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11 SUTTON AVE - BUILDING INSPECTION (3) Ire - t4 - tc� so 6b C-t= �g The Commonwealth of Massachusetts OF E__ Board of Building Regulations and Standards R�CEI�E R%4JCE&- Massachusetts State Building Code, 780 CMWSPECTIONAI s Sr\LEM Revise(yYlnr 2011 Building Pennit Application To Construct, Repair, Renovate sNeroills El 0 One-or l ivo-Fam1, Dwe111i [YY��Vv This Section For Official Use Only Building Permit Number: Date Applied: Building Official(Print Name) Signature Date SECTION ]:SITE INFORMATION 1.1 Property Ad res : 1.2 Assessors blap Br Parcel Numbers L.l a Is this an accepted street?yes__ no Map Number Parcel Number 1.3 Loniug Information: --- 1.4 Property Dimensions: --- Zoning District I'rolxucd Use Lot Area(sq It) Frontage(11) 1.5 Building Setbacks(ft) Front Yard Side Yards Rear Yard Required Provided Rcquixd Provided Required Provided 1.6 Water Supply: (ibLO.L c.4n,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: Public❑ Private❑ Zone: — Outside Flood Zone'?Check ifyes❑ Municipal ❑ On site disposal system ❑ SECTION2: PROPERTYOWNERSIIIPt 2.1 O% erl of R cor( Nunte(Print) City,State.Y.IP �1 v Ors C4V10 - o _ No.and Street Cphone Email Address SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply) New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ NumberofUnits Other ❑ Specify:__ Brief Description of Proposed Work:__ SECTION 4: ESTINIATED CONSTRUCTION COSTS Item Estimated Costs: (Labor and Ma/te�rials Official Use Only I. Building $ 'l.J� 1. Building Permit Fee: $ Indicate how fee is determined: 2. Electrical $ ❑Standard City/Town Application Fee ❑Total Project Cost'(Item 6)s multiplier x_ 3. Plumbing $ 2. Other Fees: $ _ 4. Mechanical (I IVAC) $ List: 5. Mechanical (Fire _ Suppression) $ Total All Fees: $ .�^ Check No. Check Amount: Cash Amount 6. Total Project Cost: $ V v ❑ Paid in Full 11 Outstanding Balance Due: SECTION 5: CONSTRUCTION SERVICES 5.1 Constructiod.SupetvisorLicense(CSL) h F11oO 2 P.t�[/i�G C/ License Number Expiration Date Nano_ofCSL Holder List CSL,Type(sec below) No.and Street l Description 7 , U Unrestricted(Buildings u to 35,000 cu. I1. -P Restricted 1&2 FamilyDwellin- Gi flown,State,ZIP M Masonry RC RoofingCovering WS Window and Siding L ` ) /, SF Solid Fuel Burning Appliances `�' (/ 1 1 1 Insulation Mc hone Email address D Demolition 5.2 Regist••ed11 me mprove 'entContractor(IIIC) HIC Registration Number Espirati Date HIC Company Nat r 1-II Rgist : n No,andS - Lf 6 a/*O Email address City/Fown,State,ZIP 'rele hone 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,its 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 7b: 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 appli is tr d accurate[o th •st of my knowledge and understanding. L 7 Print Owi�rAuthorizedAgent's Name(Electronic Signature)' Date L 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 i11.G.L. c. I42A.Other important information on the HIC Program can be found at www.mass.-gov/oca Information on the Construction Supervisor License can be found at www.niass.gov/dps 2. When substantial work is planned, provide the information below: Total floor area(sq. 11.) _(including garage, finished basement/attics,decks or porch) Gross living area(sq. R.) Habitable room count Number of fireplaces_ Number of bedrooms _ Nurnberofbathrooms Numberofhalt/baths _ Type of heating system _ _ Number of decks/porches Type ofcooling system-__ Enclosed 3. "Total Project Square Footage"may be substituted for"fotal Project Cost' l "54r- • ` OF alrzm' LAAJJi 1l.1Z UrJL1 lJ BL'ILDLNG DEPARTM&NT v\ , �+. s, l_'0 CV.ISHL�IGTON $TtEET, }JO F[OOR r �0 v TEL (973) 7d5-9595 KINIDERLEY DRISCOLL FA_X(973) 740-984,5 NLAYO"t DIOnAs Sr.PILgRg DIRECTOR OFPI,'©LIC PROPERTY/HC•ILOLNG CONNISSIONER Construction Debris Disposal Aff1davit (required for all demolition and renovation work) In accordance with the sixdl edition of the State Building Code, 730 CbIR sectio l l Debris, 'uid the provisions of tNtGL c 40, S 54; n I S Building Permit hiis 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 1ICL c 111, S 150A. The debris will be transported by; 1 (name ufhaulur) The debris will be disposed of in ; (nonce of facility) "j, I -- f: rrnrtapptieant CITY OF SALEM, ANSSACHL'SETTS (5CI[.D[\GDEPARTJIL\T 120 WASHLIIGTON STREET, 3e'FLOOR TEL (978) 745-9595 F,kx(978) 730-9846 KI\IBEKLEY DRISCOLL t,,rLAYOR THObLks ST.PIERBH DIRECTOR OF PLBLIC PROPERTY/BUILDING CONNISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractorq/Electricians/Plumhers Applicant Informatinn Please Print Lc ibl .Vatnc (BusinessOrganiratiominI idua Address: r / e ly city/State/zip: 5—a, 4YYI Phone N: Au4nu on employer:'Check the appropriate box: Type of project(required): I.❑ I am a employer with 4. ❑ 1 aria a general contractor and 1 g, ❑New construction employees(full and/or part-time).* have hired the sub•contractory i 2.❑ I an a sole proprietor ur panner- listed oil the attached sheet. ; 7. ❑ Remodeling ,hip and have no employees These sub-contractors have y. ❑ Demolition working for me in any capacity. wod(zrs'camp. insurance. y, ❑ Building addition [No workers*comp. insurance S. ❑ We are a corporation and its required.) officers have exercised their 10.❑ Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ 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 canp. insurance required,) •A1,y upplivvn Ilmt shucks his AI mot also fill out the ecdiun bduwahowing Choir worker,'compensation policy inlbrmatiun. 'I lomauwrw•n who submit this atndnvit indicatins ihey am doing all work and then hire uutsi la cuntmcter,mot.mhmil a new.tftldavil indicting ouch. $\unmcton thin chak this box mml anached an addiliuwl eked showing the n.une of tho subwontndor,and Ihelr worker'comp,policy information. l ant an employer that Is providing workers'conipensatlon insurance for my employees. Below is th*poBey and fob site injurntalian. Insurmcc(:mntpany Name:_rL�V Policy 4 ur Self-ins. Lie, 0: D ExpirationDate:lob Site Address: nh City/Slate/Zip: a'ei A each a copy uI the workers' campensatloa 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 tine up to S1,500.00 und/ar one-year imprisomncnt,as well as civil penalties in(he form of STOP WORK ORDER and a line of up to S250.00 a day against the violator. Ile advised that a copy of this statement may be lunvardcd to the Office of Invrstigatiuns ul the Dlr1 fur insunnee covemgc verification. - l do hereby vertijy under the pains and pen ahlex of perjury that the information provided ubo ve is true and c orrect. Si t ltnrc G� J�' { �--Data: .__ 6/•L.. `y . Phone rt: �✓ (�/ I— 770fliciuluseanly.nly. Do not write in this area, to be completed by city or town o iciat : _ Permit/i.Icensc 4rily(c're)'one):eahh 2. ISuildhtl; Ucparlu•nt ,l.Cilylfnsrn ClerkI. Electrical lnspectur 5. phtnlhing luspeetor Cunlad l`¢rtnn:_ -.___.___ Phone !t: Office of Consumer Affairs and Business Regulation . 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement Contractor Registration Registration: 166565 IT i_ ,'= %� Type: Corporation Expiration: 6/9/2016 Trk 251720 A.C. CASTLE CONSTRUCTION CO!1NG 'J BRIAN LEBLANC _ 9 TIBBETTS AVE DANVERS, MA 01923 " _ Update Address and return card.Mark reason for change. Address Renewal Employment Lost Card SCA i 0 20M-05/11 C9lfze ` Office of Consumer Affairs&Business Regulation License or registration valid for individul use only egi IMPROVEMENT CONTRACTOR before the expiration date. a found return to: egistration 166565 Type: Office of Consumer Affairs and Business Regulation Expiration 6/9/2016 Corporation 10 Park Plaza-Suite 5170 Boston,MA 02116 A.C.CASTLE CONSTRUCTIOWCO'INC. BRIAN LEBLANC = 9 TIBBETTS AVE - go DANVERS, MA 01923 -- " 4 Undersecretary Not valid without signature Massachusetts -Department of Public Safety P • Board of Building Regulations and Standards Construction Supers isor License: CS-054882 BRIAN A LEBLANC - .. 9 TIBBETTS AV] Danvers MA 019I3 I I 954— JJ Expiration ` 09/1 712 0 1 5 Commissioner I