61 VALLEY ST - BUILDING INSPECTION I - - --- 1'he C'onunonwealth of Massachusetts
Board of Building Regulations and Standards CI'I'1'OF
st 'd, Massachusetts State Building Code, 730 CNfR SALEM
Building Permit Application 'ro Construct. Repair. Renovate Or Denwiish a
One-or Two-Fa n IV Dn rllitrq
This Section For Official Use Onl
Building Permit Number: Date,\ pled: _
Building Otcial(Print N:unc) 2 — `� -
SigFtGrc But
SECTION I:SITE fNFORNIATION
I.I Property Address:�l VALLEYT 1.2 Assessors NIgp di Parcel Numbers
_
I.la Is this an acce ted slreet7 'es no Map Number Parcel Number
1.3 Zoning Information: 1.4 Property Dimensions:
Zoning District Proposed(Jse Lot Area(sit It) Frontage(It)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.I.c. 40.§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ zone: ._ Outside Flood-Zeno?
Check fifes❑ Municipal❑ On site disposal system ❑
SECTION2: PROPERTY OWNERSHIP,
2.1 Owner'of Record:
VA 1!=CNICO FELI KS _ 5�9cEM /�lg p/q7�
Nwne(Pnnl) City.Store.Z.IP
�� VhL�eY St. 479-97�-ti534
Nu.and Street Telephone Email Address
SECTION J: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building Owner•Occupied Repairs(s) Alteration(s) Addition ❑
Demolition ❑ Accessory Bldg.❑ Number of Units Other ❑ Specify:
Brief Description of Proposed Work':_ LTl ALE ,2DoM REAIo T lD
E941nl/U Ci�¢aLe�"'ioe�3 Are,) 6U.er P.e'7.4r'CD nN C fLl/U&S
n1Efj D001ZS (1Wttrzr,�o I /U cJ TR)(rn ,ao,4K I fic019RlAJi2 gCPlfifj l
SECTION 4: ESTIMATED CONSTRUCTION COSTS
licm Estimated Costs:
ILabor and Materials) Official Use Only
I. Building f 'Z) 90Q DO I. Building Permit Fee: f Indicate how fee is determined:
2. Electrical f 2 i 900 00 ❑Standard CiryrTown Application Fee
❑Total Project Cost'l Item 6)x multiplier _.._ x
_. Other Fees: f
I J. M"111utical III\.\(') 5 N//4 List: ------ --_- — . .
+. .\Iechanie;tl (Fire� rt tiuiues+ion) f /V//y" rotal ,\ii Fees:
f
Check No. ec Antowrt: uh \nwune n. Total Project Case 'S I�/f7EXZ,dJ -. --('hk ---.-
C,
0 Paid in Full 11 Du151311ding Ilal:lnce Doc:
�V
F ;
SECTION 5: CONS'I-RUCTION SERVICES
i.l C'onsfructio SUSuper isorl.iccase(C'SLI �(Z
M — --
1't I C� � I Innxe Nunlhcr Pspir;tuou D;ue
N;mleof('SI. Ilnlder Iist('St. kPClsevbeloo).__._ l'(' —
uS0_ -------J1 ---------- 'I)pe Descriplion
No aid Srccl ------- - 11 t Inresricied(Ilui Win as up to 15.000 01 It.l
N m i L To.�l _-_I—R -���Z R Realrined 1,017,unill Mwilillig
('ils i fow n.State./I P %, hfusun
RC Rooting COvOi❑
AS Windoo';md Sidin
�Jf -� '.I� Ra '• SF Solid Fuel Iluming Appliances
�X(.l )�11(�lt�(,�IhaYl�. I Insulation
D Demolition
fdc hone I`muil address
4.2 Registered flume Improvement Contractor(HIC) i 6rop8' 6 40)Z
' ONAWA CHAL, 52YD(, w5kl IIIC'Registration NuntMr IisproliunVale
I IIC'Compwly N;unc or I IIC Itegutrunt Name �7td�� �Sf ` YmC .,�0��,(D
L,F o AGG3U6iY c� Ili Wow
No.and Sueet L'mull address
s�+c� m� o�9�0 7�L9�_i-ZGlb
Ci /Town.Stale,ZIP tale hone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L c. I52.1 2SC(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 ... .....O No...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1,as Owner of the subject property,hereby authorize FC L I KS ✓A/[rn1{�O
to act on my behalf,in all matters relative to work authorized by this building permit application.
1 EL(KS V��rc��uk0 _03/oqj Zoe
Dale
Print Qwner's Nwne IEkctrunic Slgnulurc)
SECTION 7b:OWNERI 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.
,ryry�
Prior thncr'sar:\whorireJ,\ge sN;une(11ecronicSignmurc) ale
NOTES:
I. ,\n Owner who obtains a building permit to do his her own work,or an owner who hires an unregistered contractor
(not registered in the Hums Intproventent Contractor(HIC) Program),will n t have access to the arbitration
Program or guaranty fund undcr M.G.L.c. 112A,Other important information on the HIC Program can be found at
.,+.I Information on the Construction Supervisor License can be found at++1+++ of+ >:" dil,
�. \%'hen substantial work is planned,provide the information below:
total flour area(sq. tl.) (including garage. finished basement attics,daks or porch I
Habitable room count
Orocs living area uq. tl.l _._. _... . ._
\umber of fireplaces ... _ _ Number of hedruoms _
\unlher of hathrooms Number of lialf hail's
I)pc of healing system \unlher ofdccks, porches
- 1?11closcd Open
i
I 1 lie of cooling S\Stein '
1. "fatal Project Square Foolagc-nut) he subsultuvi li+r"fo(al Project Cost"
C TY OF SM.E.N[, ,NLISSACHUSETTS
i OL'ILD L\G DEP.S RTNIE.\T
120 %VASHLNGTON STREET lw FLOOR
�. TEL (978) 745-9595
F.ke(978) 710.9844
'.CI.%(DERL.EY DRISCOLL
NUYO.q THows ST.PiERRB
DIRECTOR GF PUBLIC PROPERTY/13U[LDiNG COSl31ISSIONER
Workers' Compensation insurance AflTdavit: Builders/Contractors/Electricians/Plumbers
Applicant InfnrmrHnn r�yn Please Print Leoihly
V:Ilndlnueitxs,Urganualiomindividuai): _ /'JtGl�ll/lL 52Y� ��Sk/
Address: 4 456il4y' Sf
CilpStal:OZip: A-EM m4 0/970 Phone a: W ?2 —Zti/h
,ire you An employer?Check the appropriate box: [9.
ype of pr71,
red):
I.0 1 am a employer wish 4. ❑ 1 am a general contractor and 1 ❑Newn
employees(full and/or part-lime).• have hired the sub-contractors 2. I un a sole proprietor or puancr. listed on the attached shdaL t , Rem
.,hip and have no employees . These subcontractors have V. 0 Dem
working li>r me in any capacity. workers'comp.insurance,
❑Duil(No warken:comp,inwrance 5• ❑ We are a corporation and ivrequited.) 'officm have dxercised their 0.0 Elecp or additions
7. 1 am a homeowner doing all work right of exemption per MGL 1 I CI Plumbing repairs or Additions
myself.(No workers'cump, c. 152. )1(d),and we have no 12.0 Roof repairs
insurance required) t employees.(No workers' )},0 Other
comp.insurance mquircJ.)
''any applkeot dwt cheeks boa el must alma all ran rhv wctim bdow.howing their warksa'compsnsstlun puliLy inntrmadom
1 r, avuwmvs who,uhmit this amAnvit indicsting they am doing ail writ and than him outside contmaere Mimi mhmit s now anldavil indiming.uah,
r',�mn,uran that ch,ak this box must AAxM+d an addillurul.had showing rho nwne of the and their warken'camp,policy inrommdoa.
lain an rurpluyo rhur fa providing iverkers'cumprnradun Laurance jar my employers: Below is the pollry and job site
injurnratlam
Insurance(:ontpany Vmne:
Policy 4 or Self-hoof. Lie 4: Expiration Dale:
Job Site Address: CilyistateZip:
Allacb s copy of the workers'compeneatlas pulley declaratlen page(showing the polity number and expinUon data).
F.liluru to seeura cuvdraga as required under Scclion 25A ofMGL c. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 and/or one-yea imprisonmcn4 as wall 23 civil penalties in the form of a STOP WORK ORDER and d lira
of up to M0.00 a day against flit violator. Ile advised that a copy of this atalemcm may be forwarded to ilia Oflica of
11%estigal ions of the DIA for insuranca coverage vcrincatiun.
Ida hereby certify ratdrr the pairs mrd prnal4rr ajperjury than the injannm/wt provldrJ above if true and Correct.
, ,;,.., . i 032012
D;ua:
011h ial rue oily. Oo oar write in tlriv area, to be completed by city ar town rrjj)riui
Ciryor-1•ovin __ , ___ I'crmiUl.lccme.4
luuine,\ulhorily (circle oac): - ----
I. Iluard ul Iluallh '. Iloildlng, Deparlulcnl .1. Cilyifnwn Clerk 1. Electrical f"PcOur 5. Plnnibing Innpdetur
0. Other
i
Goriest I'¢rum: 1'hnnc,h. :
r
� Y
C"'Y OF 5.1 ZNI, Alss.kcFwSETTS
3L'�tL LN(; DEP.IRT1l&VT
I'0 '7""4 `'(;TON SMIrr. Jw FLOOR
rEL (973) 145.9S9S
K13t8ERLBY OUXOLL PVt(973) 7A9344
,b6YO1t Maxw ST•pmus
OtRECTOR OP PC3LlC PROPER7Y/St:MDL,gC CO3p1,Mlo.%ER
Construction Debris Disposal Attldavit
(required for all demolition and renovation work)
In ucordanca with the sixth edition otthe State
Debrisr and the provisions ofMQL a 40, 914; Building Coder 730 CMR section
3s work shall be g permit At
this work is issued with the condition that the debris resulting from
disposed of in a ro ert licensed waste dis
11 I, $ IJOA. P P Y osel facili p
ry as deRncd by,yQL e
The debris will be transported by:
LOK1 Rio g71�C
'pit/
(name ut hauler)
The debris will be disposed Orin :
�m�o�_s� o
SNFt�1coT AC/
t=sss ar r,,,l„y)
+ynamre'r;"mit pphunt
/Z