45 STATION RD - BUILDING INSPECTION 2- 2,
The Commonwealth of Massachusetts
°uA Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code,780 CMR SALEM
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: Dale pplied:
/ l3
Building Official(Print Name) Signatur Date
SECTION 1:SITE INFORMATION
1.1 Pr�p�rty Address: 1.2 Assessors Map&Parcel Numbers
—F> STILT'10>U P—b
1.1a 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(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: 1.8 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:
; t �Lt-Em PA 01R7O
Name(Print) City,State,'LIP
4 97R 7456710
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK (check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work :
i?I�LA�CE /2A1Lik16 f=/ZoUT Pa>eC4
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ I g o 0 1. Building Permit Fee: $ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4.Mechanical (HVAC) $ List: C>e J
5.Mechanical (Fire $
Suppression) Total All Fees:$
6.Total Project Cost:
Check No. Check Amount: Cash Amount:
$
f � [�� ❑Paid in Full ❑Outstanding Balance Due:
P-V
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) 44269 / I
( C(-( e— 1 L L— License Number Expiration Date
Name of CSL Holder
n� List CSL Type(see below) l/
/ 6 8 VC
No.and Street Type Description
Ll M G 19 7U Unrestricted(Buildings u to 35,000 cu.ft.)
I R Restricted 1&2 Family Dwelling
City/Town,State,ZIP M Mason
ry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /04 39(o /
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
ll/kGL B 9 e Cawic6(-S7 NCB
No.and Street Email address
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 N M /�AtC!
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print er'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 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
www.mass.sov/oca Information on the Construction Supervisor License can be found at www.mass.gov/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 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"
CITY OF S�U.F.Mll 1r'L�SS.ICHL'SETTS
BL'ILDIING DEPARnffANT
• 130 W.1sHLNGTON STREET,3� FLOOR
TEL. (978) 745-9595
FMx(978) 740-9846
KIMBERLEY DRISCOLL
MAYOR THObIAs ST.PmRRH
DIRECTOR OF PUBLIC PROPERTY/BUILDING CONWISSIONER
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
i 11, S 150A.
The debris will be transported by:
/Uo1z771s ion �2f/a/(
(name of hauler)
The debris will be disposed of in
/VO XRNs l fJrs C✓fAr/IL/G _
(name of facility)
� 1 A*R5Co7 /Gil.75
(address of facility)
signature of permit applicant
r
/�
date
dcbrivlT.Jce
CITY OF S.UX.N4 2ANSSACHUSEM
BUI DIING DEPARTNMNT
130 W.ASHINGTON STREET,3-FLOOR
a TEL (978) 745-9595
FAx(978) 740-9W
Ki,mBERLEY DRISCOLL
MAYOR TkomAs ST.Pmm
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Anplicant Information ) Please Print Le gift
Name(BusinLss Organi:ationtindividuap: ��M<n
Address: l GrI-CIy Av,�s
City/State/Zip: SA-Z 6-1 fin' O/ey7U Phone#: 976' S7.4 14
Are you an employer?Check the appropriate box: Type of project(required):
1.0 1 am a employer with Z 4. ❑ 1 am a general contractor and 1
employees(full and/or part-time).* have hired the subcontractors 6. ❑New construction
2_❑ I am a sole proprietor or partner- listed on the attached sheet: 7. ❑Remodeling
ship and have no employees These sub-contractors have 8. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9• ❑ Building addition
[No workers comp. insurance S. ❑ We are a corporation and its
required.] officers have exercised their 1011 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I LEI 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 El Othet
comp.insurance required.]
•Any applicant that checks box#1 most also rill our the section hclow.showing ibeir worker'enmpe a ion policy infurmation.
'l lnmeowoer who submit this affidavit indicating they am doing all work and then hire outside oarzancmrn must submit a stew affidavit indicating such
;Gmtm lots that chuck this box must attached an additional sheer showing the neene of the svb- raraolm and their workers•comp.policy infommtim.
I am an employer that Is providing fvorkers'compensation Insurance for my employees. Below is the policy and job site
information
Insurance Company Name: - I)
Policy#or Self-ins. Lie.#: t"))nnC 4 0?a ] o ( Expiration Date;
Job Site Address: 5 �rl�rra {�� 4 4:4L6, City/State/Zip: , ZbNr
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 S1,500.00 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
Investigations of the DIA for insurance coverage verification.
I do hereby certify under t e pains and p nalties of perjury that the information provided abbJ��7veI tr
u
e and correct
Date• `d�/ 6 / 1
Phone h• ��/� J��d 1�'lv� - r /
Official use only. Do not write in this s req fo be completed by city or town ogwisrl
City or Town: Permit/i.ieense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityrfown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person Phone#:
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