65 TREMONT ST - BUILDING INSPECTION (3) I� The Commonwealth of Massachusetts
"gyp, Board of Building Regulations and Standards CITY
/�ul Massachusetts State Building Code,780 CMR, 7`s edition OF SALEM
f.Ill I Revised January
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008
One-or Two-Family Dwelling
This S ction F r Official Use Only
Building Permit Nuipbe Date Applied: a
Signature:
Builaing1commissione'N I s r bf Buildings Date
SECTION 1: SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
l.la Is this an accepted street?yes no Map Number Parcel Number
1.3 Zo!�g Information: 1.4 Property Dimensions:
Zoning District Proposed Use 'Lot Area(sq 11) Frontage(11)
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 fd Private❑ Zone: _ Outside Flood 7,one? Municipal C3"On site disposal system ❑
Check if yes
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner'of Record:
S-rd ueI'L J�s�,Iev �5 i PCs ,, 6- t
Name(Print) Address for Service:
r
Si aiure Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORKZ(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work : rcj, c.
L'1 )I- Cx Wo : n N r P r.l-t.
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
1.Building $ f LI o o c. —i 1. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard City/Town Application Fee
2.Electrical $ w o ! ❑Total Project Cost'(Item 6)x multiplier x
3.Plumbing $ 15-o-e ✓ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees: $.
Ch k No. Check Amount: Cash Amount:
6.Total Project Cost: $ (� d 0 0, Paid in Full ❑Outstanding Balance Due:
1 -7 (,o m/ ngme �
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
License Number Expva on Date
Name of CSL- older V List CSL Type(see below)
Addre Type Description
U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Masonry Only
7kd` - RC Residential Roofing Covering
Telephone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home Improvement Contractor(IIIC) '�0 471
HIC CQmp Name or HIC Registrant Name 11.. .. Registration Number
Addr�f�
r 1 `I i -Xotfk' 'Exp ionDatrt e
Signatur 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 Issuayce of the building permit.
Signed Affidavit Attached? Yes.......... d No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
I, S T-6 VC - �\-&�r H as Owner of the subject property hereby
authorize 1-< c v � n G t.; a w to act on my behalf,in all matters
relative to work authorized by this building permit application.
Signature of Owner Date
T40N : OWNER'OR AUTHORIZED AGENT DECLARATION
I, Ka v t " (2)ra cx- ,as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
L o v i-
Print Name
Signature of O ner or Authorized Agent Date
(Signed under the pains and penalties ofperjury)
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 and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.R6 and I l0.R5,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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"maybe substituted for"Total Project Cost"
4,
i CITY OF SALE:NI, l xsSACHUSETTS
BUILDI`i IG DEPARTNIEUNT
130 WASHLNGTON STREET,3aa FLOOR
�j TEL (978)745-9595
FAX(978)740-9846
KIMBERLEY DRISCOLL
MAYOR T Hobw ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDLNG COMMSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information / Please Print Legibly
Name(Busims&Organization/Individual): 11` ��/13 f=,r{,�. '� Vow cer) .S ('TV -C.7 `-b w
Address: I Cal �y o�. U t_<J s, RA
City/State/zip: t a � o� t �, W Ct�yS hone#:
Are on an employer?Check the appropriate box: Type orproject(required):
1. 14 am a employer with � 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet.: 7• VjfRemodeling
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 5. ❑ We arc a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ I 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' I3.❑Other
comp. insurance required.]
Any applivied that checks box#1 most also fill out the section below showing their workers'compensation policy information.
t I bmneoweexc who submit this affidavit indicating they ate doing all work and then hire outside contrecmn must submit anew anidavit indicating such
=Cantm,sma that check this has most anached an mWitional sheet showing the mane of the subcontractors and their workers'comp.policy intonation.
I um an employer that is providing workers'compensation Insurance for my employees. Below Is the policy and Job site
information. �� \\ tt
Insurance Company dame:. Al f', n �Jv
Pat icy#or Self-ins. Lie.#: 5 ff�.5 T '] Expiration Date: ^ It�
Job Site Address: City/State/Zip: ",
J
Attach a copy of the workers'compensation policy declaration page(showing the policy Dumber 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 fine
of up to S250.00 a day against the violator. lie 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 c'erdfy,rA(er th�s and pen !es of perjury that the information provided above Is true and correcL
Signantre• 0 ) Date' 2L ram_
Phone At: -7E-1 — G J --,9D L1 .2
Dfricial use only. Do not write in this area,to be completed by city or town oJJiriaL
City or Town: Permit/License#
Issuing Authority(circle one):
I.Board or Health 2.Building Department 3.Cityrfown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: ___. Phone#:
CITY OF SM-EM, XLxsSACHUSETrS
• BummNG DEPAR-MENT
f 120 WASHIINGTON STREET, r FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
IQJtBERLEY DRISCOLL
(MAYOR THo As ST.PiERRE
DIRECTOR OF PUBLIC PROPERTY/BI.'IIDLNG COMMISSIONER
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:
(name of hauler)
The debris will be disposed of in
/:
o\v3 —6 k 1'c-1..-C
(name of facility)
(address of facility)
signature of permit applicant
date
dcbriulT dux:
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