78 VALLEY ST - BUILDING INSPECTION (3) 1 '
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
m OF :M Massachusetts State Building Code, 780 CMR, 7 edition
^ l Revised dJai Junnury
Building Permit Application To Construct, Repair, Renovate Or Demolish a 1, 'oox
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: Date Applied: 0' 26-
'
X Signature: ✓/r 27 /U
= t=
Building CImm—ilsionerl Inspector of Buildings Date
SECTION 1: SITE INFORMATION
1.1 Pro Mre s y, y 1.2 Assessors Map& Parcel Numbers
L l 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 11) Frontage(It)
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 es❑ p Po y
SECTION 2: PROPERTY OWNERSHIP'
2.1 Ow" ' fo ecord
Name(Prim 4- Address for Service:
S
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ Other ❑ Specify:
Brief Description of Proposed Work':
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S I. Building Permit Fee:S Indicate how fee is determined:
❑Standard City/Town Application Fee
2. Electrical S ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 2. Other Fees: S 41d
4. Mechanical (IIVAC) S List:
5. Mechanical (Fire S Total All Fees: S
Suppression)
Check No. Check Amount: Cash Amount:
6.Total Project Cost: S 0 Paid in Full ❑Outstanding Balance Due:
SECTION 5: CONSTRUCTION SERVICES
5.1 L`icens�e/ds onstructloon`Supervisor
,(CSL)
AJJ /�i �GG`.K��,,`i• +•t'�+ �K.OIIFF�r� AMM�nrvOnly
e d 18
u2 F
taom Is3i5l p,0irU0a0wti oCen.l ul�i.W nF tt
.ee
Nam o' 'SI - Ifolder ee below)
Description
ri--Restrict
5ignalu-wip,(
i y
l�`1 RC Residential Roaring Covering
Telephone WS Residential Window and Siding
SF IResidential Solid Fuel BurningAppliance Installation
D I Residential Demolition
5.2 Regislered o e prise q -�pntfactor(HIC)
AAXkI IIC Company Name or HI Regisl rat N me Registration N tuber
Address �E ! C.{
Expiration ate
Signature Telephone
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.a 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...........O
SECTION 7a:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1, � G U W.L — as Owner of the subject property hereby
authorized c-s..l t, tl`ntS'� 'I�^� to act on my behalf,in all matters
relative to work authorized
utthorized bythis building permit application.
Q�wu
SignatureO � Date
SE TION b:O ERt OR AUTHORIZED AGENT DECLARATION
WWU�1, ,as Owner or Authorized Agent hereby declare
that the statements and in oration on the lbregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
i 2 V
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of 'u
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 W have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I IO.R6 and I IO.RS,respectively.
2. When substantial work is planned,provide the information below:
Total floors 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
Type of cooling system Enclosed Open
3. "Total Project Square Footage"maybe substituted for"Total Project Cost"
CITY OF S.U.&M. tiLuS.kCHL;SEM
BL•arlagG DEP.cvn=iT
120 W. MINGTON STUNT, !'a FLOOR
n►s. (978) 74s.9599
KI.NWEA"V DRMOLL TF1obtAgST.PQRIts
MAYOR DIRacroR OF R SLIC PWPERTY/KaDLVG CO.%IIOSSlCL%ER
Workers' Compensallorl Insurance AMdavit: Builders/Contractors/ElectrlelanslPfvmbera
at Ilca Inform Inforl"Adom
Name ltiv,m.+PPr.a�r/pnuanenlrobvmuii: -
Address- 43CL
cilyistalazip: _ Phow
Are Yee a eespMyerT Ckeek the sppr+pelaq beer Type of prefect(regralredTK
I.(] 1 am I mpioyw with 4. Q 1 we a pnaai contractor and l K ❑Now eonstructios
employs"(fwl and/or paR-liar).• have hired Law at►cenrumn
1.❑ 1 am a role prspeietQ mr Penner
listed rhoasaehod,heet = y ❑Remodeling
*hip and have no empbyees Then w►earresataaes have e Q petmlities
working far me in any capacity. worker'eomp6 inwsasma 9. Q Building addidoa
1 No workers•comp6 insurance f. ® We are a corporation oral is
rcquiradl
otllcas hew etawdwd their IO.Q Electrical repair or oddirione
5.Q 1 am a homeowner doing ad work
rilih►o/aaerrtpia►Per Mom. 1 I.❑Plumbing repairs or addkbna
myself.(Ns workers'camp. c. 13%/1(4).and we haw no 12.Q Raef repairs
insurance required(► `mployeas lNe worms' 1).Q Odra
camp.insurance regaiM&I
-Any srpaOM AN aneaa sea el ester alas M un tti rwrts teYw rawiq**who'o w"Pom eta pwky joinno sea
'I Lwtwtwttw wag nthwa srY detYair ind etba taq M dtiy to M*Md"hfr warn aaranee was gall"a now,dff*Vb idierilS I k
Y•.arwttw ttr.awr tw 6.nrotr aMwt.,a+a srate...t.i.at.►.wtaa tlr race of tee w►learerwe goer%teak wwawe•e�tiy.rr4s i.tV.td�
/aw ow swpfeye►rAr tr presf/Lsa wwAers'eoesprresedrs/wseraarsJir q earpAtryeea solar tr tAepeM►y aw//Ie1 s(Ar
;n/arnrrrdow t �C
In,uran ce Company Name V 0 1 1, l� `
Policy r or Salf ins. Lim.At C9a — Expiration DaN: ILI G6
Job Sire Adtkcsc Cityislawz*-
.%time&a copy of eke worker'compowadew Polley deelvatMs pop(showing the po1My soaker and explraMan daft)6
Failure to%acute covorap in nquiewd under Sectice MA of MQL a. 152 can lead to the impooklom of criminal ponaldes of
fine up to S 1.500.00 and/or one-year imprisonnwnL as well era civil penalties is Use Corr of a STOP WORK ORDER and a fins
Of up to S350.00 a day itlainst the violator. IM advined thus culty of this srstamem maybe ru►wurdad to rho 0117ce of
I nvc.ugatiotu d'the MA for insurance cowrogs Ywitleativa
f Je hereby err tAe pries h e Am*rAv inAdrarsdw provilerf ueshw;r'true ew a/w`reK
Dare "(/ Xkir1�
O/Jl'aArI vie doly6 ne nor brim im this r/eq ra!a vimpkid iy airy or rmtvn q/leiaf 1
City or rw,n: eermicilAcemal__.
laueng.tuthortty (circle nne):
I. Ituard of Itrallls 1. Rtulding Mparttnenr 1. City/rows Clerk 1. Electrical Impactor S. Plumbing Impecror
6. Of her
l•,MAU rcnon: _ . _ .. Phone a;
1 �i:ass:ichux'aa` - th.I)m tntcnt of p
Bu ublic `;a rd of Buildin, Nc,tdation.a ; arch
tud souuLtrtls
Construction Su
pervisor License
License: CS 65206
Restricted to: 00
NICHOLAS A MANLEY a a
17 WORCESTER RD '.
PEABODY, MA 01906
a .. i; Expiration: 3/2412011
..nn.•r
._""_.----- ._---- 7r#: 12627
i e 1°oom�seomwea� o�✓�aaoac✓uee!!a p�
Ofpee of Consumer Affairs&Business Regulation j
HOME IMPROVEMENT CONTRACTOR s
Registration �'142467 Type:
1 Expiration 4&2012 DBA 1
M _ 3
MANLEY CONSTR4CTON = r�
NICHOLAS
17 WORCESTER
r�
PEABODY, MA 01960"a-_,,•'y.e' Undersecretary
i
---------------
,S CITY OF SALEM
I PUBLIC PROPRERTY
" i DEPARTMENT
I'Jp xl f 1 "xlr 'I I -
\I .,. x 11C�1'.1d M.,,Iv)I xlL'T •5.11 1
111 4 1..
II
I'rl:'1./-.'14'14/! •1'\!t:`J71•'�a'!1M
Construction Debris Disposal Affidavit
(rtryuired lur all demolition and renovation work)
in accordance with the sixth edition of the State building Cade, 780 CMR section It I.s
Debris, and the provisions of MGL c 40, S 54;p . _ is issued with the condition that the debris resulting from
building Permit
rl 4cens�d was
disposal facility as derined by MGL e
this work shall be disposed of In a property
S 150A.
The debris will be transported by:
tname of 4haur)
The debris will be disposed of in
VV`��
puur,e ul aci ,ty
N � tk IN
I;nitlroa ul'larll,lYl
.1lnatureollxrmit.�pplic
.� 6
date
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