9 WARREN ST - BUILDING INSPECTION The Commonwealth of Massachusetts Town of
Board of Building Regulations and Standards lonammop,
Massachusetts State Building Code, 780 CMR, T"edition Building Dept
Building Permit Application To Construct, Repair. Renovate Or Demolish a �
One-or rico-Funtth Divelling
is Section For Official Use Only
Building Permit Num c ale A ff
Signature: LI'A /zq/)-//�G,
Building Commissioner/Inspoetor o Buildin Date
S ON :SITE INFORMATION
1.1 Pryp�r� ddress: Q j 1.2 Assessors Map 6 Parcel Number
�I
1.1 a Is this an accepted street?yes no Map Number Parcel Number -
IJ Zoning Information: 1.4 Property Dimensions:
Zoning Distract Proposed Use La Area(sq B) Frontage(B)
1.5 Building Setbacks(R)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
1.6 Water Supply:(M.G.L c. 40,154) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
Zone: _ Outside Flood Zone? Municipal O On site dis aal system O
Public O Private O Check if s0 P pa y
SECTION 2: PROPERTY OWNERSHIP'
2.1 or ofrecord Q� L Q V4
Name(Print) Address far Service: —�
Signature Telephone
SECTION J: DESCRIPTION OF PROPOSED WORK'(cheek all that apply)
New Construction O Existing Building O owner-Occupied O 1 Repairs(s) O 1 Alteration(s) O Addition O
Demolition O 1 Accessory Bldg.O Number of Units_ Other O Specify:
Brief Descrip ion of Proposed Work': r G
Y*tIA 6
2
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building f I. Building Permit Fee: f Indicate how fee is determined:
a Standard City/Town Application Fee
2 Electrical f O Total Project Cost'(Item 6)x multiplier x
J Plumbing f 2. Other Fen:
a. Mechanical 1HVAC) f List:
1 Mechanical (Fire f Tool All Fees. f
Su ression
Check No. _Check Amount: Cash Amount:_
6 Total Project Cost: S 3)(�071 0 Paid in Full 13 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) may3 ;2 v
f71 �D tl h IM SaLG / LJ Li/' /cense N[ummb%r— Es rw o Date
N of fS Hyl R Lid CSL Type(,ce helow)
O
i Description
A rest
U Unrexmcted u to 33,000 Cu. Ft.
R Restricted 1&2 FamilyDwelhn
''t we %fasonry Only
R Res dermal Rooting Covering
Telephone w'S Resdential Window and Sidin
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Registered Home I roremoutC�Ira tor(HIC)
HIC C m y N or' IC Repstrant Name Registration Nu bet
VA
Addressaza—Lzvc- &2 2,—?9'�71,10 Expirsificifi Date
Signs Telephone
SECTION 6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. IS2. 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 Aftdavil Attached? Yes..........Or- No........... O
SECTION 7s:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
1 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.
Signature of Owner Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
l as Owner or Authorized Agent hereby declare
that the statements and information on the foregoing application are true and accurate,to the best of my knowledge and
behalf.
Print Name
Signature of Owner or Authorized Agent Date
(Signed under the pains and penalties of perjury)
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 I HIC)Program),will W have access to the arbitration
program or guaranty fund under M.G.L. c. 142A. Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations I I 0.R6 and I MRS.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 halLDaths
Type ofhoting system Number of deckv porches
Type of coolingsyvlcm Enclosed Open
1 'Total Project Syuare Footage' may he suhstituted for-'Total Project Cost"
CITY OF SMXUNia UiSSACHUSETTS
BUI DLYG DEPARTMENT
120 WASHLNGTON STREET. )aO FLOOR
'FELL (971) 745.959S
F.ui(978) 740-98"
KI%,C3Cpt FY DRISCOLL THO&LOST.PtEtlRti
AYOTt
DIRECTOR OF PC BLIC PROPERTY/gl'ILDLV G CMDBSSION ER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electr(cians/Plumbers
karillczint Information Please PrintLegibly
Name (Busim orpnizatiaminsbvidsul): T1,"
Address: 0 M Ins 1 Jam'
City/State/zip: 1j)aJQ I/,Ile / Q4 0309 Phone a: i zDY 2_3` '9?7(;)
Are you as employer?Check the appropriate box: Type of project(required).•
J.J&Ql am a employer with 4• ❑ I am a general contractor and 1
employees(full and/or part-time).• have hired the subcontractors 7. ❑New Remodecommling
2.El am a sole proprietor or partner- listed on the attached sheet : . Q Remodeling
:hip and have wits employees These sub-contractors have V. ❑ Demolition
working rot the in any capacity. vtorkera'comp.inarrance. 9. Q Building addition
[No workers'comp. insurance S. Q We are a corporation and its IO.Q Elth:trical repair of additions
required.] offlces have exercised then
3.Q 1 am a homeowner doing all work right of exemption per MGL I I.Q Plumbing repairs or additions
myself.(No workers'comp. c. 152.41(4).and we have no 12.0 Roof repairs
insurance required.] t employees. LNo workers'
comp. insurance required.] 1.�Q Other /QQUow ; 'Do
-Any appiicam nor charts Don rl mum also,fill eta she sulion baler theories their wwtkews'ran gonads policy infumndba.
'I aysseoorwsaa who suborn this affidsrk indicating Ibcq am thine all work and show him onside txmtach"~auhmk a now anWnvil isdicowiq suck
t'.xesetWYhea shot chock this Box mutt attached an eel isonal sass slowing err nnee of tot wtb-eeassswn and whale wvrhaa'rang.polity inromtaaow
/am as employer that&providing workers'comperimtba hasaraace for any employees Qrlase is Ills,Polley andm sip
informatiots }��G / 1
h�
Insurance Company Valle: wIL�I I { `�rQ ,
Pal icy N or Self•ins. Lic. N: Expiration Data:
Job Site Address: !y " M-14 City/State/Zip: 9 /P M �rY/
,snack a copy of the workers'compensation policy declaration pap(showing the policy number and exPiratlon daft)`
Failure to secure coverage as required under Section 23A of MGL c. 132 can lead to the imposition of criminal penalties oft
fine up to S 1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
Of up to S230.00 a day against the violator. Ile advi.�l that a copy,of this statement maybe furwurded to the Office of
Invcatigmiuns Orth IA for insurance coverage w:riticatisim '
I to herrby cr lijy at die Las and pentalt/ss of perjury that me information provided above is true and correct
Win•r s r Dole:
a
!�%/!1
O�a•iol sere mile. Do raw rvritt in rhir area, re bs rornpfeted by city or town 0/fc141
I
City or ruwn: _ Permit/l.icense N__.
1%suing Aulhorily Icircle one): - --
I. it
of llrulih 2. RuildlnL Deparlment 3. City/town Clerk 4. Electrical Inspector 5. Plumbing inspector
6. Other
t.uettact Person: _ ._. _.. Phone N•
1 �
°. CITY OF SALEM
!i PUBLIC PROPRERTY
DEPARTMENT
\i ll,qt f rc %Ail ZING IONS I-SLET ♦SAI FNI, 11.Ni:\t I II'il'.1'ii
TGI:9711--74 9i95 ♦ J:AK:97S.74a-'1846
Construction Debris Disposal Affidavit
(re(Iuired 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; -sr
Building Permit It _ is issued with the condition that the debris resulting from
this work shall he disposed of in a properly licensed waste disposal facility as defined by MGL c
111, S 150A.
The debris will be transported by:
(name of hauler)
s
"l'he debris will be disposed of in
14 t L�S�aSc� l
(name of f cl ity) '
(address of facility)
si at re of permit applicant
date
Office of Consumer Affairs&Business Regulation License or registration valid for individul use only
HOME IMPROVEMENT CONTRACTOR before the expiration date. If found return to:
Office of Consumer Affairs and Business Regulation
Registration: 147865 10 Park Plaza-Suite 5170
Expiration: 8/172011 Tr# 287827 Boston,MA 02116
Type: bBA-,
PEDATO 8 SONS ROOFING
TERRI-JEAN PEDATO'
9 HEMLOCK DRIVE g '--�-a�—
DANVILLE,NH 03819' Undersecretary AN alid without signature
1 � �lussachust•
} tts_ pc
Bo:frd of Buildio pafrtmcat of Pun
lic
License:s ctiCS St.
Supery Sao,SPec aft d Sta lards
Restricted to RF BL 101032 Speci y License
TERRI,IEAN 9 HEMLO PEDATO
�>}
CK DRIVE
DANVILLE, NH 03819 '
('mm�,iwinue� EXpirdtlOq:
1/62012
Tr#: 101032