2 THORNDIKE ST - BUILDING INSPECTION The Commonwealth of Massachusetts
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 Dem ish a
One-or Two-Family Dwelling
This Section For Official Use Only `
Building Permit Number: Date Ap
l �3
Building Official(Print Name) Signature Date
SECTION 1: SITE INFO TION
1.1 Pro erty Address: 1.2 Assessors p& rcel Numbers
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(11)
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 R, Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yes❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record: .
S U_Sfi�,t'� M4)o� CA I f� /M A
Name e((Prin-t)i Cit/may State,ZIP I
I NOW(11 SV i ?L � 71� �Jf 8eve6roe"TsC
No.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WORK2(check all that apply)
New Construction❑ Existing Building El' Owner-Occupied Repairs(s) E' Alteration(s) El� Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Wo k2: E W J 0 S
der zf + t1a+ k ,tti l e.ano v e s dti , d�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1. Building $ 70 o c) 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 $ -3 D O o 2. Other Fees: $ � r �
4.Mechanical (HVAC) $ List: �[B�
5.Mechanical (Fine $
Su cession Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ I i 000 0 Paid in Full 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) rs J&sf/ 9 2—
License Number Ex mnon Date
Name of CSL Holder
Y`/7 l�� �h
List CSL Type(see below)
Q�e
No.and Street Type Description
U Unrestricted(Buildings up to 35,000 cu.ft.
/J Z R Restricted 1&.2 Family Dwelling
City/rown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
l/ SF Solid Fuel Burning Appliances
yy
!00l OV3 Py6 f'+QCObQ cL� QpG• Uo I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC) /7 3 36/
R•/aa el t9aan'meF�e L HIC Registration Number Expiration Date
HIC Company Name or IC Registrant Name
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 Al/t el 6WI u/rr k�a�ry L
to act on my behalf,in all matters relative to work authorized by this buildirK 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 application is true and accurate to the best of my knowledge and understanding.
s 7 Zo
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.eov/oca Information on the Construction Supervisor License can be found at www.mass.gov/d�s
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"
1 ® ®p DATE(MMIDDIYYYY)
A4CCP �o INSURANCE BINDER 8/14 12
THIS BINDER IS A TEMPORARY INSURANCE CONTRACT, SUBJECT TO THE CONDITIONS SHOWN ON THE REVERSE SIDE OF THIS FORM.
AGENCY COMPANY BINDER#
Kilgore Insurance Agency Continental Casualty Co an 1451
5 Centennial Drive EFFECTIVE EXPIRATION
DATE TIME DATE TIME
Peabody, MA 01960 - X AM X 12-01 AM
8/7/12 12-.01 PM 8/7/13 NOON
PH(AjC No 976 531-6550 AIG No: 978 531-9442 THSel`DE2ISISSUEDTOEXTENDCOVERAGEIN THE ABOVE NAMED COMPANY
CODE SUBCODE PER EXPIRING POUCY#
AISTOMER DESCRIPTION OFOPERATIONSIVEHICLESIPROPERTY(Including Localion)
IR 2190
INSURED
BAU Builders Construction Contractor
Roland Baumgaertel d/b/a
447 Western Avenue - Rear
Gloucester, MA 01930
COVERAGES LIMITS
TYPE OF INSURANCE COVERAGEIFORMS DEDUCTIBLE COINS% AMOUNT
PROPERTY CAUSESOF LOSS
BASIC U BROAD El SPEC
GENERAL LIABILITY EACH OCCURRENCE S
DAMAGETO S
COMMERCIAL GENERAL LIASI UTV RENTED
CLAIMS MADEOCCUR MEDEXP(Any onepereon) S
PERSONAL B ADV INJURY $ __
GENERAL AGGREGATE S _
PETRO DATE FOR CLAIMS MADE: PRODUCTS-COMPIOP AGG $
VEHICLE LIABILITY COMBINED SI NO LE LIMIT S
ANY AUTO BODILY I NIURY(Per person) S __
ALL OWNED AUTOS EDDILYINIJURY(Per accident) $
SCHEDULED AUTOS PROPERTY DAMAGE $
HIRED AUTOS MEDICAL PAYMENTS S
NON.OWNED AUTOS PERSONAL INJURY PROT S
UNI NSURED MOTOR ST S
S
VEHICLE PHYSICAL DAMAGE DED ALL VEHICLES SCHEDULED VEHICLES ACTUAL CASH VALUE
COLLISION: STATED AMOUNT $
OTHER THAN COL:
GARAGE LIABILITY AUTO NLY-EA ACCIDENT S
ANY AUTO OTHER THAN AUTO ONLY:
EACH ACCIDENT S
AGGREGATE S
EXCESS LIABILITY EA01OCCURRENCE S
UNBRELLAFORM AGGREGATE S
OTHER THAN UMBRELLA FORM RETRO DATE FOR CLAIMS MADE: ZELF-INSURED-RETENITION S
Policy number in issue X W-STATUTORY U MTS
WORKER'S COMPENSATION Coverage ID #0409195 EL.EACH ACCIDENT $ 500,000
AND EMPLOYER'S LIABILITY EL.DISEASE-EA EMPLOYEE S 500,000
EL.DISEASE-POLICY LIMIT $ 500,000
SPECIAL FEES S
CONDITIONS I - TAXES S
OTHER
COVERAGES ESP MATED TOTAL PREMIUM S
NAME&ADDRESS
MORTGAGEE ADDITIONAL INSURED
LOSSPAYEE
LOAN#
AUTHORIZED REPRESENTATIVE
C rus A. Kil ore
ACORD 75 12010/041 Pape 1 of 2 0 1993 2010 ACORD CORPORATION. All rights reserved.
I
CITY OF S�1L EMI, NLUSACHUSETrS
BUILD4\G DEPARTM&NT
` r 120 WASHNGTON STREET, 3A FLOOR
TEL (978) 745-9595
F.tiK(978) 740-9846
KIJtBERL.EY DRISCOLL
A.LWOR THosus ST.PtERRa
DIRECTOR OF PCBLIC PROPERTY/BCILDNG COJLMISSIONER
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 M 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:
fjl� SAeg7-e t ---
(name of hauler)
The debris will be disposedof in :
Sl r�l iu-Fr�- 0 c le44A- Tr�s Pr
(name of facility) /
_— --(addre . of Facility)
signature of permit applicant
date
aa, .�ad,w
EXISTING
y
OFFICE
12- 16"D SHELVING
EX
ISTING
CLOSET
U)I>
EXPOSE BRICK z
T�
IF -:::7
mo
170
WALK IN
EXISTING
CLOSET LOSET
BEDROOM m!
S'G TUB
I LINEN CL
RELOCATE
DOORNAY I
7 oll
DRESSER STACKE
N/D
REPLACE WINDOW
N/SHORTER UNIT
(RAISE -, , 1 HGT