7 TEDESCO POND PLACE - BUILDING INSPECTION Fhe Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
>v�W Re rised.11ar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Txv-Fundly Dmrellh g
This Section For O -ial U nl
Building Permit Number: Kate A,la lied:
Building Olticial(Print Name) Signature Date
1A SECTION I: SITE FOR ION
1.1 Property Ad ess: 1.2 Assess rs Map&r.Parcel Numbers
P r+ _
I.I a Is this an accepted street?yes G— no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed Use Lot Area(sq It) Fronlage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I,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)esO
SECTION2: PROPERTY OWNERSHIP'
2,.1r Owners of Re�cQ)(d:// pp Q
Narierint) City,State,ZIP
c
o.and Street 'relephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) (3 1 Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Ll Specify: or
Brief Descrip of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
(Laborand \laterials) Official Use Only
I. Building 3 ��( I. Building Permit Fee:$ Indicate how fee is determined:
'. Electrical S �� Qda ❑Standard City/Town Application Fee
❑Total Project Cost(Item 6)x multiplier x_
.3, Plumbing S d(rd 2. Other Fees: S
4. Mechanical IIIVAC) $ List:
5. Mechanical (Fire $
Suppression)) "total All Fees: S
Check No. _Check Amount: Cash Anumt n
6. Total Project Cost S 7V 00 ❑Paid in Full ❑Outstanding Balance Due: - — -
r
SECTION .5: CONSTRUCTIONSERVIC'ES
S.1 Co ruction Supervisor License(CSL) , �
f ��y3 _ ",'
- .�rd- .� r C'-s) Jp -- License Number spit ant Dafe
Name o(C' Ito Icr
List CSL Tv pc(see befoul
. and.' cet Type Description
U (Inrestricled(Buildings no to 35,000 cu. tl.)
O'l R Restricted 1&21'amil D%celling
C ity/I'UNn,State.ZIP M Masonry
RC Roofing Covering
WS Window and Siding
�y ,// SF Solid fuel Burning Appliances 1
2 0?7��/f7 /Y/16s—/rrG / 4 PA.[ I.CQt.. 1 Insulation
'I'cic hone 1[maiI a rcA, I D Demolition
5.2 Reg��Iisa({cred Ito a Improven lit Contractor(HIC) 1 l 317y a2
�� Ih a min— V;42- &Ao /a _:74C IIIC Registration Number hspir, ion Date
I[IC Con iy :unc or I Zeggistmnt Nan`
} v `� s i n r to S`1r'la? l cdkA-
No. ' P y " L 61236 7 b� o�7S 7 0 -Email address
Ci /Town, State,ZIP Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152. 1 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 .......... I:!I— 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 ,FfP tJ wy« 42
to act on my behalf,, in all matters relative to work authorized by this building permit application, p
Print mcr's Name(Electronic Si nalurc) a[e
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
collt ' ed in this application is true and accurate to the best of my knowledge and understanding.
dWeda
Print Ooner's or Autht rived Agent's Nmnc(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 Hume 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
-'ov hca Information on the Construction Supervisor License can be found at sn� �Ip,
2. When substantial work is planned, provide the information below:
Total floor area(sq. RJ _(including garage, finished basemenCattics,decks or porch)
Gross living area(sq. 11.) Habitable room count
Number of Ill rcplaces Number of bedrooms
Number of bathrooms Number of half baths
1, pc of heating system Number of decks, porches_
f)pe ol't��ling s)stent Inclosed -----Open _ .
t. "total Project Square Footage-may be substituted for-fatal Project Cost„
CITY OF SALEM
PUBLIC PROPRERTY
DEPARTMENT
W l YJ9114 I'll
\1111 YI
12:\VAe/lr.\Asti.\SlsCbt' • S.IU•.Ir,M.1».u.l a u-I n JI'77:
Ihl. 77t-?I5-93'/5 t hIx v7Y•?{C•'IYM
Workers' Compensation insurance .%tatia.,it: Uullders/Cuntractursiciectriclans/Mlumbers
� � Illcant In ormaflo
Ple' r t
Nil Inc Ilhnnww#)raantruiont Inds duulI:
ddre.\si: J S 49AIT do
.a alT
City,.Slarc./I(1f_ ��/ Phone0: '0?
.ire you as employer!Cheek the Appropriate box:
I.❑ 1:un a cmpluyer Ivills 4. O I l)M ufprnjact(required):mnpluyeus(lull Jnd/ur part-tittle). baud hidred Ih{Isuh Icunl r nisi
• (i. New euiu auction
?.❑ I am a Solo pmprietrtr or partner- listed on the attached shed : 7•1jgrBeinenblin j
.ship And have no mnpluycotl These subcontractors have
working II Ind in any eapadty. workers'comp,insurance. a' 0 Mmolition
I No worltcrs'Bump, insurance S.ZErsYe an a mtpontion and its q• ❑ ouildind addition
nquircd.) •Itttcers(lave exercised their 10'0 ElYctrieal repairs or additions
3.0 1 Ant A holrte4)III duind all work right of dramption per&M 11.0 plumbin rc
myself.(P'o waken'comp• C. 132,31(4),and we hove no Y twin or aJditiona
inSurancd rcquited.J t cmpluyeue. (No worked 12.0 Ruul'npuirs
III insurI rcquired.1 I)•O Gluier
•I nr"pphuJW III uhccb It"al mast atw is, uw Iha tccnun Iwlur
'Ilumutnten vhe ttarnul this anWsvir indfulin t 'tWe'mY'h'rrr ewhrss'cumpssuaiva laaicr InhntroaiYra
(,.nlm.nwv Ihal dwee this boor mod JnxhW.m sdd�.a dJinY At"I
aid Ilwm hint""side common mul•ulna a nsv endavil irnli.a#tin v
unsl..bust-hnYfn Ile near since ru►eenrxnas and#live%when'cmp Y wa.
III dai un.vxployer thus It care 14d/nX Iverkerr'runrpenrarloa hismrdnce er to e/n a t �i1ey'nMtnantr
iujurvnu/Gin, /• y P/J era B�/utv!s/AePtr/hy Ynd/u1 aiq
In.Yuranuc C•umpasty .Vmne:,�__
"'llicy 4 tK Sclr•ins. Lic.it:
/>> E.tpirul#on Date:
Jul) Site .-!dares,:
C'uylJtuts[Ip: Ps.!teach a cosy u/Meworker'wmptnsutlun
Pallu pulley declaration punt(shotvinp the polley number and daplratlua data):
ro w sceurY coveruye as required under Sdcliun:S/\ul'JIGL c, 132 tali lead to tits imposition orcriminal penalties of a
ILIe up ui i LSn0.1)n Jnd/ur uue-year imprivmmncnt, Js well Js ciul pcnalhus in th lun a(up fit i'SO.gOa Jay Idm th f a STOP WORK ORDER and s finer. eavl.+ud that a eupy urlhih.falunicnl may be lurwardt:d to the UI)ice vY
tnc,.hyJlwns ul';hu 01,11, IOf In�uf JCee GIiYeN�L'\NIh.JIIUn.
/du her,-by r,rri/y"77#h uinr.utJ /en°/ v Y r�llyAYr/ Ijn pryY%11a'1/YOYYI%7true(food CO/rerLr .
[)art:-
PI r-!
It)%/!riot rl+r only. Ou not Irri/v in this urea, tube rumy/etrd by Lily Of/men a/,11riYL
pcnnittl.levnte Y
f ltuinY .\W buries (circle noe);
1, ffev.d of Rv.#Irh !. Ile ddul� Ilcp.0 uncut 1. l:ily. onn Clerk 4. L•'lecerit.11 1st)dear I.I h. thht'r I Pluwliing Impcclor
t'•ulJcl l't nun:
Phwre 1;
i
i
information and Instructions
, non m the service of another un,ler.Illy contract of hire.
�L»suchu:cus Ucncral Laws chapter I i2 requlfes ells mlrYo rs to provlJA`workers' cotnpensauun dtt their enlp ogees.
11ursu All to title 141uld,an enplurea to Jet111Cd ae
;+Prebs or unPlicd, oral or wnlreri Oraliun of other legal cnfiry,or ally two or more
uftncnt"la •,sbOclallua.COfp er or the
rase. and illeluding the t.ya1 rcpreseuaiives of a deceased employ
In ctnpluyer 1+defined a,"an individual. P to in �m loge",• However the
.a the 1.1rcgultlg engaged In a JOInI CRltrp
Ie1:Clver Jr(ruble"'If.YI Iltdlvldual' Plumership,assoetauun or other legal arse,a di Y • '
none to three
Inai mentca,construction or repair work On such dwelling house
owner of a dwelling house having not more(ilea three apartmenu and who reside,(heroin,ur the occupmt o1
,Iwelhng house of another who employs Pe .
or on the grounds or building appurtenant thereto shall not lxcatssa of such employment be deemed to be an employer.'
�IGL chapter 152. 425C(6) also states that"ever) slots or local trust,con bustsildings
dings I shay withhold the thfo a or It
geaee with the Insurance coverage required."
renewal of a Ilccast ur per tult to operate•buslneu or to construct building,IN he commoawaullh or as
nypilesnt "ha has not produced acceptable evidence of cutup
WJitiunully. �IGL chaplet 15'. a25C(7) sraros*,Neither r the
u eomtil on c;C evidence of cu npliartl e w olitical subdivisions
theiiluunnco
enter into any contract for the Perfomwnce of Pit
requirements of this chopl"r haw been presented to the contra
authority."
�yyllcenro 1 to our situation and if
compensation affidavit completely,by checkingthe boxes that�u ufl fICate(t)of
Please till out the workers' comp idJress(ee)and phone numbers)AlongLLP with no employtxs usher than the
necessary.supply sub-contractors)namef.$),
workers' ed Liabsation Para net. If an LLC or LLP does have
insurallea. Limited Liability Companies carry 1 or Limited Liabilitytinsurship,
neinb"n or partners,are not requiredbe submitted to tilt Depurtmant of IndustrialId
employees,a Policy is required Be advised that this affidavit mayle artment of
Also be sun to Sit"oad dais theuanrodvaa/the pdavit thou
\ccidents for confirmation of insuranco c vets&@ for the permit or license is teeing req required to obtain u workers'
he roared to the city or town that the questions regarding the law ur if you urn fey
I nJustriul 1\caidants. Should y ens At
lba number listed below. Self-insured companies should enter their .
compensation policy,please call the NPuctm
.elf-insurance license number on the a ro riaro line.
city or Town Officials
The Department has provided u space at the(wean(
ttom
the app
Please he sure that the affidavit is complete:utJ printed legibly. heam
Of dla affiduvit for you to till out in the event the office of Investiaatiens has to contact you ran addition,
applications in an given yea,need only submit one afidavit indicating current
Of11llit a be sure to fill in the y,rmiUlicense number which will be used tN a reference Rulliber. In addltWn,as ap
Ihat must submit multiple penniulicaluld app ' i o Provided to lilt
Policy information(if necessary)and under"Job Site Address"
h marked iby+tile city Of'Own 'flay locations in Y
wwn).".\copy of lilt utiiditvit that has been cfflicially sump
tuwn)unt as proof•that a vultd affidavit is on file for ILttut permits or licenses. Anew aliiduvit must be tilled nut each
y e;lr. W hero a hums owner or citizen is obtaining a license ur permit not related to any business of commercial venture
dal{licen.+e a Permit lu burn leave,ale.) said person is NOT required to complete this affidavit. uestloll,,
I het)like , I I nveuiiialions would like to dwok ynu in advullee fur your coep"nliun and shuulJ you haw.uly q
pleu+e do not hesifaro to give us it call.
the U:Parunanl's address, telcphun" aTh A number:
Commonwealth of Massachusetts
Department of Industrial Accidents
Offlee of Invesdgadons
600 Wilistiriaton Street
8a+ton, MA 02111
'rel. 9 617.727.4900 ext 406 or 1-877-MASSAFF
Fyt M 617-727-7749
<.2tl.115 www.man.gov/dia
CITY OF S'UI &NI, ,�L1SS.�CHL'SETTS
OLMDLNG DEP.IRTIENT
120 WASHLNGTON STRM, 3i0 FLOOR
T EL (978) 74S-959S
FAX(978) 740-9846
Kl3C3ERLEY DRLSCOLL
MAYOR TnowsST.PmRRa
DIRECTOR OF PLB11C PROPERTY/BCIIALNG COSL\IISSIONER
is
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 l 11.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit N is issued with the condition that the dcbris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defincd by NIGL c
l 11,S 150A.
The debris will
be transp
orted
by:
�'i� HO � dhdAir�Pis
(name of hauler)
The debris will be disposed of in
(name of facility)
(address of facility)
l
el
signatur of permit applicant
t,afC
Ichn vl(LK
i�lassachusetU- Department of Public Safet,
Board of Building Regulations and Standards
Construction Supervisor License
. License: CS 67543
Restricted to: 00
RICHARD J OBRIEN JR
10 BALSAM DR >
BEDFORD, MA 01730
Expiration: 7/27/2011
(bnm�ieaHmer Tr#: 19608
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