20 VERDON ST - BUILDING INSPECTION LJ - Ib� 7 Eby 2l (�
ra The Commonwealth of Massachusetts ( pE.CT ZED
SERVICES,Board of Building Regulations and Standards
Massachusetts State Building Code, 780 CMR SALE'M
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p�
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Building Permit Application To Construct, Repair, Renovate Or Dern i11�h1 emo�ls a1
One-or Two-Family Dwellitkq
This Section For Official Use Only
Building Permit Number: Date Applied:
ig
Building Official(Print Name) Signalure D.to
SECTION 1:SITE INFORMATION
L1 Property Address: L2 Assessors Map &r Parcel Numbers
7C 1/erdo/1 - 0
I.1a Is this an accepted street?yes no Map Number P;accl Number
1.3 Zoning Information:_ _ — IA Property Dimensions:
Zoning District Pr—opossed Use — Lot Area(sit It) Frontage(11)
1.3 Building Setbacks(ft)
Front Yard Side Y,vds Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply: (M.G.I.,c.410,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public Private❑ Zone: _ Outside Flood,Z me'?
Check if yes`x Municip-111KOn site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.t wner of Record:
coy . C�eoC enie.� cj f}C�AI ktA Q l�l W
m (
-
Na e(Print) Gly,Stale,ZI I'
c'b
No.and Street 'telephone 1-mail Address
SECTION 3: DESCRIPTION OF PROPOSED WORK(check all that apply)
New Construction ❑ Existing Building Owner-Occupied Jii( I Repairs(s) ❑ I Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other ❑ Specily:_
Brief Description of Proposed Work-:_
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs:
Labor and Materials) Official Use Only
I. Building $ I. 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 S 2. Other Fees: S
d. Mechanical (IIVAC) $ List:
5. iNlech:mical (FireSuppression) Total All Fees:S_
eta Check No. Check Amount Cash Amount
6. Total Project Cost: 7S�o 000. ❑ Paid in Full ❑Outstanding Balance Due: ..
M ski L Tv :!�cw-vaAc-Tz;,rZ
iANI.Ep LoItq k
1'
S ` I
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction upervisor License(CSL)
// c5 - 074130 ��14 - z.al�
�'• r 'e Oil Op License Number Expiration Date
No of CSL H Wer
-�- ( p r I a ti�� C AV�. List CSL'I'ype(see below) _
No.and Street Type Description
�. �t S �I/✓ M d (q �� U Unrestricted(Buildings u to 35,000 cu. f7J
Restricted 1&2 Family Dwelling
City/Down,State,ZIP 1 R M Mason
ry
RC Rooting Covering
WS Windowand Siding
SF Solid Fuel B ming Appliances
79/—Qr 4-�93s CQ �CU�c a r%. 7 en I Insulation
Tel( hone Email address D Demolition
5.2 RegisteredH me improvement Contractor(HIC)
Av✓Sar� l(n3Sab 7-a-aol
—1�1--T?�t I-IIC Registration Number Expiration Date
HIC Company Name or HIC Rc�istnmt Name
(�s--mil a -7t.c— � c �o.ti -t
No,at rSt ect —� Email address
�� Cit / own,Stat ,ZI 'fete hone
/ 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
1,as Owner of the subject property, hereby authorize tv � -e r eA—
to act on my behalf, in all matters relative to work authorized by this building permit application.
(o- I1, -- 20
Print Owner's Name(Electronic Signature) Date
SECTION 7b:OWNERS 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.
K£y� rP yt�Pr/SGY� _lO— lB-24 4
Print Owner's or Authorized Agents Name(Electronic Signature) Dave
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. 142A. Other important information on the HIC Program can be found at
www.mass.gov/ocu Information on the Construction Supervisor License can be found at www.mass.aov/dps
2. When substantial work is planned, provide the information below:
Total floor area(sq. It.) (including garage, finished basement/attics,(leeks or porch)
Gross living area(sq. 11.) Habitable room count
Number of fireplaces Number of bedrooms _
Number of bathroorns Number of half/baths
Type of heating system Number of(leeks/porches_
Typeofcoolingsystern Fncloscd___ _Open
3. "Fetal Project Square Footage"may be substituted for"Total Project Cost"
. i
as The Commonwealth of Massachusetts
r 1s Board of Building Regulations and Standards CITY OF
Massachusetts State Building Code, 780 CMR SALEM
s.ti. Revised Mar 2011
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:
Building Official(Print Name) Signature Date
SECTION I:SITE INFORMATION
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
I.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 I)) Frontage(It)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
lieyuired Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c. .Ill,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Public❑ Private❑ Zone: _ Outside Flood%one?
Check if yes❑ Municipal ❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Nunn(Print) City,State,ZIP
No.and Street 'telephone Enmil Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ \Iteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:--__
Brief Description of Proposed Work'':
SECTION a: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 1. Building Permit Fee: $ Indicate how fee is determined:
2. Electrical $ ❑Standard Cityfrown Application fee
❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ �. Other Fees: $
4. Mechanical (I IVAC) $ List:
5. Mechanical (Fire
Suppression) $ Total All Fees:
Check No. Check Amount: Cash Amount
6. Total Project Cost $ 0 Paid in Full 11 Outstanding Balance Due:
1 , M V/re Tpwncneanwerr�f,oU�P{OtriralcirlrrJeC/A
-� Office of Consumer Affairs&Business Regulation.
A . �iOME IMPROVEMENT CONTRACTOR
egistratfon 163520 Type:
Expiration: 7/2/ O5& DBA r
CAROL ANNS HOME�IMPROVEMENT
18„
,./'"t KEVIN HENDERSONv.
j 6
61ATLANTICAVE '� �?✓ gam_
SALISBURY,MA 01952 ti-r�
Undersecretary
j
--�-
tV Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Gmstruction Supemisor
License: CS-074130 � s
KEVIN P HENDEYt50N
61 ATLANTIC AVE '
SALISBURY MA'0195
�` Expiration
J 0 211 9120 115
Commissioner
CITY OF SALEM, NLNss.IcHLSETTS
L BUILDING DEPARTMEINT
120 WASHLNGTON STREET, 3ua FLOOR
l` TEI_ (978) 745-9595
Eta(978) 740-98-16
Kl\iBERLEY DRISCOLL
INVLAYOR THows ST.Famarts
DIRECCOR OF PUBLIC PROPERTY/BUR.DING COMMISSIONER
Workers' Compensation insurance Affidavit: Builders/Contractorv/ElectricianVPlumbers
Applicant information p Please Print Leiviblit,
Nill71C(Business Organ ilz�atiom'InJividual): `
Address: (o k Ave �j,�Ii T
Ciiy/State/Zip: S O v0- Phone M: 7P�- -f— 4Y,35--�
Are you an employer?Check the appropriate box: Type of project(required):
I.❑ 1 am a employer with 4. ❑ 1 am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).* have hired the sub-contractors
2. 1 nn a sole proprietor or partner- listed on the attached sheet.t 7• El Remodeling
4lllill"""""" ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
[No workers'camp. insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.❑Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑ Plumbing repuirs or additions
myself. (No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' I3.❑ Other
cuntp. insurance required.)
•Any opplitwl that ehtvkt but 01 must alsu rill out the section below showing their worker'compensation policy inlbnmatiun.
'1 b,meuwtwa who submit this atlrhLwit indicting the ere doing all work and then hire outside contraction;mtul suhmlt anew amdavih indicating such.
:(''mtr to a thul chsek this box rant anachcvl on additional dhnt showing the rattle of ilia rubtontncton and their worker'comp.put icy infornsation,
l ut)r un eorpluyer that is providing'vorkers'conlpen,radon i+rsurunce for my employees. Qdlow Is title policy and fob site
lnforururion.
Insurance Company Name:
Policy A or Self-its. Lie.d: Expiration Date:
Job Site Address: City/State/Zip:
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 23A of MGL c. 152 can lead to the imposition of criminal penalties of a
tine up 10 S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to S250.00 a day against the violator. Ile advised that a copy of this statement may live forwarded to the Office of
Investigations of the DIA for insurance coverage 6crification.
I t/o hereby cer ify m,der t//pubis/and Peoultiex of perjury/hut the infornratlan provided ubuve is•true and correct.
11�•n I re' i/Yr r..tiy r/��- Date:
4.
0J1Aiul rue only. Do'lot'write in rhix area,to be completed by city or town offleful
City or Town: Permit[Licenseq________
issuing Authority (circle one):
1. Bourd of Health Z. Building Deparlutrnt I.Cityirnsvu Clerk 4. Electrical lnspcctor 5. Plumbing Inspector
b. Other
Phone rl:
CITY OF smz f, A-1SS:ICHUSETI'S
130 CV.ISHLNGTON STREET 3'4 FLOOR
T EL (973) 745-9595
KIMBERLcEY Dti scoLL F.UX(978) 7-0-934,S
NLAYO;'t '11NOSL+s ST.P[E.QttS
DtRECTO[t OF PGBL[C PROPER TY/auuOLNc coo nas[oNER
COnStrUctiOn Debris Disposal Aftldayit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 QJR Section I
Debris, and dte provisions of iMGL e 40, S 54;
Building Permit hi is issued with the condition that the debris resulting Prom
this work shall ba disposcd of in a properly
11, S I SOA. licensed waste disposal racility as defincd by N1GL c
The debris will be transported by;
tlt�mc utBaulcr)
The dchris will be disposed of in
('.nldre"of Eicility)
siyn�m rut prrmit.tpp(ir,tn�