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25 WEST TER - BUILDING INSPECTION (3) The Commonwealth of Massachusetts Board of Building Regulations and Standards CITY Massachusetts State Building Code, 780 CMR,7d'edition OF SALEM Revised Jamwry Building Permit Application To Construct,Repair,Renovate Or Demolish a 1, 2008 One-or Two-Family Dwelling This Section For Official Use Only Building Permit Number: I Date Applied: Signature: Building ammissioner/Inspector of Buildings Date SECTION 1:SITE INFORMATION 1.1 Property Addr 1.2 Assessors Map&Parcel Numbers ?z l.la Is this an accepted street9 yes no Map Number Parcel Number 1.3 Zoning Information: 1.4 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 H Private❑ Zone: _ Outside Flood Zone? Municipal Y&site disposal system ❑ Check if yes SECTION 2: PROPERTY OWNERSHIP" 2.1 wneruo ' GZT ame 7— N // tuff--�� Address for SServyiim:: Sr Telephone SECTION 3:DESCRIPTION OF PROPOSED WORK=(check a6 that apply) New Construction❑ 1 Existing Building Owner-Occupied girl Repairs(s) ❑ I Aheration(s) ❑ Addition ❑ Demolition ❑ 1 Accessory Bldg.❑ N ber of Units Other R Specify: Brief Description of Pro World: SECTION 4:ESTIMATED CONSTRUCTION COSTS Item Estimated Costs: Official Use Only Labor and Materials 1.Building $ _'�2� /�' 1. Building Permit Fee:$ Indicate how fee is determined: ( �� ❑Standard City/Town Application Fee 2.Electrical $ ❑Total Project Cost"(Item 6)x multiplier x 3.Plumbing $ 4 20Q 2. Other Fees: $ 4.Mechanical (HVAC) $ List: 5.Mechanical (Fire $ Suppression) Total All Fees:$ Check No. Check Amount: Cash Amount: ost: $6.Total Project C 13paid in Full ❑Outstanding Balance Due: 1 CITY OF S.UY.M. 1rLkssACHUSETTS • BtimmzG DEP.ART.%i&NT • p 130 W 1SHLNGTON STREET, 31D FLOOR TEL (978)745-9595 FAX(978) 740-9846 K1\tBER%.1✓Y DRISCOLL ,AAAYOR THmt a ST.PwjAE DIRECTOR OF PUBLIC PROPERTY/BUUMMG COMMSSIONER Construction Debris Disposal Affidavit (required for all demolition and renovation work) In accordance with the sixth edition of the State Building Code, 780 CMR section 111.5 Debris, and the provisions of MGL c 40, S 54; Building Permit# is issued with the condition that the debris resulting from this work shall be disposed of in a properly licensed waste disposal facility as defined by MGL c l 11, S 150A. The debris wi II be transported by: p (name of h4uler) The debris will be d fin (name of facility) e-�-s (address of facility) signatu ert�fC�"a i r date dcbrisal:'J:w SECTION 5: CONSTRUCTION SERVICES 5.1 Licensed Construction Supervisor(CSL) /3C 7 5� License Number Expiration Date Name oSSL �,l n / ,fin List CSL Type(see below) ddress /"/ /l L` —�C: T Description Cu.Unrestricted u to 35,000 .FL R Restricted 1&2 Family Dwelling Si z�q © 9 9� M M Only RC Residential Roofing Covering Telephone WS Residential Window and Siding SF Residential Solid Fuel Burning Appliance Installation D Residential Demolition 5.2 R ed Ho!�;el v meat Contractor(HIC) // 0/ZI-7' G .�LG/f HIC Co pan ame r C R 's$ankpl�� Re on Number A 0/7 719 6Wkxpuafion Date -Si 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 IssuarTe 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 I, as Owner of the subject property hereby authorize to act on my behalf,in all matters relative to work authori is building permit application. Si re of er Date SECT ON 7b.OWNER'OR AUTHORIZED AGENT DECLARATION I, 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. I�, Pri N e Sign of Owner or Autho Agent Date (Signed under the pains and penalties of 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 and Construction Supervisor Licensing(CSL)can be found in 780 CUR Regulations 110.R6 and 110.R5,respectively. 2. When substantial work is planned,provide the information below: Total floors area(Sq.Ft.) (including garage,finished basementlattics,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 3. "Total Project Square Footage"may be substituted for"Total Project Cost" tm_nee.CerOnt TOmOP.irfdBOD"AI.C4m zo; . r TVA mya RY tTaroTw ) w.w vu rcirwmr-rc ry vcw CORDn. CERTIFICATE OF LIABILITY INSURANC N ,„�0,0'" FR THIS CERTIFICATE IS ISSUED AS A MATTER MFORMATION,/ HUB UM NOW ERgloW QMLSB) ONLY AND CONFERS NO RIGHT3 UPON THE HOLDER.THIS CE(RRFICATE DOES NOT ALUM,EXTEND OR 299 BallardVale St ALTER THE COVERAGE AFFORKIED BY THE POLICIES BELOW. VVOmirom4 MA 01897 0451JRERS AFFORDING COVERAGE NAIL 0 e1suT� o sN A:Travelers htdelmoty 25658 mwmo johnsm Comw LLC vJBu:ERTc CIO Chris Nmtaon 3 EIM Place umA�RD Mar6lelRead,MA 01945 IxaXIERE COVERAGES THE POLICIES OF INSUIUMCE LISTED BELOW HAVE ISSUED TO THE INSURED NAMED ABOVE FOR THE PQUCY PERIOD MDICATED NOTWATHSTANMG ANY REQUIREMENT.TERM OR 00NDMDN OF ANY CONTRACT mR OTmER DOCIABIT WrTH RESPECT TOWHBXJ THIS MUNICATE MAY BE ISSUED OR WAY PERTAIN.THE DIMMARCE AFFOMED BY THE POUCRS DESGRHM HEiETN LS SUBJECT TO ALL THE TEFOM EXCLUGONS AND CON M ONS OF SUCH PT.TLEES.AGGR8GA7EUAHTSSH(JWN Bwr HAVE BEER REJUCEDBY PAD CLAIM. 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Aun ACORD 25 RWMMI I of 2 AS4070331M374351 a 1989-2009 ACORD CORPORATION. A0 d0hts reserved. The ACORD name and logo are registered mmrks of ACORD WR001 .i i i pc t uUncnt nl'Public S.ttCt) Restricted to: 00 \I;ts+ac'husCtls I „tlatiunsitndSutad:ud 13utnd ut' wtildinl Re,t i:'nr c;i:;,r 00- Unrestricted t ,>n;trurti sn uS'�' �{ �� iG-1 2 Family Homes License: CS 13076 Restricted to: 00. MONACO Failure to possess a current edition of the CHRISTOPHER At Massachusetts State Building Code 3 ELM PLACE Mq 01946 is cause for revocation of this license. MARBLEHEAD, zpiretlon; 1012g12011 Referto: WWW.Mass.Gov/DPS EB TW 6062 ( nnunlsluncr [] Addna Renewal (] &mployment L1 i DPMI 4 90W7N7.POB460 - xa eti c�DuaartcONIl RCM b enre a Qfls e�tato: „ow 9�Aot0 T» MM mogQoem M&oam % : CHRIMOHM MMIILEKEAD.M0.