10 TURNER ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code,780 CMR,7'h edition OF SALEM
Revised Jamrary
Building Permit Application To Construct,Repair,Renovate Or Demolish a 1,2008
One-or Two-family Dwelling
This ion r Official se Only
Building Permit Number: Date pplied: •U
Signature:
Building Commissioner/Insp or of Bui Date
SECTI 1:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
/o �u P✓ _? �T / oaZC3
L In.Is this an accepted street?yes no Map Num e Parcel Number
Lk4Eoning 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:
Publi4 Private❑ Zone: _ Outside Flood Zone? Municipal f3 On site disposal system ❑
Check ifyesO
SECTION2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Kris 1t✓1� �ee� /o i�.c,✓c-�2 .�T
Name(Pg'nt) Address for Service:
tGt e� ( eJz • i.e.l-I- 29--,:If- 0 - -Z
Signature Telephone
SECTION 3:DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Buildin Owner-Occupied ❑ Repairs(s),� I Alterations) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work":Q�o� e ear J rce:ce ��s i k
�69LscE B�—o7^TG+� a�0�.�v' - /�1_'S7AfG PFP d/-F/1✓� r�
SECTION 4:ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
(Labor and Materials
1.Building $ S000_op 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 $ 2. Other Fees: $
4.Mechanical (HVAC) $ List:
5.Mechanical (Fire $
Suppression) Total All Fees:$
Check No. Check Amount: Cash Amount:
6.Total Project Cost: $ 5cco- o o 13 PaidPaidnFFull 0 Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL)
Number Expiration Date
Name of CSL-Holder List CSL Type(see below) L/
/f
Address T Description
U Unrestricted u to 35,000 Cu.Ft.� am Restricted &2 Famil Dwelling
Signature MOn ly
lr7-L57--/yG/3 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(HIC)
M.19WA 6-& e /5301/3
HIC Company Name or HIC Registrant Name Registration Number
1G—'= a G (�w 1'0
Address /6-Z3-Zo/2
-�^ 6/7-L3-7- .1113' Expiration Daze
Si 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 ..........If- No...........❑
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
�
1, I S � �N y W yl 2 e U.iZ, as Owner of the subject property hereby
authorize :y�cG �t/ipo 4.� to act on my behalf,in all matters
relative to work a orized by this building permit application.
2-6 /1
Si afore of Owner Date
SECTION 7b:OWNEW OR AUTHORIZED AGENT DECLARATION
I, /h/GyAEL AZg'oc— 1, 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.
Print Name
Signature of Owner or A- u nth iixa Agent Date
(Signed under the pains and penalties of
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 I I O.R6 and I IO.RS,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"may be substituted for"Total Project Cost"
The Commonwealth of Massachusetts
Department of IndustrialAccidents
Office of Investigations
600 Washington Street
Boston,MA 02111
UIF www.mass.gov/dia
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Aolllicaut Information / Please Print Leeibly
Name(Business/Organization/Individual): /lo�� R!/✓�GC'S
Address: ,l CC,7Y7o>../ s i
City/State/Zip: GY.vc/ lY/t Phone#:
Are you an employer?Check the appropriate box: Type of project(required):
L❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑New construction
emplo ees(full and/or part-time).* have hired the sub-contractors
2,[Q I am asole proprietor or partner- listed on the attached sheet. 7. FzRemodeling
ship and have no employees These sub-contractors have g, ❑Demolition
working for me in any capacity. employees and have workers' 9 ❑Building addition
[No workers' comp.insurance comp.insurance.:
required.] 5. ❑ We are a corporation and its 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work officers have exercised their I L❑Plumbing repairs or additions
myself [No workers' comp. right of exemption per MGL 12.❑Roof repairs
insurance required.]t c. 152, §1(4),and we have no
employees. [No workers' 13.0 Other
comp.insurance required.]
*Any applicant that checks box N I most also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they arc doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContmctors that check this box must attached an additional sheet showing the name of the sub ontractors and state whether or not those entities have
employees. If the subconpactors have employees,they must provide their workers'comp.policy number.
I am an employer that is providhrg workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach 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$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$250.00 a day against the violator. Be 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 certify under the pains ndd ppenaldes of perjury that the information provided above is true and correct.
Signature: %ate/ Date:
Phone#: G/7- Z-S 7—
Official use only. Do not write in this area,to be completed by city or town oKkiai
City or Town: PermittLicense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#: