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5 VALE ST - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2017 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: !� 1 A Building Official(Print Name) Signat -;-" Date - ^ SECTION 1: SITE INFORMATION �1 1.1 Property Address: 1.2 Assessors Map&Parcel Numbers 5V,416 �MFFr 901FM , I.Ia 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(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 yes[] SECTION 2: PROPERTY OWNERSHIP' Fn o o 2.1 Owner'of Record: a C-) Ad M Jnh 1`iSC,/i : yjGi ii .TD �A/A1'F_FiFICI 618 s -Hm Name(Print) City,State,ZIP t m_ 5 7)au✓ty twyr No.and Street Telephone Em" Address D o SECTION 3:DESCRIPTION OF PROPOSED"WORIV(check all that apply) <_ New Construction❑ Existing Building e Owner-Occupied ❑ Repairs(s) EEr Alteration(s) ❑ itiotrr❑ Demolition ❑ 1 Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work : Sf2,0 Ayn Boor m,3„J ROOF i iI/tL L'�277F1N/�F,� LI�tYJl�?s92/C SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ 9, 7 D©, 1 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:$ ry Check No. Check Amount: Cash Amount: 6. Total Project Cost: $ �� / 7, i ❑Paid in Full ❑Outstanding Balance Due:' 1,1✓ � �1/�� SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) 099p/�z y-3 -,201S RA�n) (�URYr License Number Expiration Date Name of CSL Holder List CSL Type(see below) 57{ PI�DDoc� �rvC No.and Street Type< Description U Unrestricted(Buildings u to 35,000 cu.ft.) D2l�C ' T !�� O/gcZ�o R Restricted M2 FamilyDwelling City To ,State M Masonry �2� RC RoofingCovering WS Window and Siding SF Solid Fuel Burning Appliances Gr7 �yo //ic I Insulation Telephone Email address D Demolition 5.2 Registered Home improvement Contractor(HIC) Rt�lnl �unK� Qm 1N( Joel �� 7-d9 /� HIC Registration Number Expiration Dale HIC C mpany Name or HIC Registrant Name �7 r4y2ori sn2FFT No.and Street Email address Ida F1151d , MQ 01 &PO City/Town,State,ZIP Telephone SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c.M.§ 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..........2 No........... ❑ SECTION lad OWNER AUTHORIZATION TO BE COMPLETED WHEN OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize Rig/ph QU zkE gpor-J[Yc to act on my behalf,in all matters relative to work authorized by this building permit application. ()ZPk)r 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-irue and accurate to the best of my knowledge and understanding. h Qu2K— Print Owner's or Author' d g nt's Mime(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 basementlattics,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" The Commonwealth of Massachusetts Department oflndustrial Accidents Office of Investigations r 600 Washington Street Boston,MA 02111 www.massgov/dta Workers'Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legiblv Name.(BusinessfOrganiza ionllndividual): 2H(nA g� /�Y IZOOFiN Address: 7 Q yr20/Y Sn2FrT City/StateJZip: iilpKtF,�_-/d MF) ots�d Phone.#: Are you an employer?Check the appropriate box: L Ef I am a employer with 4. ❑ I am a general contractor and I Type of project(required):, employees ll au or part time).' have hired the sub-contractors 6• ❑New construction 2_❑ I am a sole proprietor or partner- listed on the-attached sheet 7. ❑Remodeling ship and have no employees These sub-contractors have g, ❑Demolition working for me in any capacity. employees and have workers' [No workers'comp.insurance comp.insurance.t 9. ❑Building addition required] 5. ❑ We are a corporation and its 10.❑Electrical repairs or additions 3.❑ I am a homeowner doing all work officers have exercised their 1 LEI Plumbing repairs or additions myself.[No workers'comp. right of exemption per MGL 12•[TRoof repairs insurance required]t c. 152,§I(4),and we have no employees.[No workers' n.❑Other comp.insurance required.] *Any eppticaut that checks box#1 must also fill out the section below showing their workers'compensation policy infomration t Homeowners who submit this affidavit indicating they are doing all work and then hive outside contractors must submit a new iiffrdavit indicating such. tConbactars that check this box must attached an additional sheet showing the name of the mbcoubactm and state whether or not those entities have errfloyecs. If the sub-contractors have arvio}roes,they must provide their workers'wrap.polity number. lam an employer that 1sproviding workers'compensation insurance for my employees. Below is thepolicy and job site information. Insurance Company Name. cn—KSH//2E h ,e_)THq,),gl/- �RFC22yT)Y 15-Mlyl71/ Policy#or Self-ins.Lie. Ex ua p' lion Date:__ Job Site Address: VA I,- .5772 IF M YYl t� City/State/Zip:__ 0/g 70 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 a 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 WORT{ORDER and a fine of up to M0.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the IJIA for insurance coverage verification. I do hereby rem nder tl, airs and penalties of perjury that the information provided above is true and correct Si tune: . F Z_ Phone#: / y FOffccial only. Do not write in this area,to a complete by city or town official n' Permit/License# ority(circle one): Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector son: Phone#: 1 Office of Consumer Affairs and Business Regulation 10 Park Plaza - Suite 5170 Boston, Massachusetts 02116 Home Improvement C,ontrctor Registration Registration: 107146 Type: DBA Expiration: 7/29/2016 Tr# 253422 RALPH J. BURKE ROOFING Ralph Burke 27 Byron St / Wakefield, MA 01880 = .Y 4 _ -'r Update Address and return card.Mark reason for change. SCA 1 t, 2CM-05r11 -- ❑ Address ❑ Renewal n Employment ❑ Lost Card � �l�C (l�dl)rI/e PlMpe2lU.G/�G�/JJ[FUI.ft C�J Office of Consumer Affairs&Business Regulation License or registration valid for individul use only — OME IMPROVEMENT CONTRACTOR before the expiration date. If found return to: C egistration 107146 Type: Office of Consumer Affairs and Business Regulation ` `--- Expiration 712912Q18; DBA 10 Park Plaza-Suite 5170 Boston,MA 02116 RALPH J. BURKE ROOFING Ralph Burke 27 Byron St Wakefield,MA 01880 -" Undersecretary / of valid without signature Rcec es 3uifcinc ieswa is s c a siaFd�.= Cnnsruetinn Ssperrk w Sprd:d arw:�SSL fl998?B DBACUT&fA