board of Building Regulations and Standards SALEM
WMassachusetts State Building Code,780 CMR 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 p t
` signature ,BuildingOfHcial(NmName)�"
- Date
SECTION 1t81TE INFORMATION
g 1.2 Assessors Map&Parcel Numbers
1.1 Prp�t'y��2U AID lt��'1 i
1.1 a Is this an accepted street?yes_ no_
Map Number Parcel Number
13 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use
Lot Area(sq ft) Frontage(il)
1.5 Building Setbacks(It)
S
Front Yard Side Yards Rear Yard
Required
Provided RequireA Provided Required . Provided _.
1.6 Water Supply:(M.G.L e.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check ifyes❑
SECTION 2: PROPERTY OWNERSHM'
2.1 Owner'of Record.-
City,cpi� �C/>,
Name City,State,ZIP
14 SYJ/ nn c D l.t�s ( x �Y� ne Address
No.and Stree
Telephone Email
SECTION 3:DESCRIPTION OF. . POSED WORK=(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Wodc2: —L L
Z�
SECT[ON 4:ESTIMATED CONSTRUCTION COSTS
Estimated Costs: Official Use Only
Item abor and Materials
j 1 Building Pemtit Fee:$ Indicate how fee is determined:
1.Building $
❑.Standard CityNowp Application Fee
2.Electrical $ ❑Total Project Costa(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List
5.Mechanical`(Fire $ Total All Fees:$
Su ression) Check No. Check Amount Cash Amounts
6.Total Project Cost: $ J 30 �� 13 Paid in Full ❑Outstanding Balance Due
SECTION 5' CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
�7A4&3 ZE i59 A--' License Number Expiration Date
Name of CSL Holder
List CSL Type(see below)
No.and Street /C jJ Type- , Description
�
Unrestricted(Buildings u to 35,000 cu.ft)
0�/(}/,3 R Restricted 1&2 Family Dwelling
city/Town,S M Masonry
RC Roofingcovering
r/ Cy WS Window and Siding
Solid Fuel Bunting Appliances
O `fO
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(RIC) lyk�5�Z()
—qA- 'Vb 5 �9 "IA-7-
HIC Registration Number xpiration Date
Inc CoyEdany Name oiF)iC gcstrant Name
N and Street �t / /L �/y�ai ,G6�O Email address
C /fown tat ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M:G.L.a 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 Issu ce of the building permit.
Signed Affidavit Attached? Yes.......... No...........❑
SECTION 79 OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner ofthe subject property,hereby authorize
to act on my behalf,in all matters relative to work authorized by this building permit application.
A S�a� S& ,al� �/�i//--
Prim 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 perjury that all of the information
contained in this application is true and accurate to the best of my knowledge and understanding.
C�- a s^l
P t er'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
www.mass.eov/oca Information on the Construction Supervisor License can be found at vncnv.mass.eov/des
2. When substantial work is planned,provide the information below:
Total floor area(sq.8.) (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 half/baths
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°
The Commonwealth of Massachusetts
Department oflndustrial Accidents
Office of Investigations
600 Washington Street
Boston,MA 02111
www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Le¢ibly
Name(Business/organization/Individual):
Address: -cu
City/State/Zip: --Y-L H t \�tPhone.` <�`1 , -, �.1 Li L.3
Are you an employer?Check the appropriate box: Type of project(required):
1.U I am a employer with \ 4. Q I am a general connector and I
employees(fall and or part-time).
have hired the sub contractors 6. ❑New construction
2.❑ I am a sole proprietor orparmer- listed on the attached sheet. 7. �Remodcling
ship and have no employees These sub-contractors have g• Demolition
working for mein any capacity. employees and have workers' 9. Building addition
[No workers'comp.insurance comp.insurance.$
required.]
5. Q We area-corporation and its MCI Electrical repairs or additions
3.❑ I am a homeowner doing all work officers have exercised then - I LM Plumbing repairs or additions
myself[No workers'camp. right of exemption per MGL 12. ]Roof repass
insurance required j t c. 152, §1(4),and we have no
employees.(No workers'
comp.insurance required]
*Any applicant that checks box pl must also fill out the swtioa below showing them workrn'wnrprnsation Policy information.
t Horneownas who submit this affidavit indicating they arc doing all work and then hive outside contractommust submit a new affidavit indicating such.
$Contractors that check this box must attached an additional sheet showing the name of the subcontractors and state whether or not those entities have
employees. if the subcontractors have employees,they must provide their workers'comp.policy number.
I am an employer that is providing workers'compensation insurance for my employees. Below is the palicy and job site
information. -
Insurance Company Name: t=i C c-v-, CA
Policy#or Self-ins.Lic. V \Z� \nS 5 Expiration Date-,,: _5 1k
\ S ZC
Job Site Address _�A.
PR� (WAf/1 City/State/Zip:c�N � OI7 7
Attach a copy of the workers' compensation policy cI ation page(showing the policy number and expiration date).
Failure.to secure coverage as required under Section 25A ofMGL c. 152 can lead to the imposition of criminal penalties of
fore up to$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$250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
Investigations of the DIA for insurance coverage verification.
I do hereby certto under the pains and p laes ofperjury that the information progtded above is true and correct
Sipnatuue• Date: l 3 ( _
Phone#: k• �-!
OfjctoI use only. Do not write in this area,to be comp feted by city or town official,
City or Town: Permit/Lfcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.CityPTown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
r
Office of Consumer Affairs and Business Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 165640
Type: LLC
Expiration: 3/15/2014 Tr9 222331
AIR -TIGHT LLC. WEATHERAZATION
JAMES FORTIN
10 PINE KNOLL DR.
BEVERLY, MA 01915 ---
Update Address and return card.Mark reason for change.
_ Address = Renewal _ Employment 1 Lost Card
OP$•CA'. ^v 5RA,*&YG1012I6
.. ✓fie Gcnu�r�nr<e'allf �f.. llaaae�aJe�Z3
_ Office of Consumer Affairs&B.. am Regulation .License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Registration: 165640 Type: Office of Consumer Affairs and Business Regulation
Expiration: 3/15/2014 LLC 10 Park Plaza-Suite 5170
Boston,MA 02116
AIR-TIGHT LLC.WEATHERAZATION
JAMES FORTIN -
10 PINE KNOLL DR.
BEVERLY,MA 01915. Undersecretary Not valid without signature
p " 11 issachusetts Department of Puhlic S tfth
Bo a d;nf Bmidin`�RLguintions;tad Standards•.
Construction Supervisor License
License: CS 52$76
JAMES E FORTIN
10 PINEKNOLL DR
BEVERLY, MA 01915
Expiration: 10�@013
- (.onmriavinner -
TrM: 6'f00
L '
MOYNIHAN LUMBER OF BEVERLY, INC.
`QUALITY BACKED BY A DESIRE TO PLEASE"
82 River Street P.O. Box 509 FEIN:04-2261995
Beverly, MA 01915-0509 aa Contractor Re No.:
978-927-0032 9H 1� 9 Exp. Date: //—
Salesperson(s):
HOMEOWNER INFORMATION
S
Name Daytime Phone
4 RA
Street Address(Not P.O.Box) Evening Phone
S�Z151g
City/Town State Zip Code Mailing Address(d different from Street Address)
WORK TO BE PERFORMED AND MATERIALS TO BE USED
a Moynihan Lumber of Beverly, Inc. agrees to perform the work set forth in Exhibit A for Homeowner and to
use such materials in connection therewith as set forth also in Exhibit A, attached hereto and made a part
hereof.
The following schedule shall be adhered to unless circums es arise beyond Moynihan Lumber of
Beverly, Inc.'s control:Work scheduled to begin: _/_ Expected date of completion: /_/—
Ma be based u ival o/spec order material
TOTAL CONTRACT PRICE AND PAYMENT SCHEDULE
Moynihan Lumber of Beverly, Inc. agrees to a n i 6 work, and furnish the material and labor set forth in
Exhibit A for the Total Contract Price of: $ U 6 (which amount includes all finance charges).
Paymentshall be made by Homeowner according to the following payment schedule:
Qt�Z Initial deposit upon signing this Contract(the initial deposit shall not exceed the greater of
one-third(1/3)of the Total Contract Price as set forth above; OR the Total Cost of Special/Custom
Orders set forth below).
$ by—LLor upon completion of delivery of materials
$ by_L/ or upon completion of install
$ upon completion of the Contract
In order to meet the completion schedule set forth above,the following materials/equipment must be special
ordered before the Contract work begins,for a Total Cost of Special/Custom Orders of$
$ to be paid for building permit
$ to be paid for
$ to be paid for
/y DO NOT SIGN THIS CONTRACT IF THERE ARE ANY BLANK SPACES
Moynihan Lumber of Beveriv.Inc. lT z
Homeowner's Sign ture-) Date Contractor I Date
Homeowner's Nam (Printed) Na (Printed)and Title of Signatory
You may cancel this Contract if it has been signed by a party thereto at a place other than an address of
Contractor,which may be its main office or branch thereof,provided you notify Contractor in writing at
its main office or branch by ordinary mail posted, by telegram sent or by delivery,no later than midnight
of the third business day following the signing of this Contract. See attached notice of cancellation for
an explanation of this right.
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