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8 WEST CIR - BUILDING INSPECTION (2) -t> 612 RECE(WED 'the Commonwealth of Massaehui W Board of Building Regulations and Standards PTisedSki, 3ALEM Massachusetts State Building Code, 78� I�QR v 1011 Building Permit Application To Construct, Repair, Renovate Or Demolish One-or Tivo-Family Dwelling 1J) This Section For Official a Only Building Permit Number:` Date Ap lied"s4''`l' MSi ure ' Date ` ,building Otficiai(Pont Name). SECTION I SITE INFORMATION. L1 Ppro.per Address: 1.2 Assessors Mop dl Parcel Numbers t1 O s an acre G. r I� 1.1 a Is this an acce ted street9 yes no M1lap Number Parcel Number 1.3 Zoning Information: 1.4 Property Dimensions: Zoning District .Proposed Use Lot Area(sq R) - Frontage(11) . . 1.5 Building Setbacks(R) Front Yard - Side Yaids Rear Yard' .. Required Provided Required Provided. Required Provided 1.6 Water Supply:(M.G.L c.40.§54) L7 Flood Zone Information: 1.8 Sewage Disposal System: Zone: _ Outside Flood Zone? Municipal❑_On site disposalsystem ❑ Public❑ Private.❑ Cheek if a❑ - - / �' SECTION2: .PROPERTY OWNERSHIPk 2.1 ,n..t of a oV t/Vl(. � N ��(a of( ivi A&A 0 P T •ttlthme(Print) f city,State,ZIP R ivej+ C I 17 d' 7'7 1 d lS3 No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction CI Existing Building❑ Owner-Occupied ❑ I Repairs(s) ❑ Alteration(s) O Addition ❑ Demolition. ❑ 1 Accessory Bldg.❑ Number of Units_ Other ❑ Specify: Brief Description of Proposed Work=: r SECTION 4:ESTIMATED CONSTRUCTION COSTS Itcm - Estimated Costs: - Official Use Only Labor and Materials - - I. Building S 2 O — I. Building Permit Fee:S Indicate how fee is determined: ❑Standard CiVrown Application Fee 2. Electrical S /, 0 0 ❑Total Project Cost'(item 6)s multiplier s J. Plumbing S 'LD 00 ,_ 2?QtherFees: S 4.1%lcchanical (HVAC) S List: 5.iMechmtical (Fire - Suppression) S "total All Fees:S a Check No._Check Amount. Cash Amount: 6. TCost-Tsotal Project /6 i 0 0 0 ❑Paid in Full ❑Outstanding Balance Due: ISaJ "TD La TLZ 1 Ol)S6 SECTION 5: CONSTRUCTION SERVICES 5.1 Construction Supe- isor License(CSL) 9s-2 Y-© a W 1�,-t License Number Expiration Date e rz Nanne of CS/L,�Holder � o List CSL Type(see below) U 6 IV q IQ H 6�1''m n � f7�'` Type . - - . Description . Nu. and Street SVJA � t Q �- /I/( A L� d�] U Unrestricted 2(Buildings a el iny- cu. It.) s• ,Jf R - Restricted L@2 Family Dwellin City/fawn,9tatc,ZIP M Masonry RC Roofinit Covering I WS Window and Siding f23� II�TeJJ'GS'�'✓1 cC.t 4na4� SF Solid Fuel Burning Appliances LAM I Insulation Tele hone Email address D Demolition 5.2 Registered Home Improvement Contractor(HIC) t `42R2-t/. llf-G (Q 4� t,f _ HIC Registration Number Expiration Date HIC Company Nome or HIC Registrant Name q.mid Street Email address . Nt 2to $f/lAal9a7 2 Citv/To%vA.State ZIP Telephone SECTION 6:WORKERS'COMPENSATION 1.INSURANCE AFFIDAVIT(M.G,L:c.152.§2SCMY Workers Compensation Insurance affidavit must be completed and submitted with this application. Failure to provide this affidavit will result in the denial of the Isivance of the building permit Signed Affidavit Attached? Yes ..........O No........... O SECTION 7o:OWNER AUTHORIZATION TO BE.COMPLETED.W HEN OWNER'S AGENT OR CONTRACT0.MAPPLIES FOR BUILDING PERMIT 1,as Owner of the subject property,hereby authorize 41;*il o we -Qj, t4rj s ;rt n m behalf,7,%",A�, matters relative to work authorized by this building permit application. 4111k ner's Nance(Electronic Signature) - Date SECTION 71b:OWNER!OR AUTHORIZED AGENT DECLARATION By entering my name below,)hereby attest under the pains and penalties of perjury that all of the information contained in his appli tion is true and accurate to the best of my knowledge and understandin .AAf �9b - Gece . 4 ro > 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 Anot registered in the Home improvement Contractor(HIC)Program);will Llgol have access to the arbitration program or guaranty fund under M.G.L.c. 1 a2A.Other important information on the F71CYrogram can 6e oun aT www rats,eov'oca Information on the Construction Supervisor License can be round at www.mass.eovldns . 2. When substantial work is planned,provide the information below: 'total floor area(sq. ft.) `r .(including garage, finished basement/attics,decks or porch) Gross living area(sq. ttJ Habitable room count Number of fireplaces Number of bedrooms Number of bathrooms Number of half/baths rype of heating system Number of decks/porches Type of cooling system Enclosed- Open 7. "rotal Project Square Footage"may be substituted I'or"Total Project Cost" CITY OF SALEEM, i/L-1SSACHLSETrS • BUILDIING DEPARTJIE.VT • N 120 WASHINGTON STREET, 3° FLOOR TEL (978) 745-9595 Fnx(978) 740-9846 KI�NtBFRi FY DRISCOLL MAYOR DIRECTOR ST.PI;:RRH DIRECTOR OF PUBLIC PROPERTY/BCILDNG COMMISSIONER 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 debrisiesulting 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: L ' � ur.2 �rViGt-J (name of hauler) The debris will be disposed of in �✓y -- (name of acility) (address of facility)— i signature of permit applicant `f 1/ / date ' i CITY OF S:1Lmmll Ir'LISSACHLSETTS r SULDING DEP1RT11LENT 3 � lrn 120%V.hsHLNGTON STREET, 3te FLOOR TEL (978)745-9595 Ria(973) 740-9846 Ks\BFRLHY DRI5COLL MAYOR THONUS ST.PiERRB DIRECTOR OF PUBLIC PRO PERTY/Bt:ILD NG C01L\IissIONER Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/Plumbers Amilicant information ((ee Please Print Legibly Nairic(Businn�ss.Orgtnizaiiorvindividual): L 14&[1 tun�t--e- V h r(Al CI -Ir Address: 7 MI f11V0V?k City/State/Zip: Brad( lrl MA Q/9® Phonen: 7E// " r2,� F— Arree you an employer?Check the appropriate box: 'ryps of project(required): 1.EP am a employer widi 4, El I am a general contractor and 1 6. ❑Now construction employees(tall and/or part-time).• have hired the sub-contractors 2.0 I am a sole proprietor or partner. listed on rho attached.sheet t 7• &2 Remodeling ship and have no employees These subcontractors have V. 0 Demolition workingfor me in an capacity. workers'camp.insurance. Ya9. ❑Building addition (No workers'comp,insurance S. ❑ We are a corporation and its required.) officers have exercised their 10.0 Electrical repairs or additions 3.0 1 am a homeowner doing all work right of exemption per MGL i 1.0 Plumbing repairs or additions • myself.(No workers'comp. C. 152.$1(4),and we have no 12,0 Roof repairs insurance required.)r employees.iNo workers' 13.O Other. comp.insurance required.) •Any uppllc:mt dud clucks box st must aisu fill out the aufoo below showing their worker'compeneadon pulley iniurmmlom r I tamvuwrwcs who sulmdt this atTdavit indicating they are doing all work sad than him onside cantrcmara must suhmit a new arndavit'ndicaing such. : onnraeuon that check this box meet attached an addie.rutl ahmt showing the name of the subaonrraetors and their worker'minp.policy infomudon. lain an eurployer that is providing workers'compeusodon Insurance for my employeex Below is the policy end Job site Injormarlon. � Insurance Company Name: �,; Policy it or Self-ins.pLic. 0:: VIf CC ZOO IJ O 0 1 �� piration Date: & lob Sila Address: 9 W r ✓ City/StatedZip: S1(eM, at'I:4 ()ly-70 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 23A of 4iGL e. 152 can lead to the imposition of criminal penalties of a line up to S 1,500.00 and(ur one-year imprisonmenk as well as civil penalties in(he form of a STOP WORK ORDER and a line of up to S390.00 a day against rho violator. Be advised that a copy of this statement may be forwarded to the Office of Invcstigeiutts ul'rha DIA f r insurance co • ag¢vcniticatiun. I do hereby certify turd the ins u a l e ejper/ory that the hrjermallon provided bav is true and c'drreca S i"n II Phone UJJicial use aaaly. Oa oar rvrhe in r/Jr area;ro br completed by city or lawn n/Jlclad City nr'1'uwn: _ Permit/l.lcense Nsuing Aulhor4y(circle one): L Board of Health Z.Building Department 3.Cityfrown Clerk 4. Electrical inspector 5. Plumbing inspector 6.Other Contact Person: _. _-- _--- Phonolf: r Page No of Pages �X11�T1YSMl Insured Litehouse Services License # 95280 Litehouse Services 67 Monument Avenue H.I.C. # 142824 Home Repairs Made Easy Swampscott, MA 01907 litehouseservices@gmaii.com Bob Pierce 781-864-5238 PROPOSAL SUBMITTED TO , .1 PHONE DATE i� �k V STREET ( . JOBNAME ly 1 1/ CITY,STAT D P CODE `/ JOB LOCATION Gt vt to l 9 V APPROX. %RTIN % TE JOB PHONE We hereby submit specifications and estimates for: Z a fr oli /"✓es A if 07 SAWS © CIO-?©h-F Pe Propose hereby to furnish material and labor—complete in accordance with above specifications,for the sum of: 6t� f— d c-- dollars $( G/ 0 ) 00 Payme [to be matle as follows: 1/3 down, 1/3 middle of job, 1/3 upon completion All material is guaranteed to be as specified.All work to be completed in a workmanlike manner Authorized cording to standard practices.Any alteration or deviation from above specifications Involving Signature extra costs win be executed only upon wriaen orders,and will become an extra charge over and a bovetheestimate. Note:This proposal may be withdrawn by us if tnnott1 accepted within days. �creptanre of Vrnposa(—The above prices,specinpabons and conditions are satisfactory and are hereby accept¢ .Youa authorized to do the work as specified.Payment Signature will be made as outlined above. Signature Dale a/Acceptance: