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0080 WASHINGTON SQUARE EAST - BPA-16-1202 253 cr-- -7oc, The Commonwealth of Massachusetts f Board of Building Regulations and Standards ",; 4y ;, 'v # s Massachusetts State Building Code, 780 CMR SALEMRm,is 2011 Building Permit Application To Construct,Repair,Renovate Or 1&600 D,a, A Q One-or Two-Family Dwelling This Section For Official Use Only � Building Permit Number: ' Daw Appli : yn ' j %lJdy Building Official(Print Name) Signature Date 1 SECTION 1:SITE INFORMATION 1.1 Property Add res : / 1.2 Assessors Map&Parcel Numbers l.la IS this an accept d street'!yes�Cno Map Number Parcel Number 13 Zoning Information: 1A 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? Check if yes[] Municipal Qr<site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP' 2.1 Owner of Record: 2mee , �r G , rur� (Pr g 4L 0 ( 9 7© City,State,ZIP far, OJA, 4I t' uU Sa �,_� .�j�tz 7t19-z3�.a c ol)on�ell fS ,rtx% No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORK'(cheek all that apply) New Construction❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) W1 Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work': SECTION 4:ESTIMATED CONSTRUCTION COSTS' Item _ Estimated Costs: Labor and Materials Official Use Only 1.Building $ 1 Building Permit Fee:$ Indicate how fee is determined: 2.Electrical $ ❑Standard City/Town Application Fee ; ❑To Project Cost'(Item 6)x multiplier "" x ' 3.Plumbing $ coo j 2 Other Fees: $ 4.Mechanical (HVAC) $ List. �'!� l✓ 5. Mechanical (Fire $ Suppcession) Total All Fees:$ Check No.; Check Amount: Cash Amount 6.Total Project Cost: $a3 O ❑Paid in Full ❑Outstanding Balance Due:,, 1 =y SECTION S,:•GONSTRUCTIONSERVICES 5.1 Construction So ervisor License(CSL) License Number Expiration Date Name of CSL Holder List CSL Type(see below) No.and Street �t O .Type:- Description (),1 /r �/' ' ^a U Unrestricted uildin u to 35,000 cu ft. t 73 own,State,ZIP/ , 1�0. oc R Restricted I&2 Family Dwelling CityM Masonry RC Roofing Covering WS Window and Siding �r � IY.� SF Solid Fuel Burning Appliances � offn '1' P� C404G.A.A I Insulation Telephone el - Email address D Demohtion 5.2 Registered Home,�Improvement Contractor((H1C) ►4 e. .I Lam. , hsd I, ,U-C (I Lrn+ HIC Registration umber Expiration Date twi c—:mpapy N ear CReegistrant-Name .can_ . nws-¢_ { C P7 C i'Ge No.apd Street\ � Email address �.y]•rJ\ O 9 7 8� cam? C /Town,State,ZIP Telephone "'SECTION;6:WORKERS'COMPENSATION INSURANCE AFFIDAVIT(M.G .,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 MIT 'AGENT OR CONTRACTOR APPLIES FOR BUILDING PER 1,as Owner of the subject property,hereby authorize to act on my behalf,in all matters relative to work authorized by 1his building permit application. or•ThOPA AS A - &�onna\I vF` Print Owner's Name(Electronic Signature) Date Y SECTION 7b:OWNER t ORAUTHORIZED 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�l An ,� /6 -//- I t- Print Ownerl or Authorized Agent's Name(Electronic Signature) Date 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(111C)Program),will not have access to the arbitration program or guaranty fund under M.G.L.c. 142A.Other important information on the RIC Program can be found at www.mass.gov/oca Information on the Construction Supervisor License can be found at www.mass.gov/dos 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.ft.) Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of haWbaths Type of heating system Number of decks/porches Type of cooling system Enclosed Open 3. "Total Project Square Footage"may be substituted for"Total Project Cost" CITY OF SMEL 4 NAXSSACHUSETM • BUILDING DEPART%m-%-r 130 WASHINGTON STREET,3m FLOOR MEL.(971)745-9595 FAX(971)740-9946 KIN(BERLEY DRISCOLL MAYOR THo&w ST.Pw-m DIRECTOR OF PUBLIC PROPERTY/Bui DING CMMUSSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information r� Please Print Legibly Name(nusirw-&Drsanintion/Individuat):Me.Ales ALe i%itt4-hpgC ifC ke;N Aeerues4LC Address: R CATde121 Awi -T), ►t)e City/State/Zip: Phone#:_97rei�sn4�['ae3�� Are you an employer'Check the appropriate box: Type of project(required): 1.0 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-cmuractots 2.0 1 am a sole proprietor or partner- listed on the attached sheet.t 7. remodeling ship and have no employees These sub•contracum;have g. ❑Demolition working for me in any capacity. w ers'comp-insurance, 9. Building addition [No workers'comp.insurance 5. c are a corporation and its required.] officers have exercised their Io.O Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL I I.0 Plumbing repairs or additions myself.[No workers'comp. c. 152.§1(4),and we have no 12.❑Roof repairs insurance required.]t employees.[No workers' 13.❑Other COMP. insurance required.] 'Ally appaml dad d ust uxks bull#t m also fin om Me satin belowsho mig their waken'omttpensation policy inforttuttoa t I hwmwwnns who submit this atRdavit indicating they ate doing all wort and the him outside co martams man submit a ttew alydavit mdisai mg sttd. =C. tr--^+thm dark dus lulu must anached an 3"60W dual showing tM anus of Ne sub-cma ctms and their wmh.,rmnp.policy mlmmudoo. 1 um an employer that is providing workers'compensaton insurance for my employees. Below is the pallcy and job site information. Insurance Company Name: Policy#or Self--ins.Lill# Expiration Date: Job Site Address: City/Smte/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 25A of MGL a 152 can lead to the imposition of criminal penalties of a fine up to S1,500.00 and/or one-year imprisonmem,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to 5250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations or the DIA for insurance coverage verification. I do hereby cent jy under the pain and penaties o rjury that the information provided above Is true and correct Sienature: o ..v.��A Date: Phone#• Official use only. Do not write in this area,la be completed by city or rawa ojjklal City or Town: Permillucense# Issuing Authority(circle one): 1.Board of Health 2.Building Department 3.Cityffown Clerk 4.Electrical Inspector 5.Plumbing Inspector 6.Other Contact Person• Phone#: 07YOPSal,FJ14 MAS'Sa(f11 MI BMAMDEPAMBMNr 110 wes►ww,M5jMr,3wjk= ]tic 715.99Af. SOa?BitiBY P197�149td/6 MAYOR Durassribm DMKmxCFRM CP Y/BEUX allVOM Construction Defi S Disposo/Afffdw t (required fo►`all demolition andrenovation work) In aoeordmw with the"edition of Me aft Bul *w Cody 780OK Sefta 11LS oeM and the P of MGL c4O SS4;8u►ft Pere* 1s based with the conrdtion"the debris reRdft from this Work shelf be diVand of in a properly Ibersed wasW*PM*Why as defined by MGL c 111,S 150A. The debris will be transported by: (name of hauler) The debris will be disposed of in: (name of fadfitV) \ (address of ci ft) Signature of applicant Date