3 UGO RD - BUILDING INSPECTION L) The Commonwealth of Massachusetts
�> Board of Building Regulations and Standards CITY OF
assachusetts State Building Code, 780 CbIR SALEM
Nf
Xavised Mnr 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied>;.
wilding Official(Print Name) St afore Dnte
SECTION I:SITE INFO ION
1.1 Pro erty Address: 1.2 A Map& Parcel Numbers
3 ,fan S-d Assessors
1.I a 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 Setbacl(s(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❑ Private❑ Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Check if yesCl
SECTION 2; PAOPERTY'OWNERSHIPA'. .
2.1 O nert f Re ord:
eV Name(Print) ''DgVj d, t_.3—ale T City,State,ZIP
l S (I l�/ask.n.ie� 5r dd7 1r V69 g0 `�( L
No.and Street r `� Telephone Email Address
SECTION 3: DESCRIPTIO PROPOSED WORW'(check all that apply)
New Construction ❑ Existing Building Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ 1 Number of Units I Other ❑ Specify:
Brief Description of Proposed Work': i Ctn fi 4P_tcZ ' ^v M
ba c
SECTION 4: ESTIMATED CONSTRUCTION COSTS-
Estimated Costs:
[rem Official Use Only. ,
Labor and N(aterials
1. Building $ I. Building Permit Fee.S Indicate how fee is determined:
2. 61cetrical i Standard.City/Town Application Fee
❑Total Project Cost ,(Item 6)x multiplier x
3. Plumbin; i 2. Other Fees: S
t. M.chanical (1IVAQ S List:
5. ;Mechanical (Fire
� � SuP vessinn) _ $ _ lbtal All Fces: .S_
Check No. _Check Amount: _Cash \utounr
n Cntal Project Cost: SIj( OO—) ❑ Paid
dhill
�rill[ ❑ Outstanding l).ilaaccl)n
S d T-6 0 f�r7 19 F i G S- Ir iK v!G/�
r ,
SECTION S: CONS'l-RUC'I'ION SERVICES
5A Construction Supervisor License(CSL) 09�7 jo -21 -2b( S-
---?,t \—I �a. Lieenst Number --— Gepirxtiun Date
Name of CSL Ilolder
f�,�p.r List CSL Type(sue below)
- Type Description
No. and Strce
,f U Unrestricted(Buildings u to 35,000 cu, tt.
_�p-� I rlr p ���� R Restricted 19c? Family City/rown,Stut��' NI NfasonrRC Roofin CoverinWS Window and SidiSF Solid Fuel [lamin(l'cle hone Email address D 5.2 Re tstered Hmne Improvement Contractor(H[C) �7 9 l7
���y�- FI[C Registration Number Expiration Date
tUr 1IIC Cum any N,une or I11C Regi• t Name
j} f 0 tt
No nd Str et . Email address
City/Town,Stag Z1P Tale hone
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 .......... ❑ 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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7h: OWNEW OR AUTHORIZED AGENT DECLARATION
Fcontained
ring my name below, [ hereby attest under the pains and penalties of perjury that all of the information
in this a licadon is true and accurate to the best of my knowledge and understanding.
— .• s Name Electronic Si nature) Date
nef'; Jf AalllJfl!-h .\�cn ( g
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 Plot have access to the arbitration
program or guaranty bold under M.G.L. c. 142A. Other important information on the H[C Program can be found at
www nI3SSA'oyoca Information on the Construction Supervisor License can be found at wtv%v.m,na.,to�.dL
2. When substantial work is planned,provide the information below:
Total tloor:trca(sq. It.) (includin"garage, finished basement/attics, decks or porch)
ros; living area(si+ tt.) Habitable room Count _
NumbernttirrphiCci --_ ----- Nmuberotbedrooms
-----------------------
Numbcr of bathrooms Number of h:AEbaths - - ----_— --
- —
I"cpdor heatingiy;tcm Numberotdecks;parelus
- ------
- "
I ,pe�!(canlim� ;y;IJw _--.---- F:ncloscd (1pcn
--
4 I',tt_tl I'r,�j:rt S�iu,ua I�n,+t t � • in,ry he ,iib;tiutl.�l t,,i f ,t iI I'inj..d (_0;t"
CITY OF S.U1 mvt, I SSACHUSETTS
BUILDLNG DEP iRTNIE.NT.
120 W.NSHLNGTON STREET,3"FLOOR
TEr_ (978)745 905
PAX(978)740-9846
NfgFRt FY DRISCOLL THadrASST.PtERxH
MAYOR DIRECTOR OF PUBLIC PROPERTY/ElU DINGCON51ISSIO:iER
Workers' Compensation insurance Aflldaviti Builders/Contractors/Electricians/Plumbers
4itplicanf Inforrnation �7 1 Please Print Ueibly
Name(Busiixssioiganiiatiorvindividuap:
Address:
City/State/Zip: Phone
Are you an employer?Check the appropriate box: Type of project(required):
4. ❑ 1 am a genea contractor and 1
1. I am a employer with rint t
6. ❑New construction
employees(full and/or part-tine).' have hired the sub-contractors
listed on the attached sheet.. y aReinndeling
2.�I am a sole proprietor or partner- '
ship and have_no employees.,, These sub-contractors have $. ❑Demolition
working for me in any capacity. workers'comp.insurance. 9. 0 Building addition
' (No workers'comp.insurance S. ElWe are a corporation and its '10.❑ Electrical repairs'or additions
required.).' otYcers have exercised thew -
3. 1 aid a homeowner doing all work right of exemption per MGL I LCI Plumbing repairs or additions , .
myself. [No workers'comp. c. 152,g 1(4),and'we have no 12,Q Roof repairs
insurance required.)t. employees.[No workers' 13.Q Other
comp.insurance required.)
Any appllaun uvt chrxks box#1 must also rill out the Section below showing their workers'mmpenuaon jus my mfurmatioo:
}I lomeownen who submit this affidavit indiwing they me doing all work and then him moside-contractors mast submit a new andavit indicating,such.
:Contractors thatcherkthisbox must anxhed an additional chat showing lhunarneofthasut:�fflfxtonand theirworken'comp:policy infomastion.
_ lam an employer that is providing Ivorkers'compensation insurance for rdy employees:I Below is the policy did Job site
information //� yy�flp
insurance Compaay Name: ��s27
Policy#or Self-ins.Lic.#: CPP 0 15-6 ia Expiration Date: C� M 3
Job Site Addross: a 4 Ild! a City/State/Zip:_ II 1 '
Attach a copy of the workers'_ ompensatlon.policy declaration page(showing the policy number and expiration bate).
Failure tosccure 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 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
Investigations ufdte n1A for insurance coverage verification.- ' -
/do hereby certify tinder the pains and pyen�altles of periary that the informallon provided above is true and correct
5i'snaturc, t Date: e. 26 ) 3
nti,.n.#, 7 Ff —7 2 7/ /92�—
OJrchd use only. Do not write in this area,to be completed by city or town offlchil. '
City ne Town: Permit/1Jcense#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.Cityfrown Clerk• 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ _— Phone#:
a 1
;. CITY OF S'.uzI,f, NL1SS.lCHUSETTS
ElU=LNG DEPARTJIENT
� y i 120 1V.13HL4GT0V STREET, 3i0 FCOOR
TEL (978) 745-9595
F.�c(973) 7-10.9343
:<l1t11EQL.EY DRISCOLL
%yo'l -J1l0X1U Sr.Ptaxu
❑ixECTOR OF PLOLIC PROPERTY/BLMDLYG CONNISSIONER
Construction Debris Disposal AFfIdavit
(required ter all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 730 ChfR section l l 1.5
Dcbris, and the provisions of h(GL e 40, S 54;
Building Permit k is issued with the condition that the debris resulting from
this work shall be disposcd of in a properly licensed waste disposal racility as deBncd by ttiIGL a
l 11. S 150A.
The debris will be transported by:
1 (namr ufhauler)
The debris will be disposed of in :
(name or facility)
(IT,C" or fitaility)
siynamra urpCrmit applic nt
r-