4 WATSON ST - BUILDING INSPECTION The Commonwealth of Massachusetts
Board of Building Regulations and Standards CITY
Massachusetts State Building Code, 780 CMR, 71h edition OF SALEM
Revised Jumrury
Building Permit Application To Construct,Repair, Renovate Or Demolish a 1, 1008
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: ( Date Applied: t ()
Signature: 1, / i I d `10
Building missioner/Ins. uildings Date -
SECTION 1:SITE INFORMATION
1.1 Pro erty ddress: 1.2 Assessors Map& Parcel Numbers
I.la 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 R) Frontage(it)
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 es❑ Municipal❑ On site disposal system ❑
SECTION 2: PROPERTY OWNERSHIP'
2.1 Owner of Record:
Name(Print) Address for Service:
Signature Telephone
SECTION 3: DESCRIPTION OF PROPOSED WORKr(check all that apply)
New Construction❑ Existing Building F I Owner-Occupied ❑ 1 Repairs(s) fA 1 Alteration(s) ❑ Addition ❑
Demolition ❑ Accessory Bldg.❑ 1 Number of Units_ I Other ❑ Specify:
Brief Description of Proposed Work'-:
SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building S — I. Building Permit Fee:S Indicate how fee is determined:
2. Electrical S ❑Standard City/Town Application Fee
❑Total Project Cost](Item 6)x multiplier x
3. Plumbing S 2. Other Fees: S
4. Mechanical (BVAC) S List:
5. Mechanical (Fire S
Suppression) Total All Fees:S
Check No._Check Amount: Cash Amount:_
6.Total Project Cost: S ���0 0 Paid in Full 0 Outstanding Balance Due:
SECTIONS: CONSTRUCTION SERVICES
5.1 Licensed Construction Supervisor(CSL) gi b p�-.(- ' d
�Aph f � ��� _ License Number Iispiration Dute
Name of CSL-1 lulder .9Ph N� List CSL 1'vpe(see below)
r)lic Description
Add •s U Unrestricted(up to 35,000 Cu.Ft.
R Restricted 1&2 Family Dwelling
Signature M Mason Onl
(s(1,StCs,�Wh43 RC Residential Roofin Covering
relcphone WS Residential Window and Siding
SF Residential Solid Fuel Burning Appliance Installation
D Residential Demolition
5.2 Igister d Hope Improvement Contractor(HIC)
�l� f7 111 NBC Registration Number
HIC Cum ame or'11L a isirunt ' e C MK_
Add ess �11 &.('���� Expiration Date
Signature Telephone
SECTION 6: WORKERS' COMPENSATION INSURANCE AFFIDAVIT(M.G.L.c. 152.1 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 ..........A 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.
Signature of Owner Date
A SECTION 71b:OWNEW OR AUTHORIZED AGENT DECLARATION
1, INI�CQ10 0 VAC%N 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.
ti
Print Na l
Signatureo Ow a or Authoriz nt Age Uate
Si ned under the sins and na ties of r'u
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 Mel have access to the arbitration
program or guaranty fund under M.G.L.c. I42A.Other important information on the HIC Program and
Construction Supervisor Licensing(CSL)can be found in 780 CMR Regulations 110.1116 and 110.115,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 half/baths
Type of heating system Number of decks/porches
Type of cooling system Enclosed Open
J. "Total Project Syuare Footage'may be substituted for"Total Project CosP'
a
CITY OF S.U.E.`Iy NWSACHUSET M
BL DLNG DEPART.%LAiT
120 W.oi3HLNGTON STREET, )'a FLOOR
T EL (978) 745-9595
FAX(978) 740.964
hq\®Ej"y DRlSCOLL Tl OSMST.PMUS
HAYOR DIRECTOR OF PL aLIC pROPERTY/eL QDLNG COSMRSSMER
Workers' Compensation Insurance AlVdavit: [builders/Contrsctora/ElectrlclanilPlumbers
a t (leant Information P1
1
VOtTIe (nus4 n Orynuationlrwkv,dual)f
Address. jS6f' IwIAj.;teS6)Gh2
Cily/St3te/zip:4Lr150- MAA C 1I Phoneir: /it
Are yea to emphyesT Chisel t e appropriate beam Type of projece(require*
1.g 1 am a""Player with Y e. 0 1 am a general contractor and 1 6. ❑New construction
cmployse(full and/or pan-time).• have hired des sub.caeers'a"
2.0 1 am a sole proprietor,tr partner- listed on the attached shcaL 7. ❑Remodeling
:hip and have no employee Then sub•comreemes have I. 0 Demolition
working for me in any capacity. workers'comp.inwranp 9. DuiWing addition
I No workers!comp insurance S. 0 We are a eorperstiea and its I0.0 Electrical i a additions
ofters have exercised their
).0 1 am a homeowner doing all work riyla otesmnpioa per MOL I I.0 Plumbing repairs or additions
myself.(No workers'comp. a 152.f 1(41 and we haw no 12.0 Roormpaire
insurance required.)► employees.(Na workers'
comp insurance required.] I l.0 Other
;Any apparar tti st+oca ba en more arse ns ua the wrier briar skrwiy heels waksa'oanpam im pWky inaannrlx
'Ihmrawwsa rhs subntr eda dndsvir Wic airy they are Joins a0 sub and does like emir cesrreeaors mar suhak a new aMd"il indlarlly sunk
<'..arayese der shah skis trot m+ea aearhs/as aJiliawl shave rMwine eke rasa anew wr►sesrrssrs swd rlwk v,arkew'ner7.polry isMnwtlo►
I ass as employer that b provlNtrR workers'cowpetosstdea fnsonaaee jar nay aarploypn eehm b tRa palky aadM db
Inwrunce Company Name: /_�� D et. r cv G' Q
Policy a or `-A Self-ins,Lie.M: h �D 90 1 � —Oil Expiration Dab: Q�S�
Job Site Address: q Wt,465 Lt 4 City/Stae/zip: SgLte let 144 Gl M
•tittack■copy of the workers'compeaeatbe pogcy dwlmtlsm page(showing the Polley member sad exploration dsb}
Failure to mxum coverage a required undar Section 23A of NGL a 152 can led to the imposition orerintinal penalties ore
Fine up to S 1.500.00 and/or one-year imprisonment,as wall a civil penalties in the farm of a STOP WORK ORDER and a litre
of up to S250.00 a day allainst the violator. Ifs advi*W that a copy of this statement may be rurwu►ded to the Olilce of
I nvc,trgariuns of the MA ror insurance covcraae wriricatunL
I r/at hereby Nfy u er the paei td me/Nn o/perjury that tM infernrerlom proviala�ORIstrue and awrrect
I)ara•
PhuneA <; .
O/JJa'id use o,rly. Dona write in this dreg to be.urnp/etd 6y rifyW tstva„//liiaL
I
City or ruwn: _ Ycrmit/Llecnse l__,
t,suing Authority(circle tine):
I. ❑uard of Ileulth 2. Ruildlnu lfcpartrrtvnt J. City/town Clerk a. Electrical In+pcoor S. Plumbing Impeerar
6. Other _
lvntact Pcnon: _ ._ _.. Phone e'
�S CITY OF SALEM
• PUBLIC PROPRERTY
DEPARTMENT
.I'.II% NI h1 ' Nlw '•I 1
\f .1'ar I'0�Y'.�,n1M.;,Lu SrNIr To
).�I rf4
rrf:')%t-7a5.9;95 •1 %x:978.740-9446
Construction Debris Disposal Affidavit
(required 1'ur all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 730 CMR section 111.5
Debris, and the provisions of MGL c 40, S 54;
Building Permit q 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
I11. S 150A.
The debris will be transported by:
yny-C •cIZ- �ipwc.�,c� F)00��9
Iname of Imuler)
The debris will
cCbee disposed of in
wol] 1) 4V U661
(lame of aclTny)
'1 P1040ti ST ESN`
laddreax of facility)
116111tircof per v 1 applicant
date
Ichi n,11 dK
_ I
Booardard of chusetts- Dement of Public Safetc
Building; partRctulatiuns and Standards
Construction Supervisor License
License: CS 96966
Restricted to: 00.
ANGELO ROMANOy
10 EMERY STREET
PEABODY, MA 01960 IL
f'•nnmixei•mer Expiration: 4/4/2012.
1,
i'
,,pp•er� aar , iasivrxoni�ea/di o�-
�\ Board of Building Regulatiohs and StanlQ�a r
9g , HOME IMPROVEMENT CONTRACTOR
Registration) 151614
�Ex ration_7i5/2010 Trill :
t tJ if: TYpe DBA�.
ANGELO J. ROM AN ROOFING�EO
ANGELO ROMANO )1'1
19 BLOOMINGDALE.STREBT`�
CHELSFA MA no+cn`�-'i`