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65 VALIANT WAY - BUILDING INSPECTION The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY OF Massachusetts State Building Code,780 CMR SALEM Revised Mar 2011 Building Pennit Application To Construct,Repair,Renovate Or Dentish a One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: Date Applied: t L z Building Official(Print Name) Signature Date SECTION 1: SITE INFORMATION 1.1 Propert�Ad� syr� 1.2 Assessors Map&Parcel Numbers 1.1 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 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' 2.1 Owner'of Record: Name(Print) ) City,State,ZIP r e� Lr¢/fc lily, S -`�/'-J�- No.and Street ' Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Altera[ion(s) ❑ 1 Addition ❑ Demolition ❑ Accessory Bldg.❑ Number of Units I Other ❑ Specify: Brief Description of Prqposed Work': A✓n 7�rt��1H e n-r SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ ® 70 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: $ U ❑Paid in Full ❑Outstanding Balance Due: de /9(' /d1 A / SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supervisor License(CSL) Cir-ll 3 ao `'TA Atj56 �641—/1U License Number Expiration Date Name of CSL Holder / /0 �0y!;E SJ 6// I�f - List CSL Type(see below) No.and Street Type - Description 71 / ) U Unrestricted Buildin s u to 35,000 cu.ft. ✓i7^116 ' /'M �/ R Restricted 1&2 Family Dwelling city/Town,Slat ,ZIP M Masonry RC Roofing Covering WS Window and Siding �p Q� SF Solid Fuel Burning Appliances d6/`� C fJsi if/�CpAlc�`�A/ I Insulation Telephone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) /65, YV �HtU.F.� 3 dT a✓ HIC Registration Number Expiration Date �lC C NWC)aegis mm Name (}KOe�7/u�� � r( a)4iPq>`t IUD and StreetI E-L�, l� A /A, ���y��— /n�n—q���_06 A�^ Email address city/Town,% ,zrp �( 7 lT Telephone Cl 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 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 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. \Q�=X,\—X� lint Owner's or Ailthorized At n '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.gov/oca Information on the Construction Supervisor License can be found at www.mass.eov/dgs 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 beating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"maybe substituted for"Total Project Cost" The CommonweaUh ofMassac#nsef s Department of IndusWaf Accidents office of Investigations 600.WashbWOn Street Boston,MA 02111 www.massgov/dia Workers' Compensation Insurance ple Affidavit: BuilderslContxactors/El asIplumbers g�X±n t Le biv A /leant Informs an Name(ausinesslocganizationnndividnaQ: — Address: \ c2--l lnQi e,v e d \ Phone#: fl City/State/Zip: Z 6 9�1 date box: Type of project(required): Are you an employer?Cheek the alp 4. ❑ 1 am a general contractor and 1 6. 0 New construction i,] I am s employer with --* hBYe hired the sub contractors 7 Remadeling employees(full tmtllo;pert time). listed oa the attached sheet.$ 2.0 I am a sole proprietor ar parater- ,ham sub-contractors have g, FJ Demolition ship and have no employees workers'comp.insurance. 9, []Building addition working for the m any capacity. 5. We are a corporation and ifs ,No worims,comp-insurance officers have exercised their 10.©Biectrical repairs m additions required.] per MGL 11.0 Plumbing reps or additions right of exemption 3.0 1 site a homeowner domg allwork c. I52 §1(4)r,r 7aniE no 12.j]Roof repairsmyself.[No workers'comp. employees.\•'0 13.ta other 1 Yl��r_ t �— insurance retpured.]tnee •Anyapplic dot checi®box�lmoata4ofillastb y mdol batawshowin8ffiekworkers eompeoeationpolicyinrormstion. mdicatin such. IHomeownerswhoaU6&tb®at5davitinacefigtbe1'ands�ngellwotkandthmhiteantsidenonttaaatsndtheirst Odmrs*waffulavit rConaactotattrstchmk tbis boxmastattaehod as odditionet etaxishowingthesame otttmaubeontraonxsand their workers'cam¢pd ry rs' ensadon tnSWWwe Jor my ernpinyw& lletow ors thepoltey and)ob stye i on an eo#C,3 a IhaI is proWdIng worJte comp lnnformrdfan. i `�� C t1\ten - lnsurance company Name: l C7 f lS l'A U 'n �Ci \ L b C_ —_ Policy#or Self-ins.Lie.#:�-- � Expirationr.�.� ✓�1l ,e- CiLy/State/zipx /L+ Job Site Address: date Attach a copy of the workers'compensation polio eeteratloa page(showing the poll ponnmber and criminal Pati°nes of a Ftulmc to secure coverage as required under Section 25A of MGL a 152 Can lead to the of sl on of criminal p . fine up to$1,50i1.0o and/or one-year imprisonment,as wolf as civil penalties in the fma o e STOP WORK�ce f a fine ofup to S250.00 a day against the violator. Be advised that a copy of this statement may be forward Investigations of the DIA.for insurance coverage verification. I do hereby cerdfy under the pains andd peennoUl as ofperjury that the information provided above is•• e and Correa. Date' O ff dol use only. Do not wr1w in this area,to be completed by city Or town oJ]Iclal City or Town: Permit(License# yssuing Authority(eirrle one): I.Board of Health 2.Building Department 3.City/Town Clerk 4.Stectrieal Inspector 5.MITI ng Inspector 6.Other Contact Person Phone#- 91ae -Commo, ci i�7Rko Office of Consumer Affairs andfusiness Regulation 10 Park Plaza- Suite 5170 Boston,Massachusetts 02116 Home Improvement_Cgnfractor Registration = Registration: 165640 Type: LLC _ Expiration: 3/15/2012 Tr~' 294567 54 AIR-TIGHT LLC. WEATHERAZATIQi�i JAMES FORTIN i 10 PINE KNOLL DR. j BEVERLY, MA 01915 Update Address and return card"Mark reason for change. -. r Address L7 Renewal v Employment _i Lost Card DPS"CA] License or registration valid for iodisidul use only VOW�: Office of Caasumer Affairs&Business Regulation before the expiration date.'If found return to: HOME IMPROVEMENT CONTRACTOR Office of Consumer Affairs and Business Regulation o� _ Registration: 16564o 10 Park Plaza-Suite 5170 , Expiration:,_ 5711312 Tr' 294587 Boston;NLA 02116, Type LLC" AIR-TIGHT LLC VPEATHERt+ZATION JAMES FORTIN 10 P1NE KNOLL DR o BEVERLY,MA 01915 _ Undersecretary not valid without signature .1lassachusetts- Department of Public Safet% - Board or Building Re_,ulations and Standards Construction Supervisor License License: CS 52576 JAMES E FORTIN 10 PINEKNOLL DR BEVERLY MA01915 rz �L �y Expiration: 10/312D13 Umnniissioncr Tr;7: 6700 ,s CITY OF SALEM PUBLIC PROPRERTY DEPARTMENT r.I;; MU1 ' Mlr.-II IrQ Q'.\d11M.,,N11'Nkl'T •5.111\I, 1t.\�iN \I .1''14 141:'171.7454i47 1 \:l:'17t•7�S'11Jh Construction Debris Disposal AMdavit (required I"ur all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 11 t.S isions of MGL c 4U, S s4; Debris, and the prov Building Permit H��- is issued with the condition that the debris resulting from this work shall he disposed of in a properly licenxd waste disposal facility as defined by MGL c 111. S 150A. The debris will be trunsportcd by: t name uC hauler) - . The debris will be disposed of in Uy1L(IIAAffm ul aci LLy �2 " I` pldllresa of txllnyl U tnaturc uY Iwrmil applicant Ili � Jate