11 WILLIAMS ST - BUILDING INSPECTION (4) rs The Commonwealth of Massachusetts
Board of Building Regulations and Standards VIC S
,' IIISRE TtO
d� Massachusetts State Building Code, 780 CMR `
Revised filar 201/Building Permit Application To Construct, Repair, Renovate Or Demolishp jjN —s •A 4
One-or Two-Family Dwelling
This Section For Official Use Only
Building Permit Number: IDate pplied:
/ol
Building Official(Print Name) Signature Date
SECTION 1:SITE INFORMATION
I. rt�tert A/ddy�ress• 1.2 Assessors Map& Parcel Numbers
—1-I—Y>A�
I.I a Is.this an accepted street?yew,— no Map 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(ft)
Front Yard Side Yards Rear Yard
Required Provided Required Pmvidcd 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'? Municipal ❑ On site disposal system ❑
Check ifyesO
SECTION 2: PROPERTY OWNERSHIP'
2)_(Ow 'of cortft
Name(1 int) City,State,ZIP
�il`1CAN � 113 -J�l 056-�
No.and Street 'telephone Email Address
SECTION 3: DESCRIPTION OF PROPOSED WORK'(check all that a )
New Construction ❑ Existing Building❑ Owner-Occupied ❑ 1 Repairs(s) ❑ Afteration(s)�N Addition ❑
Demolition ❑ Accessory Bldg. ❑ Number of Units Other Specify:
Brief Description of Proposed Work': G� �fl.>• YWh 0 �,_
4�s1��YiA �,L�L
J SECTION 4: ESTIMATED CONSTRUCTION COSTS
Item Estimated Costs: Official Use Only
Labor and Materials
I. Building $ 6r� I. Building Permit Fee: $ Indicate how fee is determined:
❑ Standard Cily/rown Application Fee
2. Electrical $ C-O ❑Total Project Cost'(Item 6)x multiplier x
3. Plumbing $ 906 2. Other Fees: $
4. Mechanical (IIVAC) $a1 VQU List:
5. Mechanical (Fire $
Suppression) Total All Fees: $
Check No. Check Amount: Cash Amount:_
6. 'Total Project Cast $ �o`�Z�O ❑ Paid in Full ❑Outstanding Balance Due:
MAtr_ —1-70 ku1--AG=— ADD
SECTION 5: CONSTRUCTION SERVICES
ej-
5.1 onstr a ton Supervisor License(CSL) � 9)h 1 t,
if License Number Espiru ion Date
troe of CSL Holler
lip }--t� 1414� 1A. List CSL Type(see below)
No.and Stree 7 Type Description
U Unrestricted(Buildings up to 35,000 cu. ft.
—/ Restricted 1&2 Family Dwelling
Cily/Towo, e,ZIP Masonry
RC Roofing Covering
WS Window and Siding
SF Solid Fuel Burning Appliances
1 Insulation
Telephone Email address D Demolition
RegisWfq Home improvement Contractor.(HIC) $ ert b �� )t
_P O"✓ i��gi oration Number Ex�tion Date
,II"Co Z Npr�e oI III 1^gtslrant Name n
I- "d
o.anret A)A� Email address
Cit /Town,State,ZIP Telephoned 1 '7
SECTION 6: WORKERS'COMPENSATION INSURANCE AFFIDAVIT(NI.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 79:OWNER AUTHORIZATION TO BE COMPLETED WHEN
OWNER'S AGENT OR CONTRACTOR APPLIES FOR BUILDING PERMIT
Vneret pr ,hereby authorize AI fA��Y
after lative to work authorized by this building permit application.ronic Signature) Date
SECTION 7h:OWNER' OR AUTHORIZED AGENT DECLARATION
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information
con a ned in t is application is true and accurate to the best of my knowledge and understanding.
Ikn "IGS 6
Print Owner's or Authunzed Agent's Name(Electronic Signature) U de -
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 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 wwwjnass.gov/dys
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. R.) 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'
-
tl( �� r000)NJt04t(t�l2 O�CY�[.952C�/6¢I
Office of Consumer Affairs&Business Regulation W
i OME IMPROVEMENT CONTRACTOR
eglstranon:
atlon �148598 Type:
Expiration 10%1 V2015 DBA
~r,,ALAN F.HAYES CARPENTER&BUILDERS
��. ALAN HAYESf tL.� �
2 FITZGERALD WAY' 4` ' �f
? BEVERLY,MA 01915
Undersecretary
iM Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor I & 2 Fumil}
License: CSFA-092258 j
ALANFIIAYES
2 FITZGERALD WAY
BEVERLY MA 11190 '
0`� Expiration
09112/2015
Commissioner
: . CITY OF S;1Lzm, A-ks&: CHUSETTS
l7L'ILOLNG DEP.IR-nLE,NT
1t h 120
_0 �N.13HL`tGTON STZEET, 1'O FLOOR
TEL (973) 745-9595
KIMSERLEY DRISCOLL F•ILX(973) 7-IQ934S
NLAYo;2
r-toNct3 Sr.PtLans
DIZECTOR OF PUBLIC PROPERTY/BCILDLv(',COJL\q�g[O,�ER
Construction Debris Disposal AYtTdavit(required for all demolition and renovation work)
In accordance with the sixdt edition of the State Building Coda, 730 Ct•,lR section l l 1.5
Debris, and the provisions of tMGL c 40, S 54;
Building permit y is issued with the condition that the debris resulting from
111 work shall ba disposed of in a properly licensed waste disposal facility as defined by tNIGL c
l l 1, S ISQA.
The debris will be trans ortcd by:
(nima of hauler)
Tcheel tlQbris will bo disposed of in ;
(nanit of lacdity) —"
(-tddress artatilit/)
I
'i nd rut P"',it applicant
II
' CITY OF SALEM, ANSSACHL'SE ITS
�
k
• pptt ISUll' ING DEP.IRTJ(E.�iT
,V4
3 4 st'!t St 120 WASHNGTON STREET, 3oe FLOOR
\�� �cF TEL (978) 745-9595
F.kX(978) 740-98.36
KINIBERLEY DRISCOLL
MAYOR T fOAIAS ST.PIEME
DIRECTOR OF PUBLIC PROPERTY/BCRDi\G CONNISSIONER
Worlcers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers
A r ilicant Information ��I41 C Please Print Legibly
Name(numness.( gmliratioml livit
Address �1� _V
Cily/State/Zip: i J'' �1 lA d1 Phone #: o
Ire you no employer?Chcc the appropriate box: 'type of project(required):
1. I am a employer with 4. ❑ I am a general contractor and 1 6. ❑New construction
employees(full and/or pan-time).• have hired the sub-contractors
2.❑ I am a sole proprietor or partner- listed on the attached sheet. t 7. ❑ Remodeling
ship and have no employees These sub-contractors have 8. ❑ Demolition
working for me in any capacity, workers'comp. insurance. y, ❑ Building addition
INo workers*comp. insurance 5. ❑ We are a corporation and its
required.) officers have exercised their 10.❑ Electrical repairs or additions
3.❑ I am a homeowner doing all work right of exemption per MGL I LEI Plumbing repairs or additions
myself.[No workers'comp. C. 152, §1(4),and we have no 12.❑ Roof repairs
insurance required.) t employees. (No workers' 13.❑Other
cutup. insurance required.)
•Any applicmn IIca checks bus A I mutt also rill out the sactiun below showing their workers'cum pen union policy inll)rmatiun.
'I lommtwntims who suhmit this aMdrivit indic.ying they am doing all work and then hire outride centmcton must.submit a new air.davit indicating such
$'animclun Out chmk this boa must ail achal in addiniurwi cheat showing uw name of the mbaentncton and(heir worken'comp.policy information.
I ant on eutptayer that is providing wor rs'camp nsarl if insurance for my employees. Below Is the policy and jab site
iufiinuution.
Insurance Company ��5
Policy A or Sclf-item`,tLic.. M ,I Expiration Datte:`�
job Site Address:l l W�' 1b1 S 4 City/State/Zip:�'1'_�A (5i cn u
Attach a copy of the workers'compensation pulley declaration page(showing the policy number and expintion data).
Failure to scene coverage as required under Section 25A at'NIGL c. 152 can lead to the imposition of criminal penalties ofa
fine up to S 1,500.00 und/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and aline
of up to$250. day against the violator. Be advised that a copy or This statement may be forwarded to the Office of
Imestigaliun o1'1 DIA for insurance coverage verification.
/do hereby -err it i!e p its penalties of perjury dint die informutiaa provided rbove '.e true and correct.
Si= re'
Phone
Official use unty. Do note write in ills urea, to be completed by city air town 0JJ1c1uL
City nr Tuwn: Permit/f.lcense p
issuing Authority (circle one): -- -- --
1. Board of lieailh 2. Building Departutcuf J.Citylrnwn Clerk 4. Electrical inspector 5. Plumbing lnspeetor
6. Other
Confact Person:_ _ .__ Phone fi: