28 SYMONDS ST - BUILDING INSPECTION � A �
The Commonwealth of Massachusetts D Board of Building Regulations and Standards CITY OF
1, Massachusetts State Building Code,780 CUR SALEM
(�U Revised Mar 2011
Building Permit Application To Construct,Repair,Renovate Or D ish
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied:
�i�/d' i
' 41Gt1-,dlt4/L/ Lr17-ZY.Ky1--x'y1 1 10711 Z
Building Official(Print Name) -Sig,, Daze
SECTION 1:SITE ORMA
1.1 Property Address,�I 1.2 Assessors 1 ap creel Numbers
8L$ SA and')IgS 5
1.la 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(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:
Publicla Private❑ Zone: _ Outside Flood Zone? Municipal'9 On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 OwniTA�of Reco
Da yr rX I'r�dc thews Stem M�
Name(Print) City,State,ZIP nM-
a B s a ,r. f.v 0J S 9�g 9 9- oYld cg`tea
No.and Street Telephone Emai Address
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building 0 Owner-Occupied P Repairs(s) X I Alteration(s);K Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work';Q pep ccalheA LI/stnO s+w41 V S1 n
C rtcc.,l Nii.A'�5
e w cr.-C otit }cIr la *cl. ea. ow
c� See o a ch
SE ON 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Cow: Official Use Only
(Labor and Materials
1.Building $ 00 1. Building Permit Fee:$ Indicate how fee is determined:
❑Standard City/Town Application Fee
2.Electrical $ Z&O, ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ /S 0(9 2. Other Fees: $ i
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
^ Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ J DOD ❑Paid in Full ❑Outstanding Balance Due:
i
1 ,
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
n II & `7�/ZfJ / /2
L!xU e Y I `C'y^'C♦•h sews License Number Expiration Date
Name of CSL Holder Type
( )
`// /� / List CSL T see below
/4/2 /�Lv<r4d ICd
No.and Street Type Description
O/�, U Unrestricted(Buildingsto 35,000 cu.ft.R Restricted 1&2 Family Dwelling
Ci /fown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Sidin
SF I Solid Fuel Burning Appliances
R7sr �99 -o75G Adm4e- ®istsh 'Co' I Insulation
Telephone E a0 address D Demolition
5.2 Regi terre,d, Ho 0me Improvement Contractor(HIC) �IJ-(1I /6//2
Wit,ty \• c'+/ '6w5 HIC Registration Number Expiration Date
C Comp$uy NameprTI Rygisgant Name
trh�ietc^w�lyhi�iYi i'Cd'
!!CS F /r/ I`✓'cam 01,50 _ 4,7V `Je6� "y9 Email address
ItinS K
Gown 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
Us 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 Owrrer's Name(Electronic Signature) Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name belowI hereby attest under the pains and penalties of perjury that all of the information
contained in s IoL_true and accurate to the best of my knowledge and understanding.
Zv /2
Prmt Owner's or A d Agent's Name(Electronic Signature) --- - --y"-"_ ate
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. 142A.Other important information on the HIC Program can be found at
www.mass. og v/oca Information on the Construction Supervisor License can be found at www.mass. og v/dps
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'
12/29/2011 17:17 7819446112 BAILLIE AND COMPANY PAGE 01/03
MORTGAGE INSPECTION PLAN
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A = 3,600 SF nto r!D* 10
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45,00' 5_Oft
SYMONDS STREET
TH13 VINN IR ft e"OX ATA BVaYEYa+oT AM maTR{IM4TR&1M/EYI ANG 15 TO BE=0 MR MORTGAGE iMAMBEa OXLY.
TXEnW'GaE TXEOFFBam Aa 9lWWn'MOOLONOTBE UBEO TO BBTABUBX PPDPERIYIP�G.
ESSEX COUNTY
DEED REFERENCE: PLAN REFERENCE.` PLAN OF LAND
BK. 5421 PG. 22 BK. PG. IN
CERT. NO, SALEM
I hereby candy that the oxlstlng structures are located approodmatelf as shown and were
not in violation of the zoning byWwa at the time of construction,or are mtempt from violation
enforcement action under,Chapter 40A Section 7 of the Mess.General Laws. The
structures are located in Zone C according to the folboft F.E.MA map. Moto:Zone C PREPARED.FOR:
represonts areas of minimal Hooding.
FLOOD HAZARD COMMUNITY NO. 250102 DAVID D. MATHEWS
BOUNDARY MAP NO. 0001 b EFFECTIVE: 5 AUG 85
HOFMA o SCALE: 1'r BE 201
TH6MAS
C. SAILLIE & COMPANY
3at� LAND SURVEYING & RESEARCH
FESSt��P�� 33 HOWARD STREET
9�0 8UW4 READING, MA. 01867
REGISTERED LANC)SURVEY R PHONE: (781) 944-2767
FAX: (781) 944-6112
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12
CITY OF Sm Em. NWSACHUSETTS
BUII.DIING DEP,,R'rJi&\T
130 WASHITNGTON STREET,3"°FLOOR
TF.L. (978) 745-9595
FAX(978) 740-9846
KL%fBERLEY DRISCOLL
MAYOR T Homs ST.Pwalta
DIRECTOR OF PUBLIC PROPERTY/BUILD ,NG COMMSSIONER
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:
�vr� M —4—k ecr S
(name of hauler)
The debris will be disposed of in
1
(name of facility)
M
(address of facility)
signature of permit applicant
a
date
dcbriulT.ax
i CITY OF &UX.N4 N-Li1SSACHUSETTS
• BL'RDLNG DEPARrinr'T
120 WASHINGTON STREET,San FLOOR
TEL (978)745-9595
FAX(978)740-9846
KI.NIBERLF-Y DRISCOLL
MAYOR THO MSST.PMM
DIRECTOR OF PL'BL1C PROPERTY/BumclL*IG CO\L%BSSIONER
Workers'Compensation insurance Affidavit: Builders!Contractors/E[ectricians/Plnmben
Applicant Information Please Print Legibly
NamelBusincs&Organimtionrindividual): '�AFo.UGtS6 t l.�'4"klpztX
Address: Z$ St4 w.,�►Lt(�
City/State/Zip: Phone#: � � k �, 7 l ' 4)? Y4
Are you an employer?Cheek the appropriate box: Ty
pe of project(required):
I.❑ 1 am a employer with 4. ❑ 1 am a general camncmr and 1 6. 0 New construction
employees(full and/or part-time).* have hired the sub•contractots
2.[] i am a sole proprietor or partner- listed on the attached sheet.: 7.,®Remodeling
ship and have no employees These subcontractors have g. C1 Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
[No workers'comp.insurance 5. ❑ 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 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' 13.0 Other
comp.insurance required.]
•Any applicant that chodr boa at mull also fill am the scene balaw Showing their worken'tnmpmption Policy intowalton.
t I lnmeownrn who submit this affidavit indicating they an,doing all wet and the hire mMide coahoutms must Submit a new affidavit indicating such.
{.sectors that chack this box mud aaachcd an additional shed showing ate mere of the a b.,MWaddom and their wadaus'comp.policy infammtioa
l am an erttployer that Js providing workers'coinpensadon insuraaee for my employees. Below Is the polley andJob site
information. /
Insurance Company Name: T a. ✓C 1 F'�i
/Z- '
Policy#or Self-ins.Lie.#:_ J �/�JJB — / I TP�ID S Upiration Date: Z/�6!Z
Job Site Address: 2 S'f, Ltwa..d� 5 City/Staudzip:_50r^ A4_
.Leach 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 file
of up to 5250.00 a day against the violator. Ile advised that a copy of this statement may be forwarded to the office of
Invcstigmions of due DIA for insurance coverage verification.
l do hereby cert that the informadoa provided above is true and comet
Sinnature: �r �p Date:_ / /Z J zo 1 T
Phonc#: 9 78 (/.!' 4 7 0-7 416
Oricial use only. Do not write is this area,to be completed by city or town nJJFcioL
City or Town: PermidUcetoe#
Issuing Authority(circle one):
1.Board of Ilealth 2.Building Department 3.City/town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Cunlact Perron: Phone#:
w,rr.��uli`ne�
Office un uummei�e�'rfal CTOR
HOME IMPROVEMENT CONTRA Type: e
Expiration:
f122541 Individual-
Expiration 9116/2012
AV! D.MATHEWS����.-
i� DAVID MATHEWSy
142 HAVERHILL RDI� : y-7'� �d 1
TOPSFIELD MA 01983z Uudersecrehry I
ry hlass:ichusetts- Oeliartment of Public Safctc
7 Board of Building RimPlations and Standards
Construction,Supervisor License
License: CS 67420
Restricted to: 00 ,
DAVID D MATHEWS)
142 HAVERHILL RD. ,t?,
TOPSFIELD, MA 01983
Expiration: 4114/2D12
F.nnmiwlid�eri Tr#: 22112 .