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4 WILFRED TER - BUILDING INSPECTION (3) The Commonwealth of Massachusetts F O CITY Board of Building Regulations and Standards C ITY Massachusetts State Building Code, 780 CMR SALEM Revised Mar 2011 Building Permit Application To Construct,Repair,Renovate Or Demolish a One-or Two-Family Dwelling This Section For Official Use Only W Building Permit Number: Date Applied: 6, Building Official(Print Name) -- Signature Date SECTION 1:SITE INFORMATION 1.1 Proper, ddress: x 1y / 1.2 Assessors Map&Parcel Numbers L4.-1 t a tno cxSa�w J>ntiTlQ70 '3O l.la Is this an accepted street?yes��no Map Number Parcel Number 13 Zoning Information: 1.4 Property Dimensions: ri n Zoning District Prop s� Lot Area(sq ft) Frontage(ft) Lc 1.5 Budding Setbacks(ft) � �- Front Yard Side Yards Rear Yard Required Provided Required Provided Required Prove 1.6 Water Supply: (M.G.L c.40,§54) 1.7 Flood Zone Information: 1.8 Sewage Disposal System: J Zone: _ Outside Flood Zone? Public t�J Private❑ Check if yes❑ Municipal EfOn site disposal system ❑ SECTION 2: PROPERTY OWNERSHIP[ 2.1 Owner of Record: So >r✓I ALAyx)e —ABLPA,e rrAI"0Vt4 t4Le 0 o� ✓r a(Q70 Name(Print) City,State,ZIP No.and Street Telephone Email Address SECTION 3:DESCRIPTION OF PROPOSED WORW(check all that apply) New Construction❑ 1 Existing Building❑ 1 Owner-Occupied ❑ 1 Repairs(s) ❑ 1 Alteration(s) ❑ Addition ❑ Demolition ❑ Accessory Bldg. ❑ Number of Units I Other ❑ Specify: Brief Description of Proposed Work :, SECTION 4:ESTIMATED CONSTRUCTION COSTS Estimated Costs: Item Official Use Only Labor and Materials) 1.Building $ 3 0 vo 1. Building Permit Fee: $' Indicate how fee is determined: ❑Standard City/Town Application Fee 2. Electrical $ 4 nop ❑Total Project Cost'(Item 6)x multiplier x 3.Plumbing $ 2. Other Fees: $ 4. Mechanical (HVAC) $ List: 5.Mechanical (Fire $ 76Total ession Total All Fees:. $ Check No. Check Amount: Cash Amount: Project Cost: $ am ©o ❑Paid in Full ❑Outstanding Balance Due: i ! lr/rC 77) SECTION 5: CONSTRUCTION SERVICES 5.1 Construction 71�� visor License(CSL) CSf A _058.iy3 � Kqz j License Number Expvation Date Name of CSL Holder List CSL Type(see below)-R-- No.and Street Type Description O 1n ,a� U Unrestricted(Buildings to Dwelling cu.ft. `( R Restricted I&2 Family Dwelling Cit�/Town,State,ZIP M Masonry RC Roofing Covering WS Window and Siding - SF Solid Fuel Burning Appliances 5 ^C�7 L.LC O Csrtrlca..'� Alet� I Insulation Telephone Email address D Demolition ,55..2.Registered Home Improvement Contractor •C-) _ a l y /C � ��-�`�`��^ IC Registration umber Expiration Date HiC Compa'ry N ne oral Registrant Name ' -I SA F.e w PD ccrw c .tiC 1a C No.and Stre t Email address Ci /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 .......... 0-�' 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 m behalf,in all matte re �ve to work authorized b this buildin permit application. Y Y g P PP Arin t er's Name(Electron Sign Date SECTION WN R' A HORIZED AGENT DECLARATION By entering my name below,I hereby attest under t e pains and penalties of perjury that all of the information contained in this application is true and�accurate to the bestof my knowledge and understanding. Print Owner's or Authorized Agent's Name lectmnc 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/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 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 SM.EM, 1NLksSACHUSETTS Bt:u. NG DEPART.\mNT ' 21 130 W.\sHLNGTON STREET,3' FLOOR "j TE1- (978) 745-9595 FAX(978) 740-9846 KINIDERL.EY DRISCOL.L MAYOR T Ho.\Lu ST.PmnE DIRECTOR OF PUBLIC PROPERTY/BUMI)LVG CONMSSIONER 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: l\�� G. A'-V AT �n aYx X N (name of hauler) The debris will be disposed 1of in (name of facili[ �Q c YA �. (address of facility) f Y — signature of p rmit applicant date ilcbrivfT.loc CITY OF S�UENi, NAXSSACHLSEM BI:ILDLNIG DEP aniENT 'f 120 WASHLNGTON STREET,3"FLOOR 1 a TEL(978)745-9595 FAX(978)740-9846 1Q,,%t3ERIBY DRISCOLL MAYOR THOMAS ST.PlPRR6 DIRECTOR OF PUBLIC PROPERTY/BL'ILDLNG COSM(ISSIONER Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information Please Print Legibly Name(Busirwss.organizatioNlndividaal): Me&Iey(j Le 1 R� tl, pRC / i C Address: 8 rATN e R L fA Nl t R l Ve City/State/Zip: ( a Phone#: Are you an employer?Check the appropriate bus: Type of project(required): 1.❑ 1 am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction employees(fill and/or part-time).* have hired the sub-coa ractors 2_❑ I am a sole proprietor or partner- listed on the attached sheet.f ?• efemodeling ship and have no employeta These sub-contractors have 8. ❑Demolition working for me in any capacity, ma�rkers'comp-insuraace, 9. ❑Building addition [No workers'comp.insurance 5. R We are a corporation and its required.] officers have exercised their 10.❑Electrical repairs or additions 3.❑ 1 am a homeowner doing all work right of exemption per MGL I I.❑Plumbing repairs or additions myself.(No workers'comp. C. 152,§I(4),and we have no 12,❑Roof repairs insurance required.]t employees. [No workers' 13.❑Other comp.insurance required.] •Any applicant that checks box of must also fill aul the scaioa below sh wing their workins'compenaauon policy information 'I lomcownas who submit this affidavit indicating they are doing all work and tic,hire amide cone coon must submit a new aBid wil4,ditiogatrch :Contrrxors that cheek this box mtn-t attached an aslditierel sheet showing the name of are sub•eommtams and their wodnia•comp,policy info,"'ti . I am an employer that is providing workers'compensation insurance jar my employees. Below is the policy and job site information, Insurance Company Name: Policy#or Self-ins.Lic.#: Expiration Date: Job Site Address: City/State/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 c. 152 can lead to the imposition of criminal penalties of a fine up to S 1,500.00 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 / ratt the pat'"Jlp1l and penahles of perjury mat the information pro vided above is true and correct I i ma ve• DS+- Date, (s Phone#: Official use only. Do not write in this area,to be completed by city or town official City or Town: Permit/L cease# Issuing Authority(circle one): 1.Board of llealth 2.Building Department 3.Cityffown Clerk 4..Electrical Inspector 5. Plumbing Inspector 6.Other Contact Person: Phone# -.�� , � , g , 8 IM�a� ., off ,�� �— r�� iff�aQ — �� � .�� �� �� �� � $/LIt �___�f�Q \ 50� o�� S-els� a�