42 VALLEY ST - BUILDING INSPECTION The Commonwealth of Massachusetts CITY OF
Board of Building Regulations and Standards SALEM
Massachusetts State Building Code, 780 CMR Revised Mar 20 '
�V Building Permit Application To Construct, Repair, Renovate Or Dem a
One- or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number , ,Date AP
q }+
But ding Official ate,
not Name):
`Si nature -
SECTION 1 SITE INFORMATION -
.1 1.2 Assessors Map& Parcel Numbers III
/ 1 Map Number Parcel Number
1.1 a Is this an accepted street? yes_ no_
1.4 Property Dimensions:
1.3 Zoning Information:
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:
Zone: _ Outside Flood Zone? Municipal❑ On site disposal system ❑
Public❑ Private❑ Check if yes❑
SECTION 2' PROPERTY'OWNERSHIPt
21 �nejrofReco
Narrke rent) City,State,ZIP
475- 7V6W 5714
No.and Street Telephone Email Address
SECTION 3:.DESCRIPTION OF PROPOSED WORK '(check all that apply) -
New Construction❑ Existing Building Owner-Occupied Repans(s) ❑ Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bid . ❑ Number of Units_ Other ❑ Specify:
Brief Description of Proposed Wo
SECTION 4: ESTIMATED"CONSTRUCTION.COSTS
Estimated Costs: Official.Use Only-;
Item Labor and Materials
1. Building $ 1 Building Permit Fee $ Indicate;how fee is determin d:,
❑ Standad City(Town Application Fee
2. Electrical $ ❑Total Pio3ect Cosf'(Item 6) mulhpher x' .
3. Plumbing $ 2 Othe`c.Fee
s: $
4. Mechanical (I-NAC) $ L st
5. Ndechanical (Fire $ Total All Fees,' S
Suppression)
!!`` Check No Check Amount. Cash Amount'.
G. Total Project Cost: $ L)0.UV ❑paid in.Full ❑Outstanding Balance Dhe:
�'l/l 14„ -To 4s,t,iC 0w L t Z4
SECTION 5: CONSTRUCTION SERVICES
r,,1,C.0SrU,
Construction Supervi�sy/oarLicense(CSL) /' L !(((��j
LLicenseNumber Expiration Datef L(-Iolder
3 List CSL Type(see below)
. teeeye J Type `. .Description
Unrestricted Family
s u g
�[vi✓ V O Restricted I&2 Fnmil Dwelellinin
City IT atate,ZIP ivl blasonr
RC Roofm Coverin
WS Window and Siding
C�j/pj/ yam' /p SF Solid Fuel Burning Appliances
Insulation
Tele hone Email address D Demolition
5.2 Registered Horne Improvement Contractor(HIC)07
--<-I �— HIC Registration Number Expiration Da
HI o p y�]Vame orHIC Re rant Name
Email address
Ci /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
to act on my behalf, in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Dale
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 tru n ac orateurate to the knowledge and understanding.
Print Owner's or Authorized A�;�,,it' Nuiiie(Electronic Sigimture) Date
NOTES:
I. 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. t42A. Other important information on the HIC Program can be found at
www.ntuss.goy/oca Information on the Construction Supervisor License can be found at w%"v.rnass.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
rype of cooling system Enclosed Open
3. Total Project Square Footage" may be substituted for"Total Project Cost" -
i! CITY OF S.U.E. 1, . LxsSACHLSETTS
BumniNG DEP iRTNIFNT
i p, 120 WASHINGTON STREET, 31D FLOOR
TEL. (978) 745-9595
FAx(979)740-9846
KIN fgFRt EY DRISCOLL
MAYOR T1 iOhtAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDIING C0\11MISSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electriefans/Plumbers
A i licant Information Please Print Legibly
Ven1C(Business, rganizatioNlndividual):
Address: QQ Bid u / Sol ¢ Q
City/Stateizip: Phone #:_
A e on an employer?Check the appropriate box: 'type of project(required):
1.5cm a employer with_ — 4• ElI am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet.t 7. ❑Remodeling
ship and have no employees These sub-contractors have 9. ❑ Demolition
working for me in any capacity. workers'comp.insurance. 9, [:] Building addition
(No workers*comp.insurance 5. ❑ We are a corporation and its
required.]
officers have exercised their ME]Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I L❑ Plumbing repairs or additions
myself. [No workers'comp. C. 152,§](4),and we have no 12.❑ Roof repairs
insurance required.)t employees.[No workers' 13.❑Other
comp. insurance required.)
Any applicar nut checks box#I mast alw fill out the section below showing their workras'compensation policy information.
t I hunuowrcra who submit this atfldavit indicating they am doing all work and then hire outside contractorsmust ,limit a new affidavit indicating such.
=Cammutors ihas check this box most aeached an additional sheer showing the name of the sub conutu tom and(heir worker'comp.policy infomution,
l um an employer that if providing worke s'c ompensation insurance for my employees. Below is the policy and Job site
Insurance Company Name: ��//�� �J
Policy 4 or Scif-ins. Lie. 0: ✓" G 9 3 6XI Expiration Date: 7 d
Job Site Address: q9- City/State/zip:
,lttacb a copy of the workers'com nsatiou policy declaration page(showing the policy number and expiration date).
Failure to secure coverage as required under Section 25A of MOL c. 152-can lead to the imposition of criminal penalties of a
tine up to S 1,500.00 and/or one-year imprisonmen4 as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to$230.00 a day against The violator. list advised that a copy of this statement may be rorwarded to the Office of
investigations orthe DIA for insurance coverage verification.
l do hereby certify it sallies of per fury that the information provided above is true asset correct.
S cri3illre,
/
Po �: /`J(! lO J•�7 .
Oflicfrd use only. Do not write in this area,to be completed by city or town official
cityor'ruwn: Permit/i.fcense#
Issuing Authority(circle one):
1. Board of Ilcullh 2.Building Department 3.Citytrown Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.01 her,—
Contact Person: _ Phone 0.
CITY OF SM.F-M, i�,LxsSACHLSETrs
• BuiLDNG DEPARTNIENT
!+ 130 WASHINGTON STREET, 3° FLOOR
TEL (978) 745-9595
FAx(978) 740-9846
KIA{gFRi FY DRISCOLL
�LAYOR THo%tAs ST.PIERRE
DIRECTOR OF PUBLIC PROPERTY/BCILDNG COSL\IISSIONER
Construction Debris Disposal Affidavit,
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit # is issued with the condition that the debris resulting from
this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
t4�
(name 09
auler)
The debris will be disposed of in :
Y!7—
(name facility)
(address of facility)
signam a of permit applicant
date
.kbtisa0:d<x
Page No. + of Pages r,•.
E O=
LEBLAIdC AND SON
xy "
k A. P.O. BOX 5389 q pp
BRADFORD, MA 01835 1 O 2 5 v
(978) 556-9440 (978) 869-6575 CELL
Lic:,#CS090414 Reg. 0135829
wwwJeblancandson.com
PROPO US 'EYED TO P OONE / DATE
STREET- p ,T a. JOB NAME + . •°CITY,'STASE2ntl ZIPC DE � _+ A,.yr /�`✓V y JOB LOCATION P t,
a
.ARCHITE17 ,' ',* '+' ", DATE OF PLANS > JOB PHONE• - ' - '
. I
We hereby submit specifications and estinlates for:
7,
-Propose hereby to furnish aterlal an olabor—complet in accordance with above specifications, for the sum of:
� �'�'r ary($den
Pa ment to be made asfollows: �• ' L -^ r///r. i
All material is guaranteed to be s specified. All work to be compleed in a workmanlike /
manner according to standard practices. Any alteration or deviation fro above specifications Authorized
involving extra costs will be executed only upon written orders, will become an extra Signature
charge over and above the estimate. All agreements contingent upon strikes, accidents or //Vote
delays beyond our control. Owner to carry fire, tomado and other necessary insurance. Our / /rv�re:This pfOposal may b2
workers are fully covered by Workman's Compensation Insurance. withdfaWn by 711
accepted within days.
/�Acceptance of f roposal —The above prices,specifications \
and conditions are satisfactory and are hereby accepted.You are authorized to do the Signat �'"��/A—Q.
_work as specified.Payment will be made as outlined above.
1"t
Date of Acceptance: — y` � Signature
y
Office of Consumer Affairs&Busidess Regulation
,10ME IMPROVEMENT CONTRACTOR
gistration 135829 Type:
eF'expiration: 5/14/2014_ Individual
LARRY LEBLANC l
1
LARRY LEBLANC
33 MEDITATION LANE
y ATKINSON, MA 03811 - �-
1t Undersecretary
a�ment of Public Safety
Regulations and Standards
Massachusetts t)ee
.F Board of Building i,it
Sunn , . 4 ..
Cun muse C3 090414 '
f_icense: frti nr qr
" C
LARRY LEB
PO X 5389� U1835
BRA�FORDj� _
0 fCti m tssioner