125 WASHINGTON ST - INT. DEMO BANK 1ST FL 16-1418 a � I115
The Commonwealth of Massachusetts
CITY OF
�— Board of Building Regulations and Standards SA EM
Massachusetts State Building Code, 780 CMR 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: n
!�-///u�r
Building Official(Print Name) Signature WI)e)
SECTION 1: SITE INFORMATION
1.1 Property Address: wAsH[N6Tw sF-
1.2 Assessors Map& Parcel Numbers
� a5
1.1 a Is this an accepted street?yes V no Map Number Parcel Number
1.3 Zoni55 ng Information: 6S 1.4 Property-Dimensions:
000 io-0
Zoning District Proposed Use Lot Area(sq ft) Frontage(11)
1.5 Building Setbacks(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Provided Required Provided
(2) O 0 U O 1 6
1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System:
/ Zone: _ Outside Flood Zone?
Public C9' Private ElCheck if yesgj� Municipal On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Recort��1t: n(� 0
AnA d 14 l
0Ilvi golArn•t5S P,'A 4y �rvsF SAi4�
Name(Print) /t City, State,ZIP !1 11
6V t2 �t° viSo., AVL 60 831 Soso hobd)@PMrL0.r'�wAllY
• C
No.and Street Telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORKZ (check all that apply)
New Construction ❑ Existing Building❑ Owner-Occupied ❑ Repairs(s) ❑ 1 Alteration(s) ❑ 1 Addition ❑
Demolition OfAccessory Bldg. ❑ Number of Units I Other ❑ Specify:
Brief Description of Proposed Work 2: 1/s F" ,arL 4itwz 1% k tw e E e^5 kQNr RA rr Ic
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Estimated Costs:
Item Official Use Only
Labor and Materials
1. Building $ 1. 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 $ 2. Other Fees: $
4. Mechanical (HVAC) $ List:
5. Mechanical (Fire $
Su ression Total All Fees: $
Check No. Check Amount: Cash Amount:
6. Total Project Cost: $ C4 0 • O0 ❑Paid in Full ❑ Outstanding Balance Due:
GI,vcc-Tn '71 /1C PLphc� ,Qel�1< Call- t1146, � y/�
SECTION 5: CONSTRUCTION SERVICES
5.1 Construction Supervisor License(CSL) o y 0 y 6 a
CS id- l0
ROb'dZ\- w License Number Expiration Date
Name of CSL Holder 1
List CSL Type(see below)
No.and Street Type Description
hAN Q U Unrestricted(Buildings up to 35,000 cu. ft.
R Restricted 1&2 Family Dwelling
Cityaown,State,ZIP M Masonry
RC Roofing Covering
WS Window and Siding
(
��r v SF Solid Fuel Burning Appliances 39 SS O n m�' )"�"it.<w� I Insulation
Telephone Email address D Demolition
5.2 Registered Home Improvement Contractor(HIC)
HIC Registration Number Expiration Date
HIC Company Name or HIC Registrant Name
No.and Street Email address
City/Town,State,ZIP Telephone
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
to act on my behalf,in all matters relative to work authorized by this building permit application.
Print Owner's Name(Electronic Signature) Date
SECTION 7b: OWNEW OR AUTHORIZED AGENT DECLARATION
By entering my name below, 1 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.
'7 — b ^ 1 6
Print Owner's 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(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/oca Information on the Construction Supervisor License can be found at www.mass.gov/das
2. When substantial work is planned,provide the information below:
Total floor area(sq. ft.) 4 S d 0 (including garage, finished basement/attics,decks or porch)
Gross living area(sq. ft.) Habitable room count
Number of fireplaces D 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"may be substituted for"Total Project Cost"
CITY OF &URN21, NaSSACHL'SETTS
• BUUMLNG DEP IRTNMNT
120 WASHINGTON STREET,P FLOOR
TEL (978) 745-9595
FAX(978) 740-98"
KlNlBERi-EY DRISCOLL
.MAYOR THo3tas ST.PIERRB
DIRECTOR OF PL:BLIC PROPERTY/B1211.13ING CO,%L\QSSIONER
Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
Applicant Information Please Print Leeibly
Name (BusirnssiOrganizationlindividtul): E.M.R. DRYWALL, INC.
Address: 63 1 /2 JEFFERSON AVE.
City/State/Zip: SALEM, MA. 01 970 Phone #: 978-744-5050
Are you an employer?Check the appropriate box: T of
Type project(required)
1.0 1 am a employer with— 60 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or part-time).' have hired the subcontractors
2.❑ 1 am a sole proprietor or partner- listed on the attached sheet t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 11. ❑ Demolition
working for me in any capacity. workers'comp. insurance. 9. ❑ Building addition
(No workers'comp, insurance 5. ❑ We are a corporation and its
required.] officers have exercised their 10.0 Electrical repairs or additions
3.❑ 1 am a homeowner doing all work right of exemption per MGL 11.❑Plumbing repairs or additions
myself.(No workers' comp. C. 152, §1(4),and we have no 12.0 Roof repairs
insurance required.]t employees. [No workers' 13.❑Other
camp. insurance required.]
•Any applicant that checks bon#1 must also fill out the sectim below showing their workers'compensuion policy infurmadon
*1 htmeowrxrs who submit this affidavit indicating they are doing all work and then hire outside contmetms most submit a new affidavit indicating such.
:Contrw-ton that shack this bon must anwhed an additional sheet showing the name of the subwntraclors and their workers'comp,policy information.
I am an employer that Is providing workers'compensation insurance for my employees. Below Is the pollry and fob site
information.
Insurance Company dame: WESCO INSURANCE COMPANY
Policy 4 or Self-ins.Lic.#: WWC31 7 7 8 7 4 Expiration Date: 1 /1 /2 01 7
Job Site Address, 125 WASHINGTON ST. City/State/Zip: SALEM, MA. 01970
Attach a copy of the workers'compensation policy declaration page(showing the policy number and expiration date).
Failure to swure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a
fine up to S1,500.00 and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine
of up to S250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of
investigations orthe DIA for insurance coverage verification.
I do hereby certify under the pains and penalties of perfury that the information provided above Is true and cows&
Signature: Date,
Phone x:
Official use only. Do not write in this area,to be completed by city or town oJrciat
City or Town: Permit/License#
Issuing Authority(circle one):
1. Board of Health 2.Building Department 3.City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector
6.Other
Contact Person: _ Phone#:
CITY OF S.U.&%I, NLksSACHUSETTS
BLILDIING DEPARTJIE,�IT
• p• 120 WASHNGTON STREET, P FLOOR
TEL. (978) 745-9595
FAX(978) 740-9846
Kl.,{BERLEY DRISCOLL
MAYOR THOMAS ST.PIERRB
DIRECTOR OF PUBLIC PROPERTY/BUILDING COMNUSSIONER
Construction Debris Disposal Affidavit
(required 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;
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
111, S 150A.
The debris will be transported by:
Cam. S b(. .moo
(name of hauler)
The debris will be disposed of in :
(name of facility)
(address of facility)
signature of permit applicant
- 6 - 'Ib
date
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