15 TURNER ST - BUILDING INSPECTION (2) The Commonwealth of Massachusetts
W
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 OREM&NED a
One-or Two-Family Dwelling INSPECTIONAL SERV CES
This Section For Official Use Only
Building Permit Number: D pplied: ; H1k SEP 31 A
Building Official(Print Name) Signature Date
SECTION l:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map&Parcel Numbers
/: Ezi -c - .e// GYis?— a
1.1 a Is this an accepted street?ycs_,oe no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
.e-Z .ems
Zoning District Proposed Use Lot Area(sq fit) 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:
Publi Zone: _ Outside Flood Zone?
Private❑ Check ifyes❑ Municipal$-On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
a
Name(P Ciry� a�te,Z /�
1p
NO.and Street Telephone Email Address
SECTION 3:DESCRIPTION OF PROPOSED WOW(check all that apply)
New Construction❑ Existing Building K Owner-Occupied Air Repairs(s)A Alteration(s) ❑ 1 Addition ❑
Demolition ❑ 1 Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work :
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials Official Use Only
1.Building $ 1. Building Permit Fee:$ Indicate how fee is determined:
2.Electrical $ ❑Standard City/Town Application Fee
❑Total Project Costs(Item 6)x multiplier x
3.Plumbing $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:_
5.Mechanical (Fire
Suppression) $ Total All Fees: $
6.Total Project Cost:
Check No. Check Amount: Cash Amount:
$� o00
Y, ❑Paid in Full ❑Outstanding Balance Due:
OWt, � A 0c1k+1co-4rv\-
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL)
G'3 Ciy�/Z9z3 6 Zr3—z�G
�f%cL/A EL / — License Number Expiration Date
Name of CSL Holder u List CSL Type(see below) ,
/l—mace
No.and Street � Type Description .
_ U Unrestricted(Buildings up to 35,000 cu.ft.)
ae 9�y R Restricted 1&2 FamilyDwelling
City/To",State,ZIP
M Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
/530/3
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
/ JT /Y1A•�!—Gi2v59 d6?�es9iH91G•Cdy
No.and Stree
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 /�x—,, .oe. 15
to act onmy behalf, in all matters relative to work authorized by this building permit application.
—JU.P� S�,a—,ram/ /cy— ,—/y
Print Owner�/'s Name(Electronic Signature) Date
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
contained in this application'is/true and accurate to the best of my knowledge and understanding.
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/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"maybe substituted for"Total Project Cosf'
i CITY OF SOU ENI, 1rLASS.AICHUSETTS
BUMDLNG DEPIRTJEENT
• 130 WASHINGTON STREET,San F200R
TEL (978)745-9595
FAx(978) 740-9846
KI\IBERLEY DRISCOLL
MAYOR THOMAs ST.PtEm
DIRECTOR OF PUBLIC PROPERTY/BUUMLNG CONMUSSIONER
Workers' Compensation Insurance Affidavit: Builders!Contractors/Electricians/Plumbera
Applicant Information ���� Please Print Leeibly
Name(BusirnsstiOrganizatioNlndividual): L'7ll_A,4 L A?L�S
Address: //
City/State/Zip: CyV-./- neX& e-jlgW4 Phone#: ,,4,*13
Are you an employer?Check the appropriate box: Type of project(required):
1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).• have hired the stir-contractors
2.01 am a sole proprietor or partner- listed on the attached sheet.t 7,0 Remodeling
ship and have no employees These subcontractors have S. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. ❑Building addition
[No workers'comp.insurance S. ❑ We are a corporation and its
required.] officers have exercised thou ]0.❑Electrical repairs or additions
3.El1 am a homeowner doing all work right of exemption per MGL 11.❑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' ME]OOter
comp.insurance required.]
;Any a"lic nt that checks box pl most also fill uut the section below showing their workers'compensation policy information.
t I lomeowners who submit this affidavit indicating they are doing all work and then hire outside comraaws mint submit a new,affidavit indicating such
'Contractors that duck this boa mint attached an aMtiowd sheet showing the name of ttn sub-contractors and their warfare'comp,policy inromration,
l am an employer that is providing workers'compensation hrsarance for my employees Below is the policy and Jab silo
information.
Insurance Company dame:
Policy 4 or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/Slate/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 S1,500.00 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. Be advised that a copy of this statement may be forwarded to the Office of
Investigaliuns of the DIA for insurance coverage verification.
I do hereby certif��ains an n lies of perjury that the information provided above is true and tarred
i t i _�_ Dat rB7e—, ellelll
Official use only. Do not write in this urea,to be completed by city or town official
City or'rown: PermidUcense#
Issuing Authority(circle one):
I.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person• Phone#
CITY OF SM.EM. 1tWSACHUSETtS
BUILDLNG DEPARINCLN'T
120 W.kSHLNGTON STREET, r FLOOR
T EL (978) 745-9595
FAX(978) 740-9846
1Q.,%tBFRr FY DRISCOLL
MAYOR T HOMAS ST.PMM
DIRECTOR OF PUBLIC PROPERTY/BUILDING COSL\RSSIO,iER
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:
�`✓,gam—� ��5
(name of hauler)
The debris will be disposed of in
(name of facility) lG+�-/
(address of facility)
sign ,re of per it applicant
�a
date
JcbrivtT.Ja:
Massachusetts-Department of Public Safety.
Board of Building Regulations and Standards
Construction Supenisor -
License: CS4)94290
' MICHAEL A NAPES
11 CLAYTON STREW RI
LYNN MA 011
Expiration
j Commissioner OW2012016
Unrestricted-Buildings of any use group which
contain less than 35,000 cubic feet(991M )of
enclosed space.
Failure to possess a current edition of the Massachusetts
State Building Code is cause for revocation of this license.
For DPS licensing Information visit: w .Mass.Gov/DPS
AXe
Office of Consumer Affairs and Susmess Regulation
10 Park Plaza- Suite 5170
Boston, Massachusetts 02116
Home Improvement Contractor Registration
Registration: 153013
Type: DBA
Expiration: 10/23/2014 Tr# 23275t
M.A. NAPLES CARPENTRY
MICHAEL NAPLES
11 CLAYTON ST
LYNN, MA 01904
Update Address and return card.Mark reason for change.
OPSCAI 0 50M4p/04-G70127e
Address Renewal Employment Lost Card
. � '