21 VICTORY RD - BUILDING INSPECTION (2) t
The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY OF
ALEM
Massachusetts State Building Code, 780 CIN SdMar
Revised Mar 2011
Building Permit Application To Construct, Repair, Renovate Or Demolish a
One-or Two-Family Divelling
This Section.For'Official Use Only.
Building Permit Number; D A d>
Building Official(Print time) .. C Si at Date -
SECTION 1:SITE IXFAWNIATIOR
1.1 Property Address: 1.2 Assessors Map& Parcel Numbers
1.I a Is this an accepted st eetf ? 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 OWNERSHIPL' `.
2.1 jWn r o Record: 5A/-af t,L C
> /o
r`lame( nn City,State,ZIP
a l j C' I' 6 2�
No. and Street Telephone - Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK='(cbeck all that apply)
New Construction Cl Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ Alteration(s) ❑ 1 Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify:
ief Description of Proposed Work: / H
to OU4 IN L) LA
SECTION 4: ESTEVLaTED CONSTRUCTION COSTS
Estimated Costs:
Item . Official Use Only,.,
Labor and Nfaterials1.
1. Building S , Building Permit Fee: S rndicdte how fee is determined:
❑Standard.City/Town Application Fee
2. Electrical S .� 1— C,
'total Project Cost (Item 6)x multiplier x
3. PlumbingOther Fees: S
I \dechanical (IIVAC) S ist:
i. Mcchanical (Fire $ otal :\ll Fees: .5Snp:ression) heck No. _Clieck Amount: Cash A[nOLLRII
G. I'utal Project r..1 $ ❑ Paid in Fill[ ❑ Outstanding 13:dance Duo:.- ____--
SECTIONS: CONSTRUCTION SERVICES
5.1 Coatsh-uction Supervis iceose (CSL)
f/ . /�� U L D _- License Number B.ep anon ute
; um of CSL [older
/ ,� - _ List CSL Type(see below)
tNCLo'ld St/reef of /�� �- MIS2
DescjD
�� ,i e A tr ^ r� cted Dui,mito
ca [t.0 l /tom p( d d 13t2 Fami
GrylCown, State, ZIP T Covc"u"and Sidin g
I n el Burning Appliances
�2 �1 PP'`��JDy CL �(��D tf�{(s��� [ Insulation
'de hone Email addr2Ts— D Demolition
5.3,41egistered
MHome Impr ment Contractor(MC)
[[IC Registration Number .rpir ion Uate
I IIC Compa ame or I-IIC Regitrant
No. . Sifn
61>,t a v � � ( Email address
Ci /Town, State,ZIP a /'Tele hone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L. c. 1.52. § 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 4 �x ezo
to act on y behalf, in all matters relative to work authorized by this building permit application.
r 1 .�,ci �,/ Z-1D>
Print wner s Name(Electronic Signature) Date
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 applicatio s true and accurate to the best of my knowledge and understanding.
I'r ;�wner's or Authorized Agent's Name(Electronic Signature) Mae
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
progrtun or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program can be found at
wWw.musSAIuv/oca Information on the Construction Supervisor License can be found at ww w.mass.eo�;'dL
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. d.) _ Flabitable room Count
Number oftircplaeas_. -- Numberofbedrooms --------- --
Vumberofbathrooms Ntlmberofhalbbaths
Iwpe of heating system ..--- — Number of decks/purchcs
---- ---- ----------
1'ype of cooling sv�lent Enclosed-- Open _
S. "I'octl PnycCt Square Fuota"'e" may he substitutM Lu ProjectCo,a"
CITY OF S:1LEM, 1rL-1SSikCHUSE-nS
BUILDING DEPARTMENT
120 W.1SHLIIGTON STREET, Yo FLOOR
�^• T EL (978) 745-9595
F.Aa((978) 740-9844
KI.%IBERI.EY DRISCOLL
T
MAYOR Honus ST.PtiraRa
DIRECTOR OF PUBLIC PROPERTY/13UMDINIG COSNISSIONER
Workers' Compensation insurance Aliidavit: Builders/Contractors/Electrlcians/Plumbers
A v slleant information
Plea
se Pr�int Le
Name tutoioess,Organizatic Individual): aleru Co
Address: , _� p
City/State/Zip: /L/Lt/_ �O PhoneN:Are yo employer?Check the appropriate best Type of project(required).
I. I am a employer with Z--' d. ❑ 1 am a general contractor and 1
employees(full and/or part-time)."' have hired the sub-contractors 6' ❑New construction
2.❑ I am a sole proprietor or partner listed on the attached sheet t 1 Z ❑Remodeling
ship and have no employees These sub-contractors have it. ❑Demolition
Workingfor me in an capacity. workers'comp.Insurance.
y a5. ❑ We are a corporation and its 9. ❑Building addition
required.)
worker'camp. insurance m10.J]Electrical repairs or additions
reyulreJ.J officers have exercised their
3.❑ I am a homeowner doing all work right of exemption per MGL 11.0 Plumbing repairs or additions
myself.(N'o workers'comp. c. 152,$1(d),and we have no 12.❑Roof repairs
insurance required.) It employees.LNo workers' 13.0 Other
comp.insurance required.)
•Any appllcanl tlul checks box 11 must also all out Ihv=am bdowahowing their svokan'componndun pulley intutmollon.
'I r,vnuuwncm who tuhmit We amdavit indlcaing they an doing all wit then him outside coalractox must submit a now oltldavil indtcadng rush.
:Cmtmcton that check this box most aoachod an addidun d vhast showing the nano of the mb.,contrrcton and their woken'mmp.policy infotmadan.
l um an employer that Is prov/ding warkrrs'camprutodan hrsurnnce for my employees Below/a the polley and/oh site
htfarnrutlon. vr1�G UyL S Insurance Company Name:
Policy A or Scif•itu,.hLic. d: Expiration Date:
Job Site Address: L v!/ Cily/State/Zip:
3v_ �4t�,
,\ttach a copy ur the workers'compensatl a policy declaration page(showing the policy number and expiration date).
Failure to sucuru coverage as required under Section 2JA of MGL e. 152 can lead to the imposition of criminal penalties of a
tine up to S1,500.00 untVer one-year imprisonment,as well as civil penalties in the farm of STOP WORK ORDER and a line
of up to S'_30.00 a day against the violator. Ile advired that a copy of this statement may be forwarded to the Oft ice of
Investigwimts of the DIA for'isuranca covcraga verification.
l do here6y e•ertlf nn�er In l a ten Iles of r/ary drat the Infannur/oa provided ubu rrlis�true nd correct
o//[t ray u3e only. Do not write in th/r urery to be campleted by city of lawn o//lclat
CiryarToWn: ._. -_ Pcrmit/T.Icensc# _--` ----__
Issuing,%uthurily (circle one):
I. hoard of health Z.Iluildinq Veparbneut J.Cily/fawn Clerk J. Metrical Inspector 5. Plumbing ltmpector
6.Other
Contact Persnn:.
f; r
r "
r
r
- ^ _ CITY OF S:UZ'Nf, L L-1SSACHUSE-fTS
1 t k SLaZL\G DEPART-M&NT
120 WASNLNGTON STREET, 3" FLOOR
TEL (978) 745-9595
F.LX(978) 740-9846
!CI\[DERL.EY DItISCOLL
i`,L�Yo1l THOSIAs ST.P1ERRa
DI:tECTOR OF Pl:BLjc PROPERTY/8L:MO04G CONW15SIO:i ER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Coda, 780 CMR section l 11.5
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
l 11, S 150A.
The debris will be transported by:
(n n,eurhauler)
The debris will be disposed of in
(name of facility)
(address of Facility)
C
sign amI ur permit applicant
due --
OfOce oCons mer f of irs.4rBu5 �l ��r�QP'mess Regu abed,.
HOME IMPROVEMENT CONTRACTOR '
Registration 4-110484 Type:.
f Expiration: 10/20/1 4 Partnership
C_ OLO REMODEEING --
RICHARD CERU&(%§
51 KIMBALL AVE
F
REVERE, MA-0215
r Undersecretary
iVi tssachusetts- Department of Public S rety
1 Board of Budding Regulations and Standards
Construction Supervisor License
License: cS 28460r,..y++>'" .q-.
RICHARD A CERLIOLO
51 KIMBALL AVE' ary Y
REVERE, MA 02151,
orG_ �y Expiration: 8/26/2013
MORTGAGE INSPECTION
f' BAY STATE SURVEYING ASSOCIATES INC_ JOB# �
100 CUMMIN►,/G�Sit CENTER, SUITE#316J, BEVERLY,MA_, 01915
Saji� I"tA, NOTES:
LOCATION :.....!.............if................2............... t)This is a mortgage inspection survey and not an
I / ,�_1D Instrument survey,therefore this plot plan k for
SCALE : 1"=36 DATE %..1.7............................. mo e' on purposes only.k is No7 to
used to h boundaries or for the,
REFERENCE :BK,Z-36$8 P6-344 consWction of an of improvements.
�y� �'�•'••• This survey is based Q survey marks of others.
7.r�c.I . ...s�...:..!.. . 4�4�..c...C.i�.U...... i)bushes,shrubs,fences=nd tree lines do not
. ?„�J„ y.Q ... .,�!,$.. I necessarily indicate property_lines.
Whenever an offset is 1'+. less,an instrur�"em
T0;.•['i f}�K ITl n)GH_ survey is recommended to de Tmine pro rly
......._.._.._...._... _...._._.
The location of the building(s)as shown,either }ipes and any possible encroa nts
complied with the local zoning setbacks at the time.of Offsets shown are approximate,and are to be
construction or Is exempt from violation enforcement used`o*for the-determination of zoning,Not to
action under Mass.G.L Title VII Chapter 40A Section 7 be used'to establish property lines.
6)In my professional opinion the building(s)are not
located in the special flood hazard zone,as
defined by/H.0.D-MAP#
x
o •
1 !� 00 3�
woo0
7A
7oEz6 �\
IF THE SURVEYOR'S SEAL LS NOT
_ EMBOSSED.THE PLAN IS A COPY
. THAT SHOULD BE ASSUMED TO'.
/ Q CONTAIN UNAUTHORIZED ALTERATIONS.
THIS DOCUMENT
OC nEATSH SHALL
NOT P ON
THIS ER MENTSN CO TAINED N
/ \V -- __. _ _ To COPIES...-- - - --
l,I a�ws� .=n. - w...�,roam:�.a��ru wuv.no,a arn,o,n�uw.r arty vonru„nrre.rowmca
upon co wH =mdZ&a fineand irMM19onm FM detests see: Title/8 U.S.Code Se M IWI and Sef M to10. _